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Problem Gentamicin dosing and prescription is often carried out incorrectly, despite very clear guidelines. Gentamicin is one of the few antibiotics which is weight-dependent in adults. The weight at which gentamicin needs to be prescribed is the patient's own body weight. This changes for obese individuals, where it must be given according to a corrected body weight, which involves a series of mathematical calculations. These calculations involve knowing the patient's height and weight and this can be a significant challenge, especially if the patient is bed-bound. An additional problem is that the gentamicin prescribing regime is relative to the patient's renal function. An accurate and acceptable measure of a patient's renal function is their creatinine clearance (CrCl). CrCl is not a measure which is provided with the rest of the blood results and it must be manually calculated. Most prescribers use eGFR as a substitute although it should not be used for its relative inaccuracy. The height and weight of patients is nearly always guessed or approximated which means that patients can be severely underdosed or overdosed.

vided with the rest of the blood results and it must be manually calculated. Most prescribers use eGFR as a substitute although it should not be used for its relative inaccuracy. The height and weight of patients is nearly always guessed or approximated which means that patients can be severely underdosed or overdosed. Background Gentamicin is an antibiotic from the class of aminoglcosides. It is used predominantly to treat gram-negative infections, particularly urinary, biliary and abdominal but does have some anti-staphylococcal activity as well. Gentamicin is being used increasingly in clinical care because of its lack of ‘diffogenicity’ (causing clostridium difficile) but there are a number of problems associated with it. Gentamicin is a potentially nephrotoxic and ototoxic antibiotic if given incorrectly. A patient is given a dose according to their body weight. If they are obese, they are dosed according to a corrected body weight. The patient's renal function will also determine how many mg/kg they will be dosed at. Once a patient is given gentamicin and is due to receive subsequent doses, they must have a level taken 6–14 hours after the initial dose which will demonstrate how well their kidneys are clearing the antibiotic as it is renally excreted. This manner of giving gentamicin is the once-daily extended interval regime which is replacing the traditional method of giving it more than once a day depending on peak and trough levels. It is presumed that this is a safer and more effective way of giving the antibiotic. Calculating the correct dose of gentamicin is dependent upon calculating the patient's ideal body weight, followed by the corrected body weight and finally their creatinine clearance. By not following this protocol significant variation can occur in dosing and subsequent prescription.

tive way of giving the antibiotic. Calculating the correct dose of gentamicin is dependent upon calculating the patient's ideal body weight, followed by the corrected body weight and finally their creatinine clearance. By not following this protocol significant variation can occur in dosing and subsequent prescription. Baseline For this project fifty patients from the surgical wards who had been prescribed gentamicin had their doses checked. Patients who had been given a prophylactic dose of 80–120mg were not included in the baseline measurement as there was no dependence on height, weight and renal function. For all of the patients, their height, weight, age, gender and serum creatinine at the time of dosing were recorded as well as the dose of gentamicin they were given. The correct gentamicin dose was calculated for each patient and compared with the dose which had been prescribed and dispensed. The results showed that only 30% of patients received the correct dose of gentamicin.

nd serum creatinine at the time of dosing were recorded as well as the dose of gentamicin they were given. The correct gentamicin dose was calculated for each patient and compared with the dose which had been prescribed and dispensed. The results showed that only 30% of patients received the correct dose of gentamicin. Design When considering the underlying cause of this problem, it became clear that the calculations involved for calculating gentamicin accurately were too complex in the busy environment that healthcare professionals work in. The reliance of mentally calculating the dose had to be overcome. The most obvious way was to automate the calculations and to generate the correct dose based on the inputting of certain parameters. A gentamicin calculator was developed which allowed users to input a patient's height, weight, age, creatinine and gender, which would then give a result by pressing a ‘dose’ button. Strategy See supplementary file: CalcScreenshots.docx PDSA Cycle 1 The calculator was initially shown to the consultant microbiologist in charge of antibiotics within the trust as well as the anti-microbial pharmacist. It was rigorously tested looking at its accuracy of calculation. Whilst being satisfied with the accuracy of the software they both had issues with its aesthetic and felt that it should be tested with end-users.

onsultant microbiologist in charge of antibiotics within the trust as well as the anti-microbial pharmacist. It was rigorously tested looking at its accuracy of calculation. Whilst being satisfied with the accuracy of the software they both had issues with its aesthetic and felt that it should be tested with end-users. PDSA Cycle 2 The calculator was subsequently trialed on the orthopaedic wards with the SHOs and house officers after it had an interface redesign. The feedback from the testing was positive, in that calculation time significantly improved and there was much reliance on the brain for calculation. A useful suggestion, which arose from the testing, was that the calculator should have a height and weight unit converter, which would allow easy conversion of units. The units required for a patient's weight is kilograms and for the height it is feet and inches. Patients often measure their weight in stones and often do not know their height, or know it in metres. The converter would help to overcome this problem. PDSA Cycle 3 In the third PDSA cycle the feedback for users was that the height and weight converter improved the user experience and made it very easy for them to convert units. Another issue which arose from this PDSA cycle was that users were not clear about when to take levels from the messages that the calculator was outputting. PDSA Cycle 4 The information messages regarding taking levels outputted by the calculator were corrected and it was trialed again with extremely positive and no negative feedback.

PDSA Cycle 3 In the third PDSA cycle the feedback for users was that the height and weight converter improved the user experience and made it very easy for them to convert units. Another issue which arose from this PDSA cycle was that users were not clear about when to take levels from the messages that the calculator was outputting. PDSA Cycle 4 The information messages regarding taking levels outputted by the calculator were corrected and it was trialed again with extremely positive and no negative feedback. PDSA Cycle 5 The calculator was then trialed for two months on the Surgical Assessment Unit with all gentamicin requests being calculated using the calculator. There was no negative feedback, rather the nursing staff felt empowered to be able to use the calculator to check doctors' prescriptions on the chart. PDSA Cycle 6 The calculator was rolled-out within the whole hospital after the two months of testing on the Surgical Assessment Unit. Post-measurement was carried out six months after rolling the calculator out. Post-Measurement Post-intervention measurement was again for the sake of comparison consistency, carried out with fifty patients on the surgical wards. Again, prophylactic doses of gentamicin were omitted. The findings were that gentamicin had been correctly prescribed in 92% of cases, demonstrating a 300% improvement in dosing. Lessons We learnt a number of lessons from carrying out this project: Small steps of change are useful when testing an intervention.

Post-Measurement Post-intervention measurement was again for the sake of comparison consistency, carried out with fifty patients on the surgical wards. Again, prophylactic doses of gentamicin were omitted. The findings were that gentamicin had been correctly prescribed in 92% of cases, demonstrating a 300% improvement in dosing. Lessons We learnt a number of lessons from carrying out this project: Small steps of change are useful when testing an intervention. When designing an intervention, consider the wider range of healthcare professionals that the intervention could impact upon. Healthcare professionals are not lazy or unintelligent people, the system that they work within limits their time, keeps them busy and makes them tired. One could not expect an individual not to make mistakes in this high-pressured environment, so interventions should seek to eliminate the human factors, which may have a bearing on the process.

re not lazy or unintelligent people, the system that they work within limits their time, keeps them busy and makes them tired. One could not expect an individual not to make mistakes in this high-pressured environment, so interventions should seek to eliminate the human factors, which may have a bearing on the process. Conclusion Instituting the intervention was an extremely positive action as it has significantly improved prescribing of gentamicin. Anecdotally, the time taken for prescribing decreased, this would have been a good process measure to measure. The number of incorrect prescriptions decreased, meaning that patients were receiving safer care and the amount of gentamicin being wasted from overdosing was being saved. What is clear is that in a busy environment such as a hospital, its workers need to be aware that they systems that they work within are in need of constant refinement to optimise working conditions and minimise the potential for harm. The introduction of the calculator has clearly had a significantly beneficial effect, but should not make individuals complacent. There is always a need to refine and optimise systems and this project has demonstrated just that. Supplementary Material Web supplement

Problem The Haringey Community Rehabilitation Team (HCRT) is within Barnet, Enfield and Haringey Mental Health Trust (BEH-MHT). This team looks after service users who have a psychotic illness, the vast majority of whom have a diagnosis of schizophrenia. These service users live in community residential care homes as they require additional support to live and function in a community setting. There are over 60 residential care homes for people with mental health problems in Haringey; the team looks after approximately 250 patients who are based in these establishments. Background Schizophrenia can be a severe and chronic illness which is often associated with poor compliance with treatment (1). Non adherence is significantly associated with an increased risk of relapse, hospitalisation and suicide attempts (2). It can be the result of a variety of different factors, one of the most important being a lack of insight (3). Other factors may include the stigma of taking medications, adverse drug reactions, forgetfulness, and a lack of social support (4). One method of enhancing compliance with antipsychotics is psychoeducation (5).

can be the result of a variety of different factors, one of the most important being a lack of insight (3). Other factors may include the stigma of taking medications, adverse drug reactions, forgetfulness, and a lack of social support (4). One method of enhancing compliance with antipsychotics is psychoeducation (5). The National Institute for Health and Clinical Excellence (NICE) defines psychoeducation as ‘the provision of information and advice about a disorder and its treatment. It usually involves an explanatory model of the symptoms and advice on how to cope with or overcome the difficulties a person may experience. It is usually of brief duration, instigated by a healthcare professional, and supported by the use of written materials’ (6). A Cochrane review undertaken in February 2010 showed that psychoeducation appeared to reduce relapse, readmission, and encourage medication compliance, as well as reduce the length of hospital stay (1). Brief group psychoeducation has been shown to improve quality of life (7). Baseline BEH-MHT measures patient satisfaction through a Patient Experience Questionnaire. The questionnaire asks three questions: 1)Do staff explain the purpose of medication to you in an understandable way? 2)Do staff explain the possible side effects of medication to you in an understandable way? 3)Do you have a say in your medication choice?

Baseline BEH-MHT measures patient satisfaction through a Patient Experience Questionnaire. The questionnaire asks three questions: 1)Do staff explain the purpose of medication to you in an understandable way? 2)Do staff explain the possible side effects of medication to you in an understandable way? 3)Do you have a say in your medication choice? The questionnaire is distributed by care coordinators and doctors to all service users, with a target that each individual should complete it at least once per year. During a six month period (November 2011-April 2012) 65 questionnaires were completed by the patients of the HCRT. A review of the responses highlighted a number of issues. 45% of patients felt that the side effects of their medication were not always explained to them in an understandable way and 60% of patients felt that they never, or only sometimes, had a say in their medication choice. This highlighted that there was inconsistency in the provision of information about medication. Only 34% of service users felt that they always had a say in their medication choice. See supplementary file: Medication Workshop Results Table.doc Design A PowerPoint presentation was prepared for the workshop which covered the topics of mental illness, schizophrenia and medication. The workshop was designed to be very interactive where attendees would be invited to answer and ask questions and to share their experiences. The session was designed to last 1 ½ hours in total with a ten minute break in the middle.

the workshop which covered the topics of mental illness, schizophrenia and medication. The workshop was designed to be very interactive where attendees would be invited to answer and ask questions and to share their experiences. The session was designed to last 1 ½ hours in total with a ten minute break in the middle. At the beginning there was a seven minute warm-up where the facilitators introduced themselves and explained the purpose of the group. Group rules and boundaries were then established (confidentiality, respect for each other's opinions, turn taking etc). The service users were then asked to introduce themselves in turn and say what they would like to get out of the workshop. The first half of the workshop lasted 30 minutes and focused on mental illness, looking at its definition and exploring how common it is. The workshop then focused on schizophrenia; in particular the definition, epidemiology, symptoms, causes and treatment of the illness. This first half of the workshop gave some background and an introduction to the topic of medication.

focused on mental illness, looking at its definition and exploring how common it is. The workshop then focused on schizophrenia; in particular the definition, epidemiology, symptoms, causes and treatment of the illness. This first half of the workshop gave some background and an introduction to the topic of medication. Following a ten minute break, the second half of the workshop lasted 40 minutes. It started off with a coloured card exercise where service users were asked to match up medications to the mental illness in which they are most commonly used. The idea behind this was to illustrate that there are a variety of different medications which can be used to treat different mental illnesses. The workshop went on to look at the different types of medication which could be used in schizophrenia, focusing in particular on antipsychotics. The workshop then examined how these drugs work, the different types of antipsychotics that are used, their side effects, their benefits and the potential risks involved if patients don't take their medication. The final part of the workshop focused on how service users could have a say when it came to making decisions about their medication treatment. This highlighted the importance of informing care co-ordinators, key workers or doctors if they had any issues with their medication. The workshop looked at the pros and cons of taking medication and illustrated the importance of finding the best medication for each service user. The presentation looked at some of the options available if service users were not happy with their medication following a discussion with their doctor. For example, a doctor might consider adding in a medication such as procyclidine if their patient were experiencing extra-pyramidal side effects.

or each service user. The presentation looked at some of the options available if service users were not happy with their medication following a discussion with their doctor. For example, a doctor might consider adding in a medication such as procyclidine if their patient were experiencing extra-pyramidal side effects. At the end there was a three minute closing where service users were thanked for their contributions. During this time information leaflets and anonymous feedback questionnaires were distributed. Service users were also given the details of additional resources they could use if they wanted to find out further information on mental illness or medication. The anonymous feedback questionnaires asked a variety of questions to see if the workshop objectives had been met. Service users were invited to give their comments and suggestions for improvements which could be made to the workshop. As a result the structure and content of the workshop was modified and improved after each session using the feedback from the questionnaires.

questions to see if the workshop objectives had been met. Service users were invited to give their comments and suggestions for improvements which could be made to the workshop. As a result the structure and content of the workshop was modified and improved after each session using the feedback from the questionnaires. A junior doctor (JP) was identified as the main facilitator for the workshops. She met with the HCRT manager in May 2012 to identify dates and care homes for the medication workshops to take place in. Different team members were identified to co-facilitate each workshop. 12 workshops were identified to take place from May-July 2012. Each care home manager provided a list of their residents with a diagnosis of schizophrenia who would be suitable to invite. We wanted to include as many people as possible in the workshops, however those service users whose mental states were considered too unstable by the care home/HCRT and would risk disrupting the group were excluded. Invitations were sent out to these service users explaining the details and purpose of the workshop. It was made explicitly clear to care home managers that their residents should come to the workshop of their own volition and should have a genuine interest in finding out more about schizophrenia and the medication used to treat it. In terms of group size we advised that this should be between two to eight people with priority given to service users under the HCRT (at some of the residential care homes there were service users who were looked after by different community mental health teams).

bout schizophrenia and the medication used to treat it. In terms of group size we advised that this should be between two to eight people with priority given to service users under the HCRT (at some of the residential care homes there were service users who were looked after by different community mental health teams). The materials required for the workshops were a laptop, projector, coloured cards, feedback questionnaires, pens and patient information leaflets. A protocol was written explaining how the workshops were set up and run. A copy of the powerpoint presentation was made available to the team on the Trust' s shared computer drive. Junior doctors on the HCRT rotate every six months and it was felt that each new doctor should continue to take leadership in the workshops with the support of the team and Consultant. The medication workshop was taken to the local clinical governance meetings to help ensure longevity of the project.

ed computer drive. Junior doctors on the HCRT rotate every six months and it was felt that each new doctor should continue to take leadership in the workshops with the support of the team and Consultant. The medication workshop was taken to the local clinical governance meetings to help ensure longevity of the project. Strategy The ‘plan’ phase was started by stating that the goal of the medication workshop was to expand patient' s knowledge and understanding of the medication used in the treatment of schizophrenia. Our hypothesis was that at least 70% of service users would meet our objectives and that we would test the intervention using anonymous questionnaires. In the ‘do’ phase the workshop was carried out and feedback questionnaires were distributed to assess the intervention. In the ‘study’ phase the feedback from the workshop questionnaires was analysed. The ‘act’ phase consisted of determining what modifications should be made to subsequent workshops as a result of the service user questionnaire feedback and from the facilitator' s experience of the workshops. A total of ten PDSA cycles were carried out (one after each workshop) and a number of changes were implemented to the workshops which included; giving a definition of what mental illness is, giving more information on the sexual side effects of drugs and giving more information on drugs used in schizophrenia which are not antipsychotics (e.g. antidepressants). See supplementary file: PDSA Cycle medication workshop.doc

Strategy The ‘plan’ phase was started by stating that the goal of the medication workshop was to expand patient' s knowledge and understanding of the medication used in the treatment of schizophrenia. Our hypothesis was that at least 70% of service users would meet our objectives and that we would test the intervention using anonymous questionnaires. In the ‘do’ phase the workshop was carried out and feedback questionnaires were distributed to assess the intervention. In the ‘study’ phase the feedback from the workshop questionnaires was analysed. The ‘act’ phase consisted of determining what modifications should be made to subsequent workshops as a result of the service user questionnaire feedback and from the facilitator' s experience of the workshops. A total of ten PDSA cycles were carried out (one after each workshop) and a number of changes were implemented to the workshops which included; giving a definition of what mental illness is, giving more information on the sexual side effects of drugs and giving more information on drugs used in schizophrenia which are not antipsychotics (e.g. antidepressants). See supplementary file: PDSA Cycle medication workshop.doc Post-Measurement From 10th May - 31st July 2012, ten workshops were carried out for a total of 47 patients, 39 of whom were under the care of the HCRT. These workshops covered twenty of the residential care homes in Haringey. The results from the feedback questionnaires showed that the patients who attended the workshop gave it an average score of 8.3/10 for usefulness (0-Not useful, 10-very useful).

a total of 47 patients, 39 of whom were under the care of the HCRT. These workshops covered twenty of the residential care homes in Haringey. The results from the feedback questionnaires showed that the patients who attended the workshop gave it an average score of 8.3/10 for usefulness (0-Not useful, 10-very useful). 83% (39/47) of patients felt that the workshop had helped them to understand more about their mental health. 77% (36/47) of patients felt that from this workshop they were able to understand the purpose of their medication. 79% (37/47) of patients felt that they were able to understand what the side effects of their medications were from this workshop. 70% (33/47) patients felt they could have a say in their medication from this workshop. Comments on the workshops made by service users were generally positive; people reported to find them ‘useful' , ‘helpful’ and ‘interesting’. See supplementary file: Medication Workshop Results Table.doc Lessons and Limitations A difficulty that we encountered was that two of the planned workshops had to be cancelled due to miscommunication between the HCRT and the care homes. This meant that only ten workshops were carried out instead of the twelve which were originally identified. The lesson learnt here was the importance of good communication between the care homes and HCRT staff.

two of the planned workshops had to be cancelled due to miscommunication between the HCRT and the care homes. This meant that only ten workshops were carried out instead of the twelve which were originally identified. The lesson learnt here was the importance of good communication between the care homes and HCRT staff. Another lesson learnt was that service user feedback is very important. Using the PDSA cycle, which encouraged an ongoing process of improvement, allowed us to develop a medication workshop which was tailored to the patients’ needs. There were a number of challenges to our quality improvement project. 17% (8/47) of the patients who attended these workshops were not under the care of the HCRT which meant that it was more difficult to compare our workshop results to the original Patient Experience Questionnaire results (November 2011-April 2012). Another limitation was that there was no way of identifying whether these workshops had led to an improvement in the results of the medication questions from the Patient Experience Survey. This is because the Patient Experience Questionnaires are given to service users at different care homes on a sporadic basis and it is not possible to identify which care homes the patients are from because the forms are anonymous. Another limitation was that the feedback questionnaires only tested people' s attitudes towards medication and it did not test their knowledge or look to see if their behaviour changed as a result of the workshop.

and it is not possible to identify which care homes the patients are from because the forms are anonymous. Another limitation was that the feedback questionnaires only tested people' s attitudes towards medication and it did not test their knowledge or look to see if their behaviour changed as a result of the workshop. Conclusion This medication workshop will continue to be used for patients in the remaining care homes under the HCRT. This workshop is transferable; it could be used in other Community Mental Health Teams (CMHTs) and it could be run by a variety of different healthcare professionals including nurses, pharmacists and doctors. The HCRT is in the process of setting up further psychoeducation workshops for service users, including a Dual Diagnosis Substance Misuse Workshop. Suggestions for further groups have included a healthy eating/lifestyle group and a medication workshop for the staff of the care homes.

Conclusion This medication workshop will continue to be used for patients in the remaining care homes under the HCRT. This workshop is transferable; it could be used in other Community Mental Health Teams (CMHTs) and it could be run by a variety of different healthcare professionals including nurses, pharmacists and doctors. The HCRT is in the process of setting up further psychoeducation workshops for service users, including a Dual Diagnosis Substance Misuse Workshop. Suggestions for further groups have included a healthy eating/lifestyle group and a medication workshop for the staff of the care homes. The results of the feedback questionnaires show that our objectives were all met at 70% or higher with regards to patients understanding more about their mental health, understanding the purpose and the side effects of their medication and understanding that they can have a say when it comes to their medication. The results from the workshop show an improvement in the medication objectives compared with the original results from the Patient Experience Questionnaires (November 2011-April 2012). The feedback was overall positive with people generally finding the workshop useful. A number of the suggestions advised by patients and a number of improvements which were a result of the facilitators’ experience of the workshops were incorporated into the project. This was done using the PDSA cycle methodology allowing for an ongoing process of improvement.

ople generally finding the workshop useful. A number of the suggestions advised by patients and a number of improvements which were a result of the facilitators’ experience of the workshops were incorporated into the project. This was done using the PDSA cycle methodology allowing for an ongoing process of improvement. Psychoeducation is associated with a variety of benefits for patients which include reducing relapse and readmission rates, encouraging medication compliance, reducing the length of hospital stay and improving patient' s quality of life (1, 7). This workshop yielded positive results, required few resources and was low in cost to implement which should make it attractive to both clinicians and managers (8). Supplementary Material Web supplement Web supplement Web supplement Acknowledgements Staff working in the Haringey Community Rehabilitation Team: Shireen Hussain-Roy (Team manager), Edward Lander, Agnes Tekyi, Patrick Mamattah, Grace Ogundayo, Nick Mangwana, Adam Madarbux, Maxine Richardson, Greg Murray, Maura Duffy Other Staff from Barnet, Enfield and Haringey Mental Health Trust: Dr Nicole Eady (Psychiatry Core Trainee), Dr Guy Thompson (Psychiatry Specialist Registrar), Dr Sujeet Jaydeokar (Consultant Psychiatrist), Professor Ikkos (Director of Medical Education), Dr Liz Sampson (Consultant Psychiatrist, UCL Senior Clinical Lecturer)

Problem ‘Suspected sepsis’ is one of the most commonly made diagnoses on any neonatal intensive care unit (NICU). Treatment of suspected sepsis needs to be timely and effective so that patients may be discharged safely and efficiently, should they proceed to the most common outcome and remain well. Neonates born with suspected sepsis are kept on neonatal units for intravenous antibiotics, pending discharge dependent blood culture results after 48 hours according to Trust policy. However, delays in this process are leading to excess bed days, excess antibiotics being administered, and unnecessary additional stress for mothers and babies.

cted sepsis are kept on neonatal units for intravenous antibiotics, pending discharge dependent blood culture results after 48 hours according to Trust policy. However, delays in this process are leading to excess bed days, excess antibiotics being administered, and unnecessary additional stress for mothers and babies. Background In order to understand the process of blood culture analysis, I followed the journey of a sample taken in the hospital. Blood samples were taken immediately after birth, however, as glass was not permitted in the direct, automatic transportation system, or ‘pod’ system, samples were then placed in a collection tray. Policy stated that porters should pass by this tray to collect any samples and transport them to the laboratory once per hour; however, this timing was unreliable. If the sample was taken during the daytime, it was placed in a queue of jobs in the microbiology laboratory and eventually incubated. A time 48 hours later was then documented and sent to the requesting doctor, via the computerised system as an expected time for culture results to become available. Laboratory technicians worked between 8.30am and 6.00pm. If the sample was received in the laboratory out of these hours, this process was delayed until the following morning. At this point, technicians were unaware of the discharge dependent nature of the neonatal blood cultures, hence they were not prioritised in the queue of samples that had been collected overnight.

0pm. If the sample was received in the laboratory out of these hours, this process was delayed until the following morning. At this point, technicians were unaware of the discharge dependent nature of the neonatal blood cultures, hence they were not prioritised in the queue of samples that had been collected overnight. 48 hours after blood culture incubation had started, the blood samples were then analysed, and if negative, this data was entered by the technician into the computer system to be seen by the doctor. Following this, all appropriate discharge paperwork was completed and the patient, discharged. Baseline In order to assess the number of patients that this would affect, admissions data was looked at retrospectively for one month. Current hospital policy states that neonates must be kept in hospital for a minimum of 48 hours after birth. On average, four neonates per week were diagnosed with suspected sepsis and discharged with negative blood cultures, with an average stay of 52 hours after birth, four hours more than necessary according to policy. The range of delay was up to 21 hours. In no cases did a neonate have positive blood cultures in this sample; however, in two cases antibiotics were continued on clinical grounds.

d discharged with negative blood cultures, with an average stay of 52 hours after birth, four hours more than necessary according to policy. The range of delay was up to 21 hours. In no cases did a neonate have positive blood cultures in this sample; however, in two cases antibiotics were continued on clinical grounds. Design The microbiology department is soon to be moving away from the current hospital, to one 16 miles away, with no current plan as to how this will be managed. It has become apparent during the analysis of this problem that the impending change of microbiology location is going to have a profound effect on delay times, and that both short term and long term solutions are going to be needed to fix a problem that may become worse. Following extensive discussions with pathology, microbiology and neonatal departments, the following solutions emerged: While microbiology is in the current hospital, and during normal hours, a porter must be called immediately to collect the sample, the microbiology laboratory must also be called to prioritise the sample, and discharge paperwork should be completed in anticipation of discharge if the neonate is clinically well in the hours leading up to potential discharge.

spital, and during normal hours, a porter must be called immediately to collect the sample, the microbiology laboratory must also be called to prioritise the sample, and discharge paperwork should be completed in anticipation of discharge if the neonate is clinically well in the hours leading up to potential discharge. Out of hours, the sample must be taken to the laboratory before the morning, but the laboratory must be called to prioritise the sample in the meantime. When the microbiology department is moved to its new hospital, in the short term, a courier service, that will also operate overnight, will be run to the new microbiology department with overnight incubation. This is only likely to be a temporary solution to the problem for two reasons; firstly the transit time to the laboratory will be around one to two hours. Secondly, communication between different hospitals and departments will be difficult due to the distance between the units. However, with overnight incubation of cultures, a significant delay problem will be resolved.

problem for two reasons; firstly the transit time to the laboratory will be around one to two hours. Secondly, communication between different hospitals and departments will be difficult due to the distance between the units. However, with overnight incubation of cultures, a significant delay problem will be resolved. Strategy The key to this project was developing a long term solution to the foreseen delay problems. The hospital to which the samples will be couriered is 16 miles (approximately 25 minutes) away so delays will occur in transit. Therefore, obtaining a blood culture analyser for the NICU department, housed in the department itself was thought to be the most appropriate solution. This would effectively reduce all delays and mean that if an organism were present in the blood, the organism would be incubated earlier and therefore immediately given the environment to start growing. Neonates would therefore have the greatest chance of being discharged without delay. In order for this to be considered, a business case will be developed with the help of colleagues in the finance department, and will then be presented to the neonatal department. Post-Measurement As mentioned previously, in order to highlight the cost effectiveness of purchasing a blood culture analyser, a business case was created. An outline of which is explained below: The proposed service will include the leasing of a BD Bactec 9050 blood culture analyser for the processing of urgent NICU blood culture samples. This is a compact analyser that can incubate up to 50 samples.

Post-Measurement As mentioned previously, in order to highlight the cost effectiveness of purchasing a blood culture analyser, a business case was created. An outline of which is explained below: The proposed service will include the leasing of a BD Bactec 9050 blood culture analyser for the processing of urgent NICU blood culture samples. This is a compact analyser that can incubate up to 50 samples. Based on an average of 3 bed days saved per week, an estimated savings worth £88,140 (£565 per day × 1 days saved × 3 neonates × 52 weeks) per annum can be made if negative blood culture results are reported within 48 hours even if incubated overnight. This also includes an estimated £137.28 saving on antibiotic costs, offset by a £910 cost of consumables and rental of the analyser, which is £5580 per annum on a 3-year contract. By reducing the length of stay per neonate, productivity throughout NICU can be increased, as more neonates can be admitted with suspected sepsis, rather than being sent to other hospitals. With the maternity unit being expanded, the number of neonates requiring treatment for suspected neonatal sepsis is set to rise, putting even more pressure on the need for bed availability on the neonatal unit. Increasing productivity on NICU will therefore allow the ward to cope with increased demand on services and generate additional income that is above the anticipated £88,140 mark.

ing treatment for suspected neonatal sepsis is set to rise, putting even more pressure on the need for bed availability on the neonatal unit. Increasing productivity on NICU will therefore allow the ward to cope with increased demand on services and generate additional income that is above the anticipated £88,140 mark. Lessons and Limitations From start to finish, this project gave me a flavour of how difficult and slow it can be to effect real change, and large numbers of parties involved means exponential numbers of meetings and makes things seemingly impossible at times. It has shown me, however, once change is made, and positive results seen, the reward is much greater. Conclusion The problem that we started with was that there was an unacceptable delay in discharging neonates with suspected sepsis, mainly due to inefficient processes in blood culture transit to the laboratory, and delayed analysis. With services moving to a completely new site, a short term solution to blood culture analysis had to be made, which was to courier samples to the site, and to ensure overnight incubation. This was achieved. A long-term solution of purchasing a blood culture analyser has now been accepted by the department, however, deemed too expensive by the Trust at present. Blood cultures are now couriered and incubated overnight. There were very few realistic alternatives to this option, so once the microbiology department relocated, this became the practice.

Conclusion The problem that we started with was that there was an unacceptable delay in discharging neonates with suspected sepsis, mainly due to inefficient processes in blood culture transit to the laboratory, and delayed analysis. With services moving to a completely new site, a short term solution to blood culture analysis had to be made, which was to courier samples to the site, and to ensure overnight incubation. This was achieved. A long-term solution of purchasing a blood culture analyser has now been accepted by the department, however, deemed too expensive by the Trust at present. Blood cultures are now couriered and incubated overnight. There were very few realistic alternatives to this option, so once the microbiology department relocated, this became the practice. Once the blood culture analyser has been purchased, I suggest that an audit should be completed to analyse the improvement in delay times between couriering to a new hospital 16 miles away and putting them into an on-site analyser. It is clear that there will be a very large saving in time and cost. Interestingly, new NICE guidance has recently been released, which emphasises reducing the necessary inpatient stay time from 48 hours to 36 hours (NICE clinical guideline 149). These should be integrated into the department, and the journey of a blood sample further analysed to find the most efficient method of analysis for discharge.

Problem Acute Kidney Injury (AKI) is a frequently encountered and expensive clinical problem. Although no definitive studies have been undertaken in the UK, the incidence of AKI in acute hospital admissions is estimated to be approximately 20%. Patients with AKI require longer hospital stays and have a poorer prognosis, with mortality ranging from 10–80% depending upon the population studied (1). In a general district hospital in Northern Ireland an audit was undertaken to assess the extent of the problem. It demonstrated that, similar to national figures, 16% of acute adult admissions had AKI and that their average length of stay was longer at 10.5 days compared to 6.9 days for all adult medical admissions. 20% of these patients would subsequently die within three months. It was evident that AKI was being poorly recognised and sub-optimally managed.

to national figures, 16% of acute adult admissions had AKI and that their average length of stay was longer at 10.5 days compared to 6.9 days for all adult medical admissions. 20% of these patients would subsequently die within three months. It was evident that AKI was being poorly recognised and sub-optimally managed. Background Warning signs for AKI can be recognised easily by sensitive indicators including hypotension, reduced urine output and a rise in serum creatinine. It has been recognised recently that even small increases in creatinine are associated with worse patient outcomes. Published studies suggest a large percentage of episodes are preventable or potentially reversible through simple interventions such as fluid volume replacement, discontinuing and/or avoiding nephrotoxic agents, relief of urinary tract obstruction and early recognition of conditions causing rapid progression of AKI. There are a number of clear, widely accessible clinical guidelines on AKI. The National Institute for Health and Clinical Excellence (NICE) AKI clinical guidance is in development and expected to be published in August 2013. Regionally, the Northern Ireland Guidelines and Audit Implementation Network (GAIN) published AKI guidelines in 2010 (2). They summarised their advice in a simple protocol which outlines how to recognise at risk patients, AKI and treatment considerations, including when to make a nephrology referral. They are based on the national Clinical Practice AKI guidelines published by the UK Renal Association (2008) (1). These guidelines formed the evidence base for the definitions and educational material used in this project.

at risk patients, AKI and treatment considerations, including when to make a nephrology referral. They are based on the national Clinical Practice AKI guidelines published by the UK Renal Association (2008) (1). These guidelines formed the evidence base for the definitions and educational material used in this project. AKI warranted a UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report in 2009, entitled Adding Insult to Injury (3). It carefully examined the care of hospital patients who had died with a primary diagnosis of AKI. 50% of patients' management was judged to be suboptimal, with 20% of cases deemed to be predictable and avoidable. It stressed numerous clinical deficiencies on the part of the medical teams responsible for these patients including a lack of awareness and knowledge of AKI. There was an unacceptable delay in recognising post admission AKI in 43% of patients and 33% of patients had inadequate investigations. The omissions included basic clinical examination and simple laboratory tests. The report showed there is much work to be done to ensure AKI is recognised and prevented. A number of recommendations were proposed including the incorporation of postgraduate training in the detection, prevention and management of AKI in all specialities. The UK Renal Association has also stressed the pressing need for renal physicians to engage in educational programmes to improve the current management of AKI.

er of recommendations were proposed including the incorporation of postgraduate training in the detection, prevention and management of AKI in all specialities. The UK Renal Association has also stressed the pressing need for renal physicians to engage in educational programmes to improve the current management of AKI. An example of good AKI practice is The London Acute Kidney Injury Network (4). Launched in 2009 it is an ambitious collaboration of healthcare professionals and organisations involved in acute kidney care throughout London. It has published AKI educational materials, guidelines, pathways and care bundles and is developing AKI electronic alerting. Baseline A baseline audit was undertaken in the Ulster hospital in December 2011, with the goal of identifying AKI incidence, recognition and management. All adult Accident and Emergency (A&E) non-surgical admissions during a one week period in September 2011 were included. A review of the electronic laboratory database identified AKI episodes in this cohort. AKI was defined according to KDIGO (Kidney Disease: Improving Global Outcomes) criteria as a rise in serum creatinine of greater than 26umol/l or a 50% rise in creatinine from baseline. Baseline creatinine values were taken as the lowest recorded value in the twelve months prior to admission. Admission creatinine was the highest recorded during admission.

idney Disease: Improving Global Outcomes) criteria as a rise in serum creatinine of greater than 26umol/l or a 50% rise in creatinine from baseline. Baseline creatinine values were taken as the lowest recorded value in the twelve months prior to admission. Admission creatinine was the highest recorded during admission. 307 acute adult admissions from A&E were identified. 16.3% (50/307) developed AKI, but were recognised within 24 hours in only 31% of cases. Basic steps to ameliorate AKI (actions including urinalysis, commencing fluids, medication review, ultrasound imaging) were implemented in only 20%. The aim of this quality improvement project was therefore to: 1) Improve early recognition of warning signs of AKI: a rise in serum creatinine, urine output of <500mls in 24 hours and systolic blood pressure of <90mmHg. (Target 80%). 2) Design a simple ABCDE checklist (see below) for AKI management. (50% AKI cases should have 80% of checklist actions considered). Design The pilot project was launched in March 2012 in a thirty bed surgical ward. Introductory teaching sessions were delivered first to doctors and then nurses, nursing assistants and pharmacists. On revisiting the ward two weeks later, it was clear that the warning signs and checklist were not in use and there was improvement in neither AKI recognition nor management. Expectations had been overly ambitious with too much information delivered too quickly. To create a change in practice it was clear that introduction of the above measures and checklist principles would need to be delivered in a staged manner.

in use and there was improvement in neither AKI recognition nor management. Expectations had been overly ambitious with too much information delivered too quickly. To create a change in practice it was clear that introduction of the above measures and checklist principles would need to be delivered in a staged manner. Strategy After this important lesson the delivery of the project was modified. A four week programme was introduced with short informal weekly teaching sessions used to train ward staff. One week was dedicated to each of the three warning signs and a final week to introduce the ABCDE checklist. Data was collected on each outcome, and the end of weeks 1, 2, 3 and 4. Immediate feedback to the MDT and two way discussion allowed us to constantly adjust the way we delivered teaching, collected data and modified the checklist before achieving a final list that was both user friendly and achievable. (See supplementary file for poster used). The renal team visited the ward several times per week in order to promote the project, encourage participation, answer questions and feedback results.

Strategy After this important lesson the delivery of the project was modified. A four week programme was introduced with short informal weekly teaching sessions used to train ward staff. One week was dedicated to each of the three warning signs and a final week to introduce the ABCDE checklist. Data was collected on each outcome, and the end of weeks 1, 2, 3 and 4. Immediate feedback to the MDT and two way discussion allowed us to constantly adjust the way we delivered teaching, collected data and modified the checklist before achieving a final list that was both user friendly and achievable. (See supplementary file for poster used). The renal team visited the ward several times per week in order to promote the project, encourage participation, answer questions and feedback results. Positive audit results from the pilot project (see supplementary files) were followed by roll out of the project first across all surgical wards with 120 beds (August-September 2012) and the medical admissions unit (MAU) with 40 beds (October-November 2012). The project was launched each time with teaching sessions introducing and increasing awareness of the project. The project was then delivered in a similar manner in both these patient areas as described above. Data collection methods differed, sampling being used in the surgical directorate wards and total numbers used on the MAU. See supplementary file: Charts.docx

Positive audit results from the pilot project (see supplementary files) were followed by roll out of the project first across all surgical wards with 120 beds (August-September 2012) and the medical admissions unit (MAU) with 40 beds (October-November 2012). The project was launched each time with teaching sessions introducing and increasing awareness of the project. The project was then delivered in a similar manner in both these patient areas as described above. Data collection methods differed, sampling being used in the surgical directorate wards and total numbers used on the MAU. See supplementary file: Charts.docx Post-Measurement Two months post induction AKI recognitionwas 80%. At three months AKI recognition was 100%. 80% checklist compliance was achieved in 67% of AKI cases. Similar success with the project was observed across the surgical directorate and MAU. Surgical directorate had an AKI recognition of 100% and 80% checklist compliance was achieved in 75% of AKI cases. On MAU AKI recognition was 100%. 80% checklist compliance was achieved in 83% of AKI cases. (See supplementary file for run chart illustrating Recognition of Acute Kidney Injury and Action Taken).

Post-Measurement Two months post induction AKI recognitionwas 80%. At three months AKI recognition was 100%. 80% checklist compliance was achieved in 67% of AKI cases. Similar success with the project was observed across the surgical directorate and MAU. Surgical directorate had an AKI recognition of 100% and 80% checklist compliance was achieved in 75% of AKI cases. On MAU AKI recognition was 100%. 80% checklist compliance was achieved in 83% of AKI cases. (See supplementary file for run chart illustrating Recognition of Acute Kidney Injury and Action Taken). Lessons and Limitations This project clearly demonstrates that complicated measures are not necessary to improve standards. Simple interventions can successfully enhance patients' quality of care. The renal team was struck by the willingness of all MDT members to be educated and empowered to improve patient safety and experience. The valuable contribution of every member in obtaining successful results should not be underestimated; for example often it was nursing assistants who measured blood pressure and urine output and were consequently first to highlight positive warning signs to the rest of the team.

improve patient safety and experience. The valuable contribution of every member in obtaining successful results should not be underestimated; for example often it was nursing assistants who measured blood pressure and urine output and were consequently first to highlight positive warning signs to the rest of the team. It was clear from the outset however, that if staff were to incorporate changes into daily practice, that these should be introduced gradually. Implementing this initiative therefore takes time. Consecutive weeks were taken within wards to train the team on one aspect of care for improvement at a time. Engagement of the renal team with ward staff was of fundamental importance. It required enthusiasm, motivation and sustained effort to maintain project momentum. Several ward visits were beneficial to allow interaction with as many staff as possible because of shift patterns. Staff responded well to encouragement, praise and immediate feedback of positive results, which enabled them to engage and take ownership of the project on their own wards. The project's positive results were publicised throughout the hospital at directorate, audit and management meetings. The Northern Ireland Medical and Dental Training Agency expressed interest in including the checklist in their generic training AKI module for all junior doctors in Northern Ireland. The Trust has further endorsed the project by including it in their Quality Improvement Plan for 2012–2013 and consequently, a dedicated Quality Improvement Team has now been established in order to effect trust wide delivery.

he checklist in their generic training AKI module for all junior doctors in Northern Ireland. The Trust has further endorsed the project by including it in their Quality Improvement Plan for 2012–2013 and consequently, a dedicated Quality Improvement Team has now been established in order to effect trust wide delivery. Although this study demonstrates significant improvements in recognition and initial management of AKI, it has not yet demonstrated a reduction in AKI incidence or length of hospital stay. Our aspiration is that with increased and sustained compliance with the ABCDE checklist, including implementation in Accident and Emergency, that in time improvements in these outcome measures may be realised. Conclusion AKI has significant implications for patients and health care providers. Early recognition and action is critical to potentially ameliorate its course and facilitate timely referral to specialist services. Prevention and treatment of AKI should be a core competency for all clinical staff irrespective of profession or speciality. Educating and empowering the multidisciplinary team improves standards and should be the cornerstone of strategies aimed at addressing AKI. To improve identification, management and outcomes a systematic approach is required. The introduction of simple orderly interventions (three early warning signs and a logical management checklist) ensures AKI is considered and that basic clinical care is always delivered through a co-ordinated multidisciplinary approach.

improve identification, management and outcomes a systematic approach is required. The introduction of simple orderly interventions (three early warning signs and a logical management checklist) ensures AKI is considered and that basic clinical care is always delivered through a co-ordinated multidisciplinary approach. Parallel initiatives will no doubt further enhance our performance, e.g. National implementation of E-warning systems for early recognition of AKI. However, our message is simple and relies upon the fundamental principles of communication, sharing and empowerment. Through this study significant improvements have been demonstrated in AKI recognition and management, positively impacting on patient safety, quality of care and the experience of both patients and staff. Supplementary Material Web supplement

Problem An on-going audit on medication reconciliation, comparing the medical, surgical and trauma and orthopaedics wards in a district general hospital in Belfast, Northern Ireland, highlighted consistently lower medication reconciliation statistics in surgery compared with the rest of the hospital. Although there were no reports of critical incidents occurring this could still have serious implications for patients, with an increased risk of preventable adverse drug events (pADE), for example, the accidental omission of a drug during the admission process, or failing to restart at discharge an essential drug which was temporarily stopped prior to surgery. The risk of this increases further with the high patient turnover in surgical wards and polypharmacy in elderly populations. Background Medication errors are the leading cause of injury to hospital patients, resulting in increased morbidity and mortality and prolongation of hospital stay. (1) Half of all errors occur at the interface of care, with the majority being omission of a drug. (2) Guidance outlining ways to reduce the risk of medication error at care interfaces was published in 2006 by the Royal Pharmaceutical Society of Great Britain and since then multiple organisations, including the National Institute for Health and Clinical Excellence and the National Patient Safety Agency, have published documents aimed at highlighting the need for improvement in medication reconciliation. (3,4,5)

ed in 2006 by the Royal Pharmaceutical Society of Great Britain and since then multiple organisations, including the National Institute for Health and Clinical Excellence and the National Patient Safety Agency, have published documents aimed at highlighting the need for improvement in medication reconciliation. (3,4,5) Medication reconciliation is the process whereby the most accurate list of a patient's medications is created, including drug name, dosage, frequency and administration route. This is then compared to the admission, transfer or discharge documentation, discrepancies are identified and changes documented, resulting in a complete and accurate list. (6) Baseline Measurement From July 2010 a monthly audit was performed assessing medication reconciliation in medicine, surgery and trauma & orthopaedics in the Ulster Hospital. Twenty patients' notes were audited per month in each specialty. Notes were picked at random across the wards and checked to see if medications had been reconciled within 24 hours of admission. Surgery consistently performed below the rest of the hospital with an average medication reconciliation of 60% compared with approximately 80% for the rest of the hospital. See supplementary file: Baseline Measurements.pdf

Baseline Measurement From July 2010 a monthly audit was performed assessing medication reconciliation in medicine, surgery and trauma & orthopaedics in the Ulster Hospital. Twenty patients' notes were audited per month in each specialty. Notes were picked at random across the wards and checked to see if medications had been reconciled within 24 hours of admission. Surgery consistently performed below the rest of the hospital with an average medication reconciliation of 60% compared with approximately 80% for the rest of the hospital. See supplementary file: Baseline Measurements.pdf Design Following the new design of the MOA form, a trial was carried out amongst junior doctors to test how it compared with the previous version. Feedback received was positive for the most part, with it described as easier to use and understand. However many users stated that the main problem was not the form, but convincing junior staff to seek out and complete extra paperwork on top of an already busy schedule. Strategy Using the feedback from our initial cycle the team decided to create a surgical admissions proforma. This would combine all documentation needed for admission as was already the case in the medical wards. Over the next month this was developed and a pilot commenced on one of the elective surgical wards. The process measures identified the majority of admissions were performed by junior staff; this information was used to target education at this population to help improve compliance.

ready the case in the medical wards. Over the next month this was developed and a pilot commenced on one of the elective surgical wards. The process measures identified the majority of admissions were performed by junior staff; this information was used to target education at this population to help improve compliance. Post-Measurement Results were gathered on a monthly basis, allowing the intervention and performance of further PDSA cycles as necessary to improve the chance of reaching the previously outlined objective. The main outcome measure was percentage patients with all medicines reconciled within 24 hours of admission. Further to this there were process measures that would help target any further interventions that might be needed. These included; who was the admitting clinician, was the MOA form filled in, was allergy status completed and was the source of medication history indicated? Twenty charts were audited per month in the pilot ward, five per week, chosen at random. This was then compared with the rest of the surgical wards. In the first month after implementation of the proforma, medication reconciliation increased from 60% to 80%. This trend continued, with the pilot ward consistently outperforming the rest of the surgical wards.

the pilot ward, five per week, chosen at random. This was then compared with the rest of the surgical wards. In the first month after implementation of the proforma, medication reconciliation increased from 60% to 80%. This trend continued, with the pilot ward consistently outperforming the rest of the surgical wards. However, after the six months the pilot ward failed to meet the target of 95% medication reconciliation, instead achieving a maximum of 85%. A number of contributing factors led to this, including the fact that not all admissions on the pilot ward used the proforma, but were still included in data collection due to randomisation. When looking specifically at data for when the proforma was used it was noted to have 100% medication reconciliation over two consecutive months. Lessons and Limitations 1. Having a multidisciplinary team involved in the project is key to success. There are many barriers to overcome but involvement of the whole team can help to limit these, such as nursing staff on the wards to ensure proformas are available for use, doctors to gain permission for pilot from senior staff and to educate colleagues and pharmacy to help in the design and assessment of interventions. 2. Difficulties were noted around the time of changeover for junior doctors; a dip can be noticed in the statistics. This could have been overcome with a short induction session to educate the staff in the use and importance of the proforma.

Lessons and Limitations 1. Having a multidisciplinary team involved in the project is key to success. There are many barriers to overcome but involvement of the whole team can help to limit these, such as nursing staff on the wards to ensure proformas are available for use, doctors to gain permission for pilot from senior staff and to educate colleagues and pharmacy to help in the design and assessment of interventions. 2. Difficulties were noted around the time of changeover for junior doctors; a dip can be noticed in the statistics. This could have been overcome with a short induction session to educate the staff in the use and importance of the proforma. 3. Having varied admission practice over the numerous surgical wards made it increasingly difficult to ensure proper completion of the admissions proforma on the pilot ward. Conclusion Medication reconciliation was noted to be considerably lower in surgery for over a year with little improvement of any interventions thus far, with a medication on admissions form that many did not understand and most did not use. This was putting many patients at risk of preventable adverse drug events. What started off as an analysis into the cause of underperformance slowly became a myriad of solutions which were implemented over a number of months; the skill mix in the team allowed effective critique of what would and wouldn't work, and as mentioned in previous projects, the engagement of a senior management figure has provided a link to allow change to become implemented successfully.

y became a myriad of solutions which were implemented over a number of months; the skill mix in the team allowed effective critique of what would and wouldn't work, and as mentioned in previous projects, the engagement of a senior management figure has provided a link to allow change to become implemented successfully. The initial target of 95% medication reconciliation was not achieved in the assigned 6 month timeframe. Nevertheless, significant improvements could be noted with the introduction of the admissions proforma. Looking at the results, the rate of medicines reconciliation on the pilot ward was 100%, when the proforma was utilised, for two consecutive months. However, when including non-proforma admissions this rate fell to 85%. This was interpreted as a demonstration of the effectiveness of the documentation and further confirms the need for standardisation across all specialties to reduce prescribing errors. It also indicates the need for further encouragement to be given to admitting physicians to utilise the documentation. Following this audit, the trust has implemented standardised admission documentation in all specialties throughout its hospitals. Despite the success of the project, work must continue to educate medical staff, who rotate between all trusts throughout Northern Ireland on a regular basis, to ensure the continuity of high standards achieved thus far. One possible solution for this would be regional standardisation of admission documentation which can hopefully be achieved in the near future.

Problem St Peter's hospital (SPH), Chertsey, England is a 400-bed district general hospital providing a range of acute care services including Accident and Emergency. Whilst there is a robust handover of acute surgical admissions twice a day, no system exists for inpatients at weekends, some of which have complex surgical and medical pathologies. Furthermore, at weekends, there is a reduced workforce to review general surgical patients and to manage new acute general surgical admissions. The clinical care for inpatients may subsequently be compromised by lack of knowledge of the patient, their reason for admission and their comorbidities (1). The aim of this quality improvement project was to create a robust handover system for general surgical patients over the weekend. We evaluated handover before and after the introduction of a paper handover tool created to improve patient safety. Background The European Working Time Directive and economic challenges have led to a paradigm of shift-work becoming common, and yet the continuation of high-quality patient care remains paramount. Many incidents in the clinical environment have been attributed to communication breakdown. Effective and safe transfer of clinical information is critical as emphasised by the Royal College of Surgeons (2). Clinical handover provides a platform to facilitate the continuity of patient information transfer and helps identify and anticipate potential problems for the forthcoming shift. However, handovers are largely informal and the quality is variable and at worst can compromise patient care.

Royal College of Surgeons (2). Clinical handover provides a platform to facilitate the continuity of patient information transfer and helps identify and anticipate potential problems for the forthcoming shift. However, handovers are largely informal and the quality is variable and at worst can compromise patient care. Baseline This project was performed at St Peter's hospital and involved upper gastrointestinal, colorectal, breast and vascular surgery. Registrars, senior house officers, house officers (FY1-FY2) and nursing staff were involved. Pre-intervention data was compiled assessing the proportion of patients with a documented weekend handover. An online questionnaire was sent to all current surgical trainees of all levels of experience (from FY1 to registrars) to gauge their confidence in performing weekend responsibilities that involved managing patients on the ward, their understanding of patient clinical information during the weekend and their estimated duration of weekend ward-rounds. A 65% response rate was achieved. Opinions from nursing staff were sought to gain comprehensive insight. Quantitative data detailing the proportion of weekend patients being discharged was obtained.

eir understanding of patient clinical information during the weekend and their estimated duration of weekend ward-rounds. A 65% response rate was achieved. Opinions from nursing staff were sought to gain comprehensive insight. Quantitative data detailing the proportion of weekend patients being discharged was obtained. Results showed that only 35% of patients had a weekend handover sheet. The more junior surgical trainees (FY1 to core surgical trainees) lacked confidence in executing clinical care and took a long time in executing clinical tasks and occasionally did not understand the clinical situation of the patient. Weekend ward-rounds took more than 3.5 hours on average with less than 5% of surgical patients being discharged over the weekend. Almost 100% of respondents agreed that a proforma with specifically defined categories should be introduced to improve the weekend ward-round. Design Following analysis of the questionnaires, consultation with senior colleagues and a nursing and doctor forum, a weekend handover proforma was created (figure1). The handover proforma includes a ‘traffic light’ code system to visually highlight the clinical urgency for the patient to be reviewed over the weekend: RED: Patient must be reviewed, patient at risk YELLOW: Patient stable but not ready for discharge over the weekend GREEN: Patient is medically fit, social/other issues are prohibiting discharge. BLUE: Patient can be discharged over the weekend.

The handover proforma includes a ‘traffic light’ code system to visually highlight the clinical urgency for the patient to be reviewed over the weekend: RED: Patient must be reviewed, patient at risk YELLOW: Patient stable but not ready for discharge over the weekend GREEN: Patient is medically fit, social/other issues are prohibiting discharge. BLUE: Patient can be discharged over the weekend. All blue-coded patients must have discharge summaries completed by the patient's host team, therefore reducing the burden on the on-call team and providing an accurate summary of the inpatient stay. The aim of the text spaces for admission summary, patient history and potential concerns, investigations and radiology were to provide the assessing doctor with information about the patient ‘at a glance’. The text box entitled ‘jobs’ allowed the patient's usual team to communicate the clinical tasks needed to be completed for the patient over the weekend.

on summary, patient history and potential concerns, investigations and radiology were to provide the assessing doctor with information about the patient ‘at a glance’. The text box entitled ‘jobs’ allowed the patient's usual team to communicate the clinical tasks needed to be completed for the patient over the weekend. Strategy An educational session aided introduction of the handover and aimed to encourage the junior doctors to complete the handover proforma for each patient on a Friday, ready for the weekend. Verbal, email, and poster communication as well as consultant support ensured appropriate advertising of the proforma. Following the pre-intervention questionnaire a pilot trial was performed over 4 weekends. A post-intervention questionnaire was sent out to surgical doctors. The number of weekend patients being discharged over the weekend before and after the intervention was obtained. Results of the intervention were emailed to surgical doctors and suggestions for additional improvements were welcomed.

ed over 4 weekends. A post-intervention questionnaire was sent out to surgical doctors. The number of weekend patients being discharged over the weekend before and after the intervention was obtained. Results of the intervention were emailed to surgical doctors and suggestions for additional improvements were welcomed. Post-Measurement The results demonstrated that 85% of the surgical patients had a surgical proforma for the weekend on-call team post-intervention. 70% of respondents (n=21) were confident in understanding the patient's clinical condition and executed the clinical jobs faster (Figures 2,3). Weekend ward-rounds lasted less than 3 hours on average with 20% of patients successfully discharged every weekend, post-intervention. With these new changes, the principle problem relates to compliance and the accurate completion of the new handover proforma. A summary of the results pre- and post-quality improvement intervention are displayed in figure 4. See supplementary file: BMJ Safety-diagram results.docx

Post-Measurement The results demonstrated that 85% of the surgical patients had a surgical proforma for the weekend on-call team post-intervention. 70% of respondents (n=21) were confident in understanding the patient's clinical condition and executed the clinical jobs faster (Figures 2,3). Weekend ward-rounds lasted less than 3 hours on average with 20% of patients successfully discharged every weekend, post-intervention. With these new changes, the principle problem relates to compliance and the accurate completion of the new handover proforma. A summary of the results pre- and post-quality improvement intervention are displayed in figure 4. See supplementary file: BMJ Safety-diagram results.docx Lessons and Limitations The importance of accurate weekend handover is highlighted in a study by Freemantle et al (3) that looked into 14 million admissions to English NHS hospitals in the financial year of 2009/2010. 187,337 deaths occurred within 30 days of admission in England. When the authors looked at factors associated with risk they found that a patient admitted on a Sunday had 16% increased risk of dying following admission compared to a person admitted on a Wednesday. Whilst confounding factors exist, a significant cause is attributable to communication and handover. Handover is a fundamental part of modern surgery. We now work in shift patterns and precise handover is vital in protecting patient safety and improving clinical outcomes.

n compared to a person admitted on a Wednesday. Whilst confounding factors exist, a significant cause is attributable to communication and handover. Handover is a fundamental part of modern surgery. We now work in shift patterns and precise handover is vital in protecting patient safety and improving clinical outcomes. Junior doctors are in a unique position to experience first hand and assess the strengths and weaknesses of existing systems of management and can help provide a fresh outlook on existing problems. With resource limitations, leadership in a doctor's early career is becoming increasingly important to help change practice and is listed as part of good practice by the General Medical Council (4). As this project demonstrates, large and significant changes in practice led by junior doctors are possible without significant input from management or consultants. However, a successful initiative requires adequate education, repeated advertisement and at least some senior-level support for its implementation.

il (4). As this project demonstrates, large and significant changes in practice led by junior doctors are possible without significant input from management or consultants. However, a successful initiative requires adequate education, repeated advertisement and at least some senior-level support for its implementation. One limitation of this project is that the study commenced at the beginning of the training cycle for all junior surgical doctors and may have led to a potential bias of the results. Firstly because the majority of the junior doctors may have had reduced confidence levels even prior to the intervention, as many of them would have begun their first job post-graduation and hence unfamiliarity and compliance with completion of the forms may have been poor, contributing to possible skewed results. Consequently, this intervention will be revisited at the end of the rotational year. In the future, email reminders about the correct completion of the proforma will help maintain quality and compliance rates. Another learning point is that quality improvement projects are a dynamic process. Initially, the handover proforma was detailed and time consuming to fill in. We adjusted this following continuous feedback from trainees to make it simple and not too laborious. Following numerous modifications, the proforma sheet became a simple and easy form to fill in, whilst being detailed enough to serve its purpose. Another point to highlight is the average percentage of patients being discharged over the weekend (Figure 4). The results showed that during the four-week trial period, there was a marked increase in successful discharge but potential confounding factors such as higher proportion of day case patients may have contributed to these figures. It should be noted that a small sample was analysed and the period of the studies was short. Consequentially, it would be interesting to analyse the change over a longer period of time.

sful discharge but potential confounding factors such as higher proportion of day case patients may have contributed to these figures. It should be noted that a small sample was analysed and the period of the studies was short. Consequentially, it would be interesting to analyse the change over a longer period of time. Conclusion Our findings support the use of a surgical proforma by providing a consistent and structured approach to handover, coupled with an educational session. This allows transfer of information in a time-efficient manner (4,5). Furthermore, technological advances should be used as an adjunct to clinical effectiveness and have proven to provide better continuity of care than verbal/written handover (5,6,7). However, larger studies would be required to assess whether the changes enforced by the surgical proforma affect patient morbidity or mortality rates. Supplementary Material Web supplement

Problem Ashford & St Peter's Hospital NHS Foundation Trust is a District General Hospital in the South of England. It is located in the county of Surrey and has a significant elderly population. There are many patients with Parkinson's disease (PD) and the admission of these patients to hospital presents a number of challenges. Administration of PD medications needs to be carried out at a particular time and suboptimal delivery may result in motor and non-motor complications (1). This is consistent with the recent National Patient Safety Agency (NPSA) report (2). A significant proportion of inpatients across the nine medical wards audited at the hospital were prescribed the right dosage and frequency of Parkinson Disease (PD) medication over a two-week period. However, the timing of PD medication administration were in certain cases incorrect, for example, one patient's Co-Beneldopa 50/200mg dose was prescribed at 12:00 on their drug chart, but only given at 15:00. For another patient, their Rotigotine patch 4mg/24hrs was not given as it was unavailable and Sinemet 62.5mg prescribed on the drug chart was not given as the patient had become nil by mouth and no parenteral alternative had been prescribed. The possible reasons for incorrect administration of PD drugs include: existing guidelines not being well publicised or not being easily accessible via the Trust intranet; on acute admission, the most appropriate sources of information for drug doses and timings may not be easily available (e.g. GP); the patient may be confused and unable to provide this information.

of PD drugs include: existing guidelines not being well publicised or not being easily accessible via the Trust intranet; on acute admission, the most appropriate sources of information for drug doses and timings may not be easily available (e.g. GP); the patient may be confused and unable to provide this information. On discussion with nursing staff, we found that staff may forget specific times to administer medication due to multitasking. Additionally, there are often delays with the provision and delivery of drugs to the admitting ward on first admission, which may be attributed to the reasons above. Despite the presence of a ward pharmacist who may be able to clarify questions concerning types of PD medications available and their subsequent action, queries requiring specific clinical expertise in the acutely admitted medical patient with PD are often delayed due to the lack of an in-hospital specialist nurse to whom questions may be referred, and the PD specialist physician may not be available to answer queries immediately. The inexperience of junior doctors and lack of awareness of help available may also impact on quality of care. The majority of doctors surveyed were unaware of existing PD guidelines, and were not confident in converting PD medication from oral to non-oral formulation. Understandably, this delays any necessary conversions until after a specialist review has happened.

areness of help available may also impact on quality of care. The majority of doctors surveyed were unaware of existing PD guidelines, and were not confident in converting PD medication from oral to non-oral formulation. Understandably, this delays any necessary conversions until after a specialist review has happened. Background PD patients are regular health care service users. Highlighted in the campaign by Parkinson's UK, these patients usually come into hospital for primarily non-Parkinson's issues, and struggle to get medication on time (1). As inpatients, omitted medication doses may adversely affect patient experiences, and increase duration of hospital stay. A recent NPSA report (3) stated that omitted or delayed PD medications has led to reduced symptom control. Our project aims to look at the current practice in hospital, uncover challenges staff face with PD drug formulation and administration and find ways in which to improve it.

and increase duration of hospital stay. A recent NPSA report (3) stated that omitted or delayed PD medications has led to reduced symptom control. Our project aims to look at the current practice in hospital, uncover challenges staff face with PD drug formulation and administration and find ways in which to improve it. Baseline We analysed PD medication delivery to patients on general medical wards over two weeks. We reviewed drug charts as well as doctors notes available on the wards to find out PD medications prescribed and delivered, sources used by junior doctors to prescribe and how change in a patient's clinical condition altered prescription of PD medication. They were followed up daily and medication changes were tracked. We recorded drug formulation, frequency and time, and compared them to their previous regime obtained from a number or sources. These sources included recent discharge summaries, clinical letters, telephone conversations with patients' GPs regarding their PD medication and in-person interviews with patient and relatives. The sources used varied from patient to patient depending on the availability of information. For example, in the event that the patient or relative could not provide information regarding PD medication, a recent discharge summary or clinical letter was used. If the latter did not provide sufficient information, the GP was contacted. Of the 13 PD patients identified, two were newly-diagnosed and therefore excluded from analysis. Of the remaining 11 patients, there were 28 prescriptions for PD medications. Three prescriptions were newly-started, and we could not compare two other prescriptions as old notes were not available (together 18%). Of the remaining 23 prescriptions, 12 (43%) were accurate to drug type, frequency, and time. 11 (39%) were correct drug types and frequency, but not time. This is illustrated in Fig.1. Amongst this cohort of patients, we identified 2 nil-by-mouth (NBM) patients for which non-oral routes of PD medication were administered correctly, but it was unclear how the non-oral route conversions were calculated. We surveyed 32 junior doctors (FY1 and SHOs) to assess the challenges they faced with the acutely admitted PD patient.

t of patients, we identified 2 nil-by-mouth (NBM) patients for which non-oral routes of PD medication were administered correctly, but it was unclear how the non-oral route conversions were calculated. We surveyed 32 junior doctors (FY1 and SHOs) to assess the challenges they faced with the acutely admitted PD patient. We discussed with the pharmacists what they considered to be good sources to obtain dose and frequency information, and designated the patients' GP and the patients themselves to be good sources, whilst old TTOs and the pharmacy were less appropriate as the information may be out-of-date or not available. We also assessed whether junior doctors knew the consequences of missed Parkinson's medications: 91% recognised reduced mobility, 81% recognised increased falls and 75% recognised increased anxiety. We asked whether they were confident to change the formulation of medications, for example from oral to naso-gastric tube or parenteral forms. Only 25% were confident to do so. Only 13% of the doctors were aware of the existence of trust guidance. We also elicited the opinions of nursing staff regarding the barriers to effective delivery of PD management. Nursing staff expressed that it was often difficult to give PD medications at the right time due to multitasking and having to remember specific timings of PD medication delivery. Delay in doctors converting oral to non-oral formulations when patients become nil by mouth was also cited as a reason for delayed PD delivery in addition to practical difficulties such as time taken for PD medication to be delivered to the ward once it had been ordered following patient admission.

medication delivery. Delay in doctors converting oral to non-oral formulations when patients become nil by mouth was also cited as a reason for delayed PD delivery in addition to practical difficulties such as time taken for PD medication to be delivered to the ward once it had been ordered following patient admission. See supplementary file: userfiles-Figure 1.docx Design Our interventions included: 1. Discussion with ward-based medical teams and a poster on where to obtain up-to-date information on timings of medications 2. Enlisting help from ward pharmacists to ensure medications were administered correctly 3. Summarising, publicising, and distributing an updated Trust guideline. To create this summary guideline, we reviewed the existing guidelines and simplified the conversion of oral to nasogastric and parenteral formulation. We also included hints and tips on general PD management. Strategy To promote our project, PD summary guideline and highlight patient safety within the context of PD management, we have presented our work during a foundation (FY1) teaching session and at the hospital Grand Round. Given the amount of time we had to carry out this quality improvement project, we were only able to undertake a single PDSA cycle. Whilst our interventions demonstrated improvements in the majority of areas we looked at, there is plenty of scope for improvement and subsequent PDSA cycles using our interventions will hopefully yield even better results.

carry out this quality improvement project, we were only able to undertake a single PDSA cycle. Whilst our interventions demonstrated improvements in the majority of areas we looked at, there is plenty of scope for improvement and subsequent PDSA cycles using our interventions will hopefully yield even better results. Post-Measurement Following our intervention, we repeated our audit after two months. Of the 14 patients with PD identified, two were omitted from analysis due to new diagnosis of PD. Of the remaining 12 patients, there were 33 prescriptions, 27 of which were accurately prescribed for time and frequency (82%), three that were inaccurate for time (9%) and three that we were unable to compare (9%). This is illustrated in Fig.2. We repeated our survey of junior doctors (F1-ST2) from the same cohort. Of the 24 junior doctors 79% would use the GP as a resource to prescribe the correct PD medication. However, only 62.5% would consider the patient to be a suitable resource. Despite our flyers posted across medical wards, detailing appropriate sources of information as a tool for junior doctors to guide correct prescribing, a large proportion would still use the old TTO (75%) and pharmacy (62.5%) to prescribe PD medication. In terms of resources used to prescribe medications at the right time, 71% of those surveyed cited pharmacy, 67% cited the patient, and 50% willing to use GP or the old TTO as a resource. The majority of junior doctors surveyed identified the potential consequences of failure to prescribe PD medications (96% increased falls, 100% reduced mobility, and 88% increased anxiety). 42% were aware of the existence of current PD management guidelines. 42% of doctors were confident to convert formulation of medication from oral to other forms. The accuracy of PD prescriptions from round one and two improved from 43% to 82%. This may reflect increased doctors' awareness of the importance of prescribing at the right time and the right dose. Multiple factors may have contributed to this: our multifaceted interventions, early involvement of the specialist PD consultant, and increased vigilance surrounding PD medication management by pharmacists and nursing staff.

eased doctors' awareness of the importance of prescribing at the right time and the right dose. Multiple factors may have contributed to this: our multifaceted interventions, early involvement of the specialist PD consultant, and increased vigilance surrounding PD medication management by pharmacists and nursing staff. See supplementary file: userfiles-Figure 2.docx Lessons and Limitations We have learnt a number of things from carrying out this quality improvement project. i. Healthcare professionals have a limited knowledge base around Parkinson's disease, which is considered a sub-specialist area and often treated as such. The ramifications of incorrect management from the perspective of giving a Parkinson's patient their medication later than it is due are severe and often not fully appreciated. ii. Despite the introduction of interventions to help junior doctors identify the best sources from which to gain medication information for Parkinson's patients, sub-optimal sources were still being identified with and used. Our work needs to go through some further PDSA cycles to establish an intervention which makes it easy for junior doctors to obtain this information as well as ensuring that it is sustainable. iii. Although we demonstrated an improvement in prescription of medications, change takes time to embed within an organisation. iv. Junior doctors may choose the path of least resistance, i.e. do things in the most convenient way possible for them, which may not always be best for the patient.

ii. Despite the introduction of interventions to help junior doctors identify the best sources from which to gain medication information for Parkinson's patients, sub-optimal sources were still being identified with and used. Our work needs to go through some further PDSA cycles to establish an intervention which makes it easy for junior doctors to obtain this information as well as ensuring that it is sustainable. iii. Although we demonstrated an improvement in prescription of medications, change takes time to embed within an organisation. iv. Junior doctors may choose the path of least resistance, i.e. do things in the most convenient way possible for them, which may not always be best for the patient. v. Conversion of oral to non-oral routes for medications was something which healthcare staff found particularly difficult despite having a guideline. A potential solution may be to have an online tool which facilitates this. vi. Inpatient management needs a multi-disciplinary team and without it, patients may come to harm. Conclusion This project focused on the medical aspects of PD medication management: prescriptions, the frequencies and formulations of the different medications, awareness of where to seek help, and the consequences of missing medications. It has not looked at other aspects, such as improving availability of the various formulations of medications, and the delivery of medications by nursing staff at the right time.

the frequencies and formulations of the different medications, awareness of where to seek help, and the consequences of missing medications. It has not looked at other aspects, such as improving availability of the various formulations of medications, and the delivery of medications by nursing staff at the right time. Our survey indicates that despite our interventions, junior doctors continue to rely on suboptimal sources of information for type and timing of PD medications. We have shown an improvement in the awareness of trust guidance, and confidence in conversion of oral to non-oral PD medication formulations. However, the overall proportions aware of guidance and confident to switch formulations remain low. There has been an improvement in the awareness of the consequences of medication omission. However, the awareness of lesser-known psychological consequences remains lower than physical consequences. Supplementary Material Web supplement Web supplement

Problem During the first few weeks on a busy Respiratory/General Medical ward at Ashford and St Peter's NHS Foundation Trust, Chertsey, UK, multiple telephone calls were received both from patients and General Practitioners. They were enquiring as to when investigations or appointments (interventions) were going to happen for recent discharges. It quickly became apparent that despite interventions being listed on the discharge summary they were not all requested or booked. This could lead to missed investigations, undiagnosed illness, investigations not being followed-up or lack of appropriate specialist input for chronic diseases. Ultimately this may lead to poor patient care and impact on patient safety.

tions being listed on the discharge summary they were not all requested or booked. This could lead to missed investigations, undiagnosed illness, investigations not being followed-up or lack of appropriate specialist input for chronic diseases. Ultimately this may lead to poor patient care and impact on patient safety. There were also incidents on the surgical assessment unit (SAU) when there was a period of time with no ward clerk. This led to no follow-up appointments being booked for any patient discharged from SAU for approximately six weeks. The problem was finally acknowledged and seniors were informed. It was then agreed amongst the doctors that the junior doctors would liaise directly with secretaries to arrange appointments but it quickly became apparent that there were problems outside of normal working hours when secretaries were unavailable. One example is as follows: a patient was discharged after being admitted with abdominal pain thought to be due to gallstones. She was supposed be seen in outpatients to get the results of her investigations but did not, and subsequently was not listed for a cholecystectomy. She presented again to the Accident & Emergency department with pain and was admitted to the ward. A follow-up appointment would have prevented this repeat admission and would have alleviated the pain caused to this patient. This highlighted that when clerical staff are away, or there are vacant posts, there is a need for an alternative system to enable follow-up appointments to be requested and booked. Junior doctors are always present and, as those responsible for producing discharge summaries, are well placed to request such appointments.

is highlighted that when clerical staff are away, or there are vacant posts, there is a need for an alternative system to enable follow-up appointments to be requested and booked. Junior doctors are always present and, as those responsible for producing discharge summaries, are well placed to request such appointments. Background During induction to the hospital for incoming foundation doctors, there was no formal guidance about arranging follow-up interventions. It was relied upon the senior doctors more familiar with the hospital systems to pass on information to the new doctors. It was generally accepted on the medical ward that the ward clerk would arrange follow-up appointments and doctors would organise investigations. It was well known that the task of compiling the discharge summaries fell to the most junior members of the team (often without appropriate guidance from seniors). For example, all those admitted with an infective exacerbation of COPD should be referred to the respiratory care team on discharge and be seen in the respiratory clinic within four weeks of discharge with a chest x-ray on arrival. As junior doctors we would rely on senior colleagues to inform us of protocols such as this one. Decisions about follow up were made at the time the patient was being discharged and when the junior doctor was writing the discharge summary, so this would be the ideal time to put in follow up arrangements. However guidance was not always available and as junior doctors we proposed that more specific guidance was needed in this essential area to prevent poor follow-up.

atient was being discharged and when the junior doctor was writing the discharge summary, so this would be the ideal time to put in follow up arrangements. However guidance was not always available and as junior doctors we proposed that more specific guidance was needed in this essential area to prevent poor follow-up. Baseline Our online discharge summary programme was used to identify the last 20 patients discharged from the ward in October. Notes were screened retrospectively for all investigations or appointments that were desired upon discharge. These were recorded and compared with the discharge summary produced for that admission. Over the next 3–4 months the computer programmes; WinPath (a Laboratory Information Management System), Centricity (a radiology software programme) and PAS (a Patient Administration System), were used to find out if each intervention on the discharge summary had occurred, when, and how this compared to the desired time period on the discharge summary. Design The follow-up prompt sheet was introduced into the notes of all patients admitted onto the ward over a three week period after which a further 20 records from November were reviewed in the same way as detailed above. The follow-up prompt was a simple A4 sheet with space for patient details at the top and a table with the following headings; Speciality? Intervention? Within what time period?

admitted onto the ward over a three week period after which a further 20 records from November were reviewed in the same way as detailed above. The follow-up prompt was a simple A4 sheet with space for patient details at the top and a table with the following headings; Speciality? Intervention? Within what time period? The follow-up prompt sheet was placed at the back of the current admission medical notes and doctors were informed. Any visiting specialties were also introduced to the prompt and asked to utilise it as necessary. The sheet was filled-in throughout the admission and then used upon discharge to ensure that all interventions for each patient were requested/arranged in an appropriate time frame. Strategy Comparisons between the two sets of patients were made looking particularly at the number of interventions that made it to the discharge summary, the number that actually occurred and whether they happened in the desired time period stated on the discharge summary.

The follow-up prompt sheet was placed at the back of the current admission medical notes and doctors were informed. Any visiting specialties were also introduced to the prompt and asked to utilise it as necessary. The sheet was filled-in throughout the admission and then used upon discharge to ensure that all interventions for each patient were requested/arranged in an appropriate time frame. Strategy Comparisons between the two sets of patients were made looking particularly at the number of interventions that made it to the discharge summary, the number that actually occurred and whether they happened in the desired time period stated on the discharge summary. Post-Measurement The introduction of a follow-up prompt increased the number of interventions that were recorded on the discharge summary from 93.8% to 100% as derived from the comparison of the medical notes with the discharge summaries produced for that admission. The interventions on the discharge summary were divided into primary and secondary care. Of the secondary care interventions, successful follow-ups increased from 73% to 79%. Patients who were readmitted within the time frame specified for interventions to be performed within were excluded as this meant they were unable to attend appointments or the required interventions had to be expedited due to a change in clinical need. Those who did not attend appointments or refused to attend follow-ups were also excluded. On average 20% of follow-up arrangements on discharge summaries were requests to GPs recorded on the discharge summary in the section for GP action. These ranged from checking blood tests to arranging further investigations. 75% of blood tests were initially followed up appropriately and this increased to 100% with the introduction of the follow-up prompt. Mean time to follow-up was 26 days prior to the prompt (range 72) and 24 days after (range 58). The audit extended for more than three months after patients were discharged, a time frame within which all interventions listed should have occurred. The computer systems could also show any future appointments and this was also taken into consideration. Despite better follow up rates overall the percentage of patients that were followed-up within the expected time frame (as specified on the discharge summary) was 63.2% prior to the prompt but only 37.5% after. This may have been due to an increase in the number of interventions requested or unrealistic expectations of the current system's ability to meet demand. It should be noted that this was a small scale audit so this may be an anomaly.

ecified on the discharge summary) was 63.2% prior to the prompt but only 37.5% after. This may have been due to an increase in the number of interventions requested or unrealistic expectations of the current system's ability to meet demand. It should be noted that this was a small scale audit so this may be an anomaly. It is clear that not all patients require follow-up after an inpatient stay, 15% of patients did not have any follow-up listed prior to the follow up prompt compared with just 5% after. This may reflect that prior to the follow-up prompt some patients were discharged without any interventions arranged despite it being indicated clinically which could have lead to poor patient care. See supplementary file: Improving Patient Follow Up data.docx Lessons and Limitations Studies that use patient notes are time consuming, requiring organisation and patience. It was sometimes difficult to track notes down; they could be on a different site or in another department within the hospital. This project enforced the well-known need for accurate, legible documentation, as this was paramount for the data collection. The authors now have a better knowledge of the allocation of responsibility when it comes to arranging follow-up and realise just how important it is to have a good handover when starting a new job or specialty. Junior doctors need guidance about discharge plans from experienced colleagues and support from seniors when it comes to trying to make a long-lasting change to a current system. This support is vital when trying to bring about change.

st how important it is to have a good handover when starting a new job or specialty. Junior doctors need guidance about discharge plans from experienced colleagues and support from seniors when it comes to trying to make a long-lasting change to a current system. This support is vital when trying to bring about change. Conclusion Timely and appropriate patient follow-up is essential for the future care and safety of our patients following discharge. We have a duty, as doctors, to make sure that these arrangements are made and it is clear from this study that a change is needed in our current system. After discussions with colleagues, there was a consensus that an online system would be most appropriate and given the times at which patients are discharged and that doctors work, there is a need for access to appointments 24-hours a day. Supplementary Material Web supplement Web supplement

Problem Doctors working in follow-up outpatient clinics at Services Hospital, Lahore (Pakistan) have noted very poor levels of adherence to patient's TTO (‘to take home’) discharge medication regime given on previous admissions and clinics. The problem is particularly marked among the large illiterate patient population served by this hospital. This non-adherence can have serious implications for the patient's overall health outcome, with incorrectly taken medications potentially resulting in relapses of the patient's condition, medication dependence, drug resistance and potential accidental overdosing. Background Adherence is a concept defined by the World Health Organisation (WHO) as ‘the extent to which a person's behaviour in taking medication … corresponds with agreed recommendations from a healthcare provider’ (1). The consequences of non-adherence are potentially serious, ranging from failure to treat the patient's condition and drug resistance from under-dosing, to possible fatal toxicity if overdosing takes place. The WHO has identified five ‘dimensions’ of a patient's experience that can influence their adherence to medication regimes (1). These five ‘dimensions’ are – (i) their social/economic circumstances (including health literacy) (ii) factors relating the healthcare system itself (including information given out) (iii) the nature of the patient's underlying condition (lack of symptoms or mental health issues) (iv) factors relating to the therapy being prescribed (side effects, duration of therapy)

(i) their social/economic circumstances (including health literacy) (ii) factors relating the healthcare system itself (including information given out) (iii) the nature of the patient's underlying condition (lack of symptoms or mental health issues) (iv) factors relating to the therapy being prescribed (side effects, duration of therapy) (v) the physical and psychological factors relating to the patient themselves (for example, individual motivation or debilitating co-morbidities) The WHO estimates that there is around 50% non-adherence to treatment regimes for chronic conditions in the developed world (1) but that this figure is likely to be even worse in the developing world where factors from each of the above five ‘dimensions’ of non-adherence are likely to be exacerbated. The situation in Services Hospital, Lahore is illustrative of this. It is a large 1096 bed teaching hospital serving both a large local urban population and a rural population who attend from their villages many days travel away. The majority of patients are economically impoverished and many have very little formal education, and consequently health literacy and overall literacy levels are extremely low.

ed teaching hospital serving both a large local urban population and a rural population who attend from their villages many days travel away. The majority of patients are economically impoverished and many have very little formal education, and consequently health literacy and overall literacy levels are extremely low. In terms of primary healthcare there is only the most rudimentary general practitioner systems outside of secondary care hospitals. For the majority of patients their only access to healthcare advice is within the walls of the hospital itself. This makes patients’ understanding of their TTO (‘to take out’) discharge medication regimes crucial at the point of discharge as they have virtually no way of correcting any misunderstandings in terms of what they should be taking before they return for outpatient follow-up often several months down the line. Currently, upon discharge a patient is handed a handwritten TTO discharge prescription on a loose piece of paper (and most commonly in English) by the junior doctor on the ward and told to go to the hospital pharmacy to collect their medicines. A typical prescription might use abbreviations such as ‘Clarithromycin 500mg bd po 7/7’. A busy junior doctor may or may not have time to sit down and try to explain the discharge prescription to the patient.

n English) by the junior doctor on the ward and told to go to the hospital pharmacy to collect their medicines. A typical prescription might use abbreviations such as ‘Clarithromycin 500mg bd po 7/7’. A busy junior doctor may or may not have time to sit down and try to explain the discharge prescription to the patient. Then at one of the extremely busy hospital pharmacies a box or unlabelled strip of tablets are given to the patient without explanation of what the medicines are or how they are to take them. Patients then return to their homes, often rural villages with no healthcare professionals within hundreds of miles, with nothing other than the boxes of medications and the doctor's handwritten TTO discharge prescription. This is an extremely challenging situation for any patient to be in, and illiterate patients (who make up a very large percentage of the patient population) are forced to rely almost entirely on any verbal instructions they might have been given from the junior doctor on the ward. Some patients who are regular attenders have learnt to recognise the shape of certain medicine names on the prescription, whilst others receive some help back in their village from literate relatives or community members. Unsurprisingly outpatient clinic doctors report very poor levels of adherence on the patient's subsequent return to the hospital.

This is an extremely challenging situation for any patient to be in, and illiterate patients (who make up a very large percentage of the patient population) are forced to rely almost entirely on any verbal instructions they might have been given from the junior doctor on the ward. Some patients who are regular attenders have learnt to recognise the shape of certain medicine names on the prescription, whilst others receive some help back in their village from literate relatives or community members. Unsurprisingly outpatient clinic doctors report very poor levels of adherence on the patient's subsequent return to the hospital. Baseline For this improvement project we first wanted to establish the percentage of the hospital's patients who were illiterate and therefore would have difficulties in interpreting their TTO discharge medication prescriptions. We then wanted to establish four outcome measures – (i) the percentage of literate patients who could understand their TTO after an explanation from the junior doctor (‘counselling’) (ii) the percentage of literate who could understand their TTO without any counselling from the junior doctor (iii) the percentage of illiterate patients who could understand their TTO with counselling from the junior doctor (iv) the percentage of illiterate patients who could understand their TTO without any counselling from the junior doctor.

(ii) the percentage of literate who could understand their TTO without any counselling from the junior doctor (iii) the percentage of illiterate patients who could understand their TTO with counselling from the junior doctor (iv) the percentage of illiterate patients who could understand their TTO without any counselling from the junior doctor. We did this by selecting a random sample of 100 medical inpatients at Services Hospital and asked each of them to read a simple sentence written in Urdu (their first language) to establish whether or not they were literate. We found that overall 52% of patients were literate and 48% of patients were illiterate. We then showed each of the patients a typical example of a TTO discharge medication prescription. Through random selection, some patients received counselling as to what the TTO showed, whereas other patients were simply asked to interpret it themselves, thus reflecting the realities of the current situation as much as possible. The numbers of patients who were given counselling or otherwise are shown in Table 1. Each patient was then asked to explain back to the doctor the meaning of the TTO discharge prescription in terms of which drugs were prescribed, the dosages, what times of day they were to be taken, and the length of the course of treatment.

bers of patients who were given counselling or otherwise are shown in Table 1. Each patient was then asked to explain back to the doctor the meaning of the TTO discharge prescription in terms of which drugs were prescribed, the dosages, what times of day they were to be taken, and the length of the course of treatment. The results were that 93% of literate patients understood the TTO without any counselling and this figure rose to 100% of literate patients understanding the TTO when given counselling with it. Amongst illiterate patients only 5% understood the TTO without any counselling, and even with counselling only 12% of illiterate patients understood the TTO correctly. Extrapolating these percentages gives us a figure that 51% of the total patient population understand the TTO without counselling with this figure increasing to 58% of the total patient population understanding the TTO when counselling is given. Counselling the patient would therefore seem to be a worthwhile improvement. See supplementary file: Baseline measurement.docx Design Instead, the agreed intervention was to design a standardised TTO discharge medication prescription for the doctor to fill in and give to the patient to take home with them. This standardised form would be picture rather than word based. For example, instructions such as ‘bd’ and ‘tds’ could be replaced by pictures of a sun rising over the mountains to represent morning, and a moon and stars to represent night time.

for the doctor to fill in and give to the patient to take home with them. This standardised form would be picture rather than word based. For example, instructions such as ‘bd’ and ‘tds’ could be replaced by pictures of a sun rising over the mountains to represent morning, and a moon and stars to represent night time. Along with writing the names of medications on the form each medication could also be assigned an Arabic number (which the illiterate patients were able to read). Pharmacists could then be asked to write the equivalent number on the strip of tablets or box of tablets that they dispensed to the patient. That way, a patient would only have to recognise the number on the box of tablets rather than read the name of the medication. Posters could be produced to educate the pharmacists on this simple intervention. This intervention was felt to be effective for the following – (i) it would inexpensive to print out black and white standardised TTO discharge medication proformas in bulk (ii) the use of pictures rather than words on the form was more likely to make the form comprehensible to illiterate patients who could then keep the form as a reference point of the correct dosages/timings/length of treatment throughout their course of treatment (iii) the form could be easily edited should changes become desirable at a later date. (iv) the new form would not take any more time than the old system for the busy junior doctors

(ii) the use of pictures rather than words on the form was more likely to make the form comprehensible to illiterate patients who could then keep the form as a reference point of the correct dosages/timings/length of treatment throughout their course of treatment (iii) the form could be easily edited should changes become desirable at a later date. (iv) the new form would not take any more time than the old system for the busy junior doctors (v) the new system involves minimal co-operation from the pharmacists apart from writing the corresponding number for each medication from the form onto the box of tablets they are dispensing. The new standardised TTO discharge medication proforma was designed and following various revisions the final form was trialed among the same 100 medical inpatients previously shown a handwritten TTO. Strategy PDSA Cycle 1 An example of a TTO discharge medication regime using the new picture-based proforma was shown to a selection of illiterate patients and junior doctors involved in the discharge process in order to get their feedback. Whilst the illiterate patients liked and understood the use of the image of a sun rising and setting over the mountains to represent various times of day and night they were confused by the use of a calendar to represent the number of days that the treatment was to run for. A hospital pharmacist was shown the new discharge form and asked to label the medication boxes appropriately. He found the form easy to follow and understand.

Strategy PDSA Cycle 1 An example of a TTO discharge medication regime using the new picture-based proforma was shown to a selection of illiterate patients and junior doctors involved in the discharge process in order to get their feedback. Whilst the illiterate patients liked and understood the use of the image of a sun rising and setting over the mountains to represent various times of day and night they were confused by the use of a calendar to represent the number of days that the treatment was to run for. A hospital pharmacist was shown the new discharge form and asked to label the medication boxes appropriately. He found the form easy to follow and understand. PDSA Cycle 2 The form was redesigned using the symbol of the sun, rather than a calendar, to represent the number of days of treatment. Our illiterate patient sample group decided that whilst still not perfect, it was big improvement on the calendar, and that it was far more intuitively understood. We trialed the new proforma with a larger group of pharmacists this time asking them to correctly complete the labelling using only our educational poster as a guide. They were all able to do this without difficulty. See supplementary file: userfiles-Discharge PDSA cycles.pdf

PDSA Cycle 2 The form was redesigned using the symbol of the sun, rather than a calendar, to represent the number of days of treatment. Our illiterate patient sample group decided that whilst still not perfect, it was big improvement on the calendar, and that it was far more intuitively understood. We trialed the new proforma with a larger group of pharmacists this time asking them to correctly complete the labelling using only our educational poster as a guide. They were all able to do this without difficulty. See supplementary file: userfiles-Discharge PDSA cycles.pdf Post-Measurement We wished to measure the impact of the new TTO, so we showed each of the 100 medical patients used in the baseline measurement a sample of a new picture-based discharge regime and asked them to explain back to us the discharge medications, the dosages, the time of day they should take them, and the length of the course of treatment on that pro-forma. Patients were randomly selected to receive counselling. The results were as follows – - Literate patients who received counselling with the new proforma understood it 100% of the time (vs. 100% with the old handwritten TTO) - Literate patients who did not receive counselling with the new proforma understood it 100% of the time (vs. 93% with the old handwritten TTO) - Illiterate patients who received counselling with the new proforma understood it 35% of the time (vs. 12% with the old handwritten TTO) - Illiterate patients who did not receive counselling with the new proforma understood it 23% of the time (vs. 5% with the old handwritten TTO)

- Literate patients who did not receive counselling with the new proforma understood it 100% of the time (vs. 93% with the old handwritten TTO) - Illiterate patients who received counselling with the new proforma understood it 35% of the time (vs. 12% with the old handwritten TTO) - Illiterate patients who did not receive counselling with the new proforma understood it 23% of the time (vs. 5% with the old handwritten TTO) The new picture-based discharge proforma has markedly improved understanding of discharge medication regimes among illiterate patients. We demonstrated a relative increase in understanding of 192% among illiterate patients who received counselling and a relative increase of 360% among illiterate patients who were not counselled. See supplementary file: userfiles-Supporting_documents.pdf Lessons and Limitations 1) Improving patient care is possible in a short space of time with hard work and motivation. Introducing the first new picture-based discharge proformas took less than a week with a team of four junior doctors. 2) Engaging stakeholders is key in any quality improvement project. We knew that the senior staff would ultimately decide whether or not the proformas would be allowed to be used on their wards. Presenting the project to them together with evidence from repeated patient surveys allowed us to persuade and demonstrate the benefits of the pro forma winning their approval.

ovement project. We knew that the senior staff would ultimately decide whether or not the proformas would be allowed to be used on their wards. Presenting the project to them together with evidence from repeated patient surveys allowed us to persuade and demonstrate the benefits of the pro forma winning their approval. 3) Carrying out PDSA cycles as part of the design of the final proforma was a crucial step in increasing illiterate patients understanding of the discharge. Without these, a major flaw in the original design – that the symbol of a calendar was very poorly understood especially by rural villagers – would not have been picked up upon and subsequently redesigned. Conclusion The problem that we started with was that illiterate patients, who made up around half of the entire patient population, were being poorly served by the old discharge system. Illiterate patients were simply being handed a loose piece of paper containing a handwritten prescription by busy junior doctors. Illiterate patients were not only unable to read the names of the medication on the boxes but also were confounded by the handwritten prescription instructing them how to take their medicines.

literate patients were simply being handed a loose piece of paper containing a handwritten prescription by busy junior doctors. Illiterate patients were not only unable to read the names of the medication on the boxes but also were confounded by the handwritten prescription instructing them how to take their medicines. The picture-based discharge medication proforma which was developed along with hospital pharmacists numbering the boxes of medication was designed to combat this problem. The patient surveys seem to show success in this area with 23%–35% of illiterate patients understanding the new proforma (depending on the level of counselling given) versus only 5%–12% of illiterate patients understanding the old handwritten TTOs. The new proforma increased the number of illiterate patients who can understand their discharge medication threefold but it is important to recognise that there is still room for improvement. Even using the new proforma the majority of illiterate patients can still not understand the new system. The proforma will benefit from further reviews and by using patient feedback to maximise illiterate patients' comprehension of it as much as possible. For example, many patients found the use of a picture of the sun to represent the number of days of a course of treatment not immediately intuitive. We feel future improvements in the design of the form could be made in areas such as this.

edback to maximise illiterate patients' comprehension of it as much as possible. For example, many patients found the use of a picture of the sun to represent the number of days of a course of treatment not immediately intuitive. We feel future improvements in the design of the form could be made in areas such as this. Secondly if the ultimate aim of the project was to improve patients’ adherence to their medication regimes then we should remember that this project does not actually directly measure compliance at any stage. Whilst it seems reasonable that having a prescription that is better understood by vast illiterate patient population will improve overall adherence this is an assumption rather than evidence-based at present. Such a measurement would of course be fraught with difficulty due to the numerous influences on adherence. It is for similar reasons that we were unable to calculate the total resource savings for this project. Despite these difficulties it will be interesting to gather anecdotal evidence on the success of this project from doctors and patients in the future. We feel the innovation is likely to be of benefit to large numbers of patients, particularly in the illiterate population, and as such feel the project is applicable to other patient populations with low literacy rates elsewhere in the developing world. Supplementary Material Web supplement Web supplement Web supplement Web supplement

Problem Blood component transfusion can be a vital and lifesaving intervention when given appropriately. However transfusion is not risk-free, and therefore careful consideration of its clinical benefit for each individual patient is essential. Supply of blood components is a finite resource, relying on continuous public donation to maintain adequate stocks, as components have a limited period of viability. Blood and its various components is therefore an extremely valuable commodity, requiring careful allocation to maximise clinical benefit and avoid wastage. In 2008, we decided to look at our patterns of ED blood component use. This had not previously been studied in our ED, and more general information on the use of blood components and the characteristics of transfusion recipients was found to be limited [1–3]. A search of the literature using Medline revealed no information on the usage of blood components within UK EDs. We were also aware that in 2005, the ‘Blood Safety and Quality’ regulations were established stating that there must be full traceability of all aspects of the transfusion process from donor to recipient vein, maintained and available for 30 years [4]. Our performance in traceability had been poor over the previous couple of years however we had no information as to which components and which clinical conditions were involved. We also had no idea generally as to our pattern of blood component usage.

donor to recipient vein, maintained and available for 30 years [4]. Our performance in traceability had been poor over the previous couple of years however we had no information as to which components and which clinical conditions were involved. We also had no idea generally as to our pattern of blood component usage. Background The appropriate use of donor blood and its components, and effective alternatives is a much discussed public health issue, partly because of the increasing age of the population, the subsequent increase in demand for blood components and increasing costs of healthcare attributable to transfusion therapy [5–6]. In 2001, the National Blood Stocks Management project reported 2.2% red cell concentrate (RCC) clinical wastage in 40 NHS hospitals [7]. In the USA, Wallace et al reported that 1.8 million (13.5%) of 13.3 million RCC units were wasted in 1994 (combined laboratory and clinical wastage) [8]. Reasons for this disparity may include differences in patterns of injury between the USA and UK or may reflect the improvements made in blood component utilisation over the intervening years. We were not able to find any information on other UK or international EDs’ performance at tracing each blood component unit from donor to its final fate and therefore obviously no evidence for how to solve our potential poor traceability problem.

rovements made in blood component utilisation over the intervening years. We were not able to find any information on other UK or international EDs’ performance at tracing each blood component unit from donor to its final fate and therefore obviously no evidence for how to solve our potential poor traceability problem. Baseline measurement In September 2008, we performed a retrospective case note review to establish blood component usage and wastage within our ED in 2007 during which we had a total of 104,294 presentations. All adult patients (>12 years of age) presenting to the ED for whom blood components were ordered were enrolled. Albumin orders were excluded as albumin is not ordered on a patient-specific basis. Routinely kept records of all blood components issued by the Royal Infirmary of Edinburgh (RIE) blood bank were obtained for the period 1 January 2007 to 31 December 2007. A data extraction form was designed and information regarding age, sex, type and amount of blood component, and indication for the transfusion was collected for all ED patients requiring blood components. Only patient-specific components were included in the study. If a patient had more than one reason for requiring a transfusion, all indications were documented. The outcome of the transfusion request was recorded as wasted (unit of blood component was not transfused to the patient for whom it was requested and was not returned to the blood bank in time for it to be recycled, and was wasted), recycled (unit of blood component was not transfused but was returned to the blood bank in adequate time to enable it to be recycled) or transfused (intended patient received that unit of requested blood component). Data were entered into a Microsoft Excel database (Microsoft Corporation, Redmond, Washington, USA) for statistical analysis. Results were analysed by individual episodes of transfusion. Median and interquartile range (IQR) were calculated for non-parametric data and mean and standard deviation for parametric data.

t). Data were entered into a Microsoft Excel database (Microsoft Corporation, Redmond, Washington, USA) for statistical analysis. Results were analysed by individual episodes of transfusion. Median and interquartile range (IQR) were calculated for non-parametric data and mean and standard deviation for parametric data. Between 1 January 2007 and 31 December 2007, 770 transfusion requests were identified, representing a total of 3209 units of blood components. After albumin was excluded, 758 case notes were searched for and 722 were successfully retrieved and reviewed (95.3%). These 722 reviewed requests represented 550 patient episodes and 3048 requested units; some patients required more than one type of blood component and others presented frequently over the 1-year period. The median age of recipients was 65 (IQR 46-78) years and 56% of all transfusions were given to patients over 60 years old with an increase in transfusion rate across all age groups, continuing to 90 years and above. 57% of transfusion requests were for men [9].

t and others presented frequently over the 1-year period. The median age of recipients was 65 (IQR 46-78) years and 56% of all transfusions were given to patients over 60 years old with an increase in transfusion rate across all age groups, continuing to 90 years and above. 57% of transfusion requests were for men [9]. Of the 3048 units requested, 97 were wasted (3.2%) and 1458 (47.8%) recycled; 1204 were transfused (39.5%) leaving 289 (9.5%) unaccounted for. The highest wastage rates (10%) were seen with Fresh Frozen Plasma (FFP). Gastrointestinal bleeding was the most frequent indication for blood component usage with 5.2 units being requested per patient; a total of 1128 units of blood components. The highest mean number of units ordered per request was 6.0 units for abdominal aortic aneurysm (AAA). A total of 50 RCC units, 23 units of platelets and 24 units of FFP were wasted. Red Cell Concentrate (RCC) wastage was most frequently seen in patients presenting with alcoholic liver disease-associated bleeding. See supplementary file: ds1587.jpg

Of the 3048 units requested, 97 were wasted (3.2%) and 1458 (47.8%) recycled; 1204 were transfused (39.5%) leaving 289 (9.5%) unaccounted for. The highest wastage rates (10%) were seen with Fresh Frozen Plasma (FFP). Gastrointestinal bleeding was the most frequent indication for blood component usage with 5.2 units being requested per patient; a total of 1128 units of blood components. The highest mean number of units ordered per request was 6.0 units for abdominal aortic aneurysm (AAA). A total of 50 RCC units, 23 units of platelets and 24 units of FFP were wasted. Red Cell Concentrate (RCC) wastage was most frequently seen in patients presenting with alcoholic liver disease-associated bleeding. See supplementary file: ds1587.jpg Design After our initial review of ED blood component usage in 2007, we decided that our emergency transfusion performance was poor and we needed to implement improvement measures. We improved links between our ED and our Blood Transfusion Service (BTS) and then set out to implement a set of improvement measures. These measures included improved formal ED medical and nursing staff education with increased awareness of the mandatory Module 1 Safe Blood Transfusion which also highlights Medicines and Healthcare products Regulatory Agency (MHRA) traceability regulations where the importance of returning blood component tags is stressed, monthly traceability reports sent to the clinical management teams, the introduction of an ED departmental transfusion guideline (which includes guidance on which components to order for which conditions, how many and how quickly), refinements to the major transfusion protocol allowing faster access to emergency blood and having pre-thawed FFP available, moving our blood fridge into the resuscitation room, limiting the storage to emergency O negative only (enabling easier access to the blood fridge meaning only one unit would be removed at a time during an emergency and making it easier for staff to record the removal of the unit on the satellite fridge register which completes the audit trail requirements), the introduction of a named transfusion consultant and transfusion link nurse in the ED (meaning staff know where to get advice if needed), ensuring ED consultant representation on the Hospital Transfusion Group, and finally increasing awareness of emergency transfusion by undertaking ED based research into Rotational Thromboelastometry (ROTEM) near-patient coagulation testing.

fusion link nurse in the ED (meaning staff know where to get advice if needed), ensuring ED consultant representation on the Hospital Transfusion Group, and finally increasing awareness of emergency transfusion by undertaking ED based research into Rotational Thromboelastometry (ROTEM) near-patient coagulation testing. Strategy Our main strategy revolved around improving links between key personnel in the ED and BTS. Key individuals in the ED of the RIE were identified at senior medical and nursing level. These individuals liaised with identified key individuals in the SNBTS of the RIE including a blood transfusion consultant and a transfusion practitioner. A named ED transfusion consultant and transfusion link nurse in the ED were also identified and ED consultant representation on the Hospital Transfusion Group was ensured. By identifying key links between both departments, it meant that a named individual in both departments was available for communication when any issues arose. This also allowed the ED medical and nursing teams to work effectively with each other and also with the SNBTS team. The identification of early goals of reducing blood component ordering and usage, and improving traceability meant also that both teams were able to work towards a shared target. It is apparent that this approach worked well and that the teamwork built up between both departments, and between the nursing and medical ED staff was a huge factor as the same improvements have not been apparent in any other departments in our hospital.

also that both teams were able to work towards a shared target. It is apparent that this approach worked well and that the teamwork built up between both departments, and between the nursing and medical ED staff was a huge factor as the same improvements have not been apparent in any other departments in our hospital. Results In June 2012 we performed a second retrospective case note review looking at 2011 practice after our interventions. The hospital blood bank; RIE BTS (run by SNBTS) provided information on all blood components ordered and transfused by the ED in 2011, with corresponding patient hospital numbers. The Lothian Regional Ethics Committee deemed that the study was a service evaluation and therefore did not require formal ethical review. A data extraction form used previously for the baseline measurement was used to record information. One extraction form was used per patient episode where blood components were ordered. Individual Electronic Patient Records (EPRs) were accessed to obtain information on the ED admission history and indication for transfusion. Additional information including blood pressure and haemoglobin level at the time of the transfusion request was also recorded. The outcome of each transfusion request was recorded as transfused, recycled, discarded or unaccounted for. Data provided by the blood bank allowed transfused units to be recorded for specific patient episodes; however, discarded or unaccounted for blood component data was obtained from monthly figures, as this information was not available on an individual patient basis. Recycled units were those units returned to the blood bank with a secure ‘cold chain’ (within acceptable storage conditions while outwith blood bank control) and therefore able to be re-entered into stock for issue to another patient; discarded units were those units returned to blood bank whose cold chain was not secure and so could not be reissued. In cases where a unit of a blood component was issued by the blood bank and neither the unit nor the unit-specific identification tag was returned, this unit was recorded as unaccounted for. Data was entered into a Microsoft Excel database (Microsoft Corporation, Redmond, Washington, USA) for statistical analysis. Results were analysed by individual episodes of transfusion. Median and IQR was calculated for non-parametric data and mean and SD for parametric data.

this unit was recorded as unaccounted for. Data was entered into a Microsoft Excel database (Microsoft Corporation, Redmond, Washington, USA) for statistical analysis. Results were analysed by individual episodes of transfusion. Median and IQR was calculated for non-parametric data and mean and SD for parametric data. Between 1st January and 31st December 2011, blood components were requested for 255 patient episodes, totalling 1034 individual units. 687 units (66.4%) of blood component were transfused, 248 components (24.0%) were recycled, 90 components (8.7%) were discarded and nine units (0.9%) were unaccounted for. There was a 64% reduction in blood component ordering (3209 vs 1034 units), a 39% reduction in blood component transfusion (1131 vs 687 units), a 68% increase in the proportion of ordered units that were transfused, and a 96% reduction in unaccounted units (214 vs 9 units) between 2007 and 2011 [10]. There was also interestingly, a rise in the median age of the patient for whom a transfusion request was made from 63.9 years in 2007 to 67.0 years in 2011. Gastrointestinal (GI) bleeding was again the most common indication for transfusion with 116 requests (45.5%). See supplementary file: ds1590.jpg

There was a 64% reduction in blood component ordering (3209 vs 1034 units), a 39% reduction in blood component transfusion (1131 vs 687 units), a 68% increase in the proportion of ordered units that were transfused, and a 96% reduction in unaccounted units (214 vs 9 units) between 2007 and 2011 [10]. There was also interestingly, a rise in the median age of the patient for whom a transfusion request was made from 63.9 years in 2007 to 67.0 years in 2011. Gastrointestinal (GI) bleeding was again the most common indication for transfusion with 116 requests (45.5%). See supplementary file: ds1590.jpg Lessons and limitations We have been able to demonstrate a 64% reduction in blood component ordering, a 39% reduction in component transfusion, a 68% increase in the proportion of ordered units that are transfused and a 96% reduction in unaccounted units, undoubtedly improving patient safety as a result of better emergency transfusion practice. These improvements are immediately generalizable across the UK. In addition we have attempted to cost the savings resulting from our changes. In Scotland, SNBTS, unlike NHSBT (National Health Service Blood and Transplant) in England and Wales, do not charge locally for blood components. We have therefore used charges to local private hospitals to estimate savings. In 2007, the total cost of 770 transfusion requests leading to the issue of 2879 units was estimated to be £389,401. £183,920 was the estimated unnecessary handling cost of units not transfused. In 2011 the total cost of 255 transfusion requests leading to the issue of 1034 units was estimated to be £133,586. £43,001 was the estimated unnecessary handling cost of units not transfused. Accounting for a 13% change in the value of the pound between 2007 and 2011, SNBTS spent £306,437 less in 2011 compared to 2007 on handling and issuing all transfusion requests, including £159,238 less on handling units not transfused. The fact that SNBTS are not able to use local financial incentives to drive down wastage and recycling, usually a very effective way of changing practice highlights just how good our strategies have been. The potential saving to the NHS is enormous.

on requests, including £159,238 less on handling units not transfused. The fact that SNBTS are not able to use local financial incentives to drive down wastage and recycling, usually a very effective way of changing practice highlights just how good our strategies have been. The potential saving to the NHS is enormous. This study does have some limitations. While we have observed a huge improvement in blood component ordering, usage and traceability since 2007 in our ED following implementation of simple strategies, we cannot prove that this implementation directly caused the improvement. The importance of 100% traceability on all blood components has been promoted greatly both locally and nationally by SNBTS and their many initiatives to improve staff education have most definitely contributed something to this improvement. The study was also retrospective in design; not all desired information was available for each patient episode and in some cases judgement had to be used when the indication for transfusion was unclear. However, data was available on the fate of every unit ordered by the ED during 2011 allowing our results to be a true representation of blood component usage in our ED.

desired information was available for each patient episode and in some cases judgement had to be used when the indication for transfusion was unclear. However, data was available on the fate of every unit ordered by the ED during 2011 allowing our results to be a true representation of blood component usage in our ED. We hope that with the identification of named ED transfusion link nurses and now excellent relationships between the ED and BTS, as well as a culture in our ED of blood transfusion audit and research, these improvements can be maintained and we can now focus on reducing wastage rates, which paradoxically, now we know what has happened to all of our units, have risen (previously these units were coded as unaccounted for). This will be tough, however since our review in June 2012 we have started to make inroads into this as well, using a similar ED teamwork approach to that demonstrated here. Conclusion Blood component ordering, usage and traceability within our ED have improved significantly since 2007 following implementation of simple strategies. We have been able to demonstrate a 64% reduction in blood component ordering, a 39% reduction in component transfusion, a 68% increase in the proportion of ordered units that are transfused and a 96% reduction in unaccounted units, undoubtedly improving patient safety and potentially saving money, as a result of better Emergency Transfusion practice. The age of ED transfusion recipients is increasing; this may have implications for future ED transfusion practice.

rtion of ordered units that are transfused and a 96% reduction in unaccounted units, undoubtedly improving patient safety and potentially saving money, as a result of better Emergency Transfusion practice. The age of ED transfusion recipients is increasing; this may have implications for future ED transfusion practice. Thanks to Carol McFarlane for help with baseline measurement. Huge thanks are also required to Kate McIlwraith and Rachel O'Brien, our ED transfusion link nurses and to the ED nursing and medical staff who have implemented these changes so effectively. Declaration of interests: Nothing to declare

Problem In the UK POCT (point of care testing) devices lead a lonely, solitary existence. Unlike laboratory analysers, they are not connected to networks with the result that overall efficiency and data integrity is poor. This initiative was carried out to ascertain whether interfacing POCT devices to a clinical order communications system (Sunquest ICE) improves clinical data integrity and reduces patient waiting times in an Accident and Emergency Department. Interfacing POCT to an order communications system, rather than to a laboratory or proprietary system, (both rare events) is an unusual and innovative approach, providing clinicians with direct electronic access to diagnostic devices. This initiative principally addresses the national problem of patient waiting times in A&E while at the same time addressing the need to improve the level of clinical data integrity in the context of conventional POCT implementations. In most diagnostic systems, the handling data adheres to recommended practice involving the registration of authenticated patient demographics, user details and the electronic rather than manual transcription of patient test results. In contrast, POCT devices used as ‘stand alone’ devices are fairly promiscuous about data, accepting ‘XXXX’ instead of unique patient identifiers and ‘333’ or shared passwords in the place of pre-registered and trained users. Patient data may be printed out on paper strips and the results transcribed (6% error rate) into case notes.

OCT devices used as ‘stand alone’ devices are fairly promiscuous about data, accepting ‘XXXX’ instead of unique patient identifiers and ‘333’ or shared passwords in the place of pre-registered and trained users. Patient data may be printed out on paper strips and the results transcribed (6% error rate) into case notes. Background Initially, in 2010, we carried out a feasibility study of interfaced point of care testing in general practice (The Brentford Group Practice - Dr Stuart Lane's practice). The devices measured chemistry and haematology profiles and were connected by small dedicated server to a patient electronic order communications system (ICE - Integrated clinical environment) manufactured by Sunquest Inc. This study proved the concept that interfaced POCT was feasible, very easy to use, reliable and likely to improve patient management in situations where the rapid availability of results was an important consideration.

nic order communications system (ICE - Integrated clinical environment) manufactured by Sunquest Inc. This study proved the concept that interfaced POCT was feasible, very easy to use, reliable and likely to improve patient management in situations where the rapid availability of results was an important consideration. In view of these positive results, the present study beginning in 2012 was designed to test whether ‘on-line’ POCT analysers could work in the demanding environment of an Accident and Emergency (A&E) department. The objective of this study was to demonstrate whether this configuration could reduce the duration of patient waiting times and whether the interface would work reliably in the demanding environment of an A&E department that managed over 100 000 patients per year.. In the WMUH for example, the recent introduction of POCT in the anticoagulation clinic has improved the patient experience (patient surveys), reduced cost and markedly diminished waiting times. This case study shows that POCT when focused on a discrete group of patients can be very advantageous. The problem with A&E, is the unpredictable arrival of patients with a large range of disorders requiring a large repertoire of different tests.

ce (patient surveys), reduced cost and markedly diminished waiting times. This case study shows that POCT when focused on a discrete group of patients can be very advantageous. The problem with A&E, is the unpredictable arrival of patients with a large range of disorders requiring a large repertoire of different tests. Previous studies using POCT devices in A&E departments have shown reduced patient waiting times in some cases but not in others. Lee-Lewandrowski et al (1) measured blood glucose, urine chorionic gonadotrophin, urine dipstick, creatine kinase-MB and Toponin levels in an emergency department by POCT. and observed an overall reduction in patient length of stay of 41.3 minutes (1). Similarly, Murray et al (2) reported that tests processed by POCT compared to the central laboratory resulted in waiting times of 3 hours 28 minutes and 4 hours 22 minutes respectively. In contrast, Parvin et al (3) observed no change in the patient waiting time in a 5 week period involving 2067 patients when a hand-held device was used to estimate Na, K, CL, urea and glucose concentrations. In this study, the length of stay during the POCT period was 209 minutes compared to 201 minutes for the control periods when the central laboratory was used (3). Kendall, Reeves and Clancy (4) studying 1728 patients noted that clinical decisions were made 74 minutes earlier when POCT rather than the central laboratory was used for haematological tests; 86 minutes earlier for biochemical tests and 21 minutes earlier for blood gases. Despite these accelerated times, there was no difference between the groups in the amount of time spent in the A&E department.

ons were made 74 minutes earlier when POCT rather than the central laboratory was used for haematological tests; 86 minutes earlier for biochemical tests and 21 minutes earlier for blood gases. Despite these accelerated times, there was no difference between the groups in the amount of time spent in the A&E department. To test whether a more comprehensive repertoire of laboratory tests could influence patient waiting times, Leman et al (5) established a satellite laboratory within the boundaries of an A&E department. Tests included electrolytes, urea, creatinine, LFT, Amylase, calcium and phosphate, C reactive protein, Troponin T, paracetamol and salicylate, full blood count and D-Dimer test. 1065 patients were studied using equipment producing results comparable to those reported by the central laboratory. Compared to the main laboratory, the time to haematology results decreased by 47.2 minutes; to D-dimer results by 66.1 minutes and to chemistry by 41.3 minutes. The time to decide whether to discharge patients was reduced by 28.2 minutes but unfortunately the effect on patient waiting time was not reported.

laboratory. Compared to the main laboratory, the time to haematology results decreased by 47.2 minutes; to D-dimer results by 66.1 minutes and to chemistry by 41.3 minutes. The time to decide whether to discharge patients was reduced by 28.2 minutes but unfortunately the effect on patient waiting time was not reported. Patient waiting times in A&E depends on many factors including overall department efficiency, high demand for services (flu season; public holidays when GP practices), insufficient in-patient beds to accept referrals from A&E, delays accessing specialist opinions, insufficient nursing or junior medical staff as well as delayed access to diagnostic services. These varied causes indicates that diagnostic services is one of many rate limiting steps determining patient waiting times in A&E and that other approaches (e.g. time to clinical decision making) might more sensitively reflect the usefulness of POCT.

nior medical staff as well as delayed access to diagnostic services. These varied causes indicates that diagnostic services is one of many rate limiting steps determining patient waiting times in A&E and that other approaches (e.g. time to clinical decision making) might more sensitively reflect the usefulness of POCT. Baseline measurement The time taken to produce POCT tests was calculated as the time elapse (TE) between requesting tests and the time at which completed results were returned to the ICE system. Patient waiting times were derived from the patient administration system (Symphony) used in the A&E department. To assess the true effect of POCT on patient waiting times the analysis was confined to cases associated with POCT tests only (n = 217). A control population (n=229) was randomly selected from the clinical laboratory database. The time interval between requesting a test and receiving the results for the POCT tests was 23 minutes and for the laboratory tests, 60 minutes. The patient waiting times (time of discharge - time of arrival) was 167 minutes for the POCT group and 208 for the clinical laboratory group, a difference of 31 minutes. The project confirmed that interfaced (on-line) POCT has many advantages with respect to the quality and safety of data management. The benefits include reliable identification of the requesting clinician and patient and the assurance that the right result is allocated to the right patient. The study also showed that the quality of results produced by the POCT devices met the requirements of the clinical environment.

and safety of data management. The benefits include reliable identification of the requesting clinician and patient and the assurance that the right result is allocated to the right patient. The study also showed that the quality of results produced by the POCT devices met the requirements of the clinical environment. Design In this initiative, Two POCT devices were interfaced to a clinical electronic order communications system (ICE) via the hospital N3 network. The POCT devices included the Abbott I-Stat and the Sysmex XS haematology analyser. The I-Stat assayed serum concentrations of sodium, potassium, chloride, urea and creatinine (abbreviation - ‘U&E’). The XS produced a full blood count (FBC) including five part differential and messages describing pathological features requiring follow-up by microscopic examination. The I-Stat and XS were unidirectionally interfaced to a small server (Midlynx) which via the hospital network was linked to the ICE server.

on - ‘U&E’). The XS produced a full blood count (FBC) including five part differential and messages describing pathological features requiring follow-up by microscopic examination. The I-Stat and XS were unidirectionally interfaced to a small server (Midlynx) which via the hospital network was linked to the ICE server. Clinicians requisitioned test profiles using specially designed forms on the ICE system. Orders were downloaded to a networked printer which produced bar code labels that were read by the POCT devices. Completed test results were electronically transferred to the ICE system for viewing using networked terminals throughout the hospital. A comprehensive quality management system involved formal user training, internal and external QC checks and correlation with analysers located in the main clinical laboratory. The POCT devices were operated in shifts by two University students using material generated by the study to apply for the Msc degree by research rather than by examination. Data for the study was extracted from the hospital clinical systems using SQL queries. Strategy Considerable interest generated within the Trust. One possibility discussing whether portals of entry into the hospital should be served by POCT devices linked to the hospital network. Entry points under consideration being A&E, AAU and UCC. The intention is to place the same POCT devices and test menus in each location to standardise rapid testing facilitating the hospital admissions process. The test repertoire included UE, FBC, Amylase, LFT, glucose, CRP and troponin I.

ed to the hospital network. Entry points under consideration being A&E, AAU and UCC. The intention is to place the same POCT devices and test menus in each location to standardise rapid testing facilitating the hospital admissions process. The test repertoire included UE, FBC, Amylase, LFT, glucose, CRP and troponin I. A reduction in waiting time was only observed when patients received POCT exclusively. Implementing this strategy involves multidisciplinary collaboration. A POCT policy document from senior management endorsed by the Trust Board and translated into SOP's is used for training users to ensure appropriate and safe use of tests. In this regard, preliminary work should ensure POCT device test profiles and main laboratory demonstrate a degree of correlation satisfactory for the clinical environment thus increasing confidence in the POCT system encouraging clinicians to utilise the system for patient management.

appropriate and safe use of tests. In this regard, preliminary work should ensure POCT device test profiles and main laboratory demonstrate a degree of correlation satisfactory for the clinical environment thus increasing confidence in the POCT system encouraging clinicians to utilise the system for patient management. Our study showed on-line POCT configuration was robust, reliable and user friendly, resolving staffing arrangement issues. HCA's with appropriate training from the clinical laboratory produce accurate and precise results. Using on-line POCT devices at portals of entry to the hospital help front line staff accelerate decision making, reduce congestion and most importantly, improve patient waiting times. A comprehensive quality management system involved formal user training, internal and external QC checks and correlation with analysers located in the main clinical laboratory. The initiative is of significant interest to other healthcare providers especially those developing new patient care pathways. An important example is the proliferation of Urgent Care Centres (UCC) which is designed to reduce the number of less urgent cases referred to A&E departments. In this context, the speed and efficiency of the clinical process will be enhanced by the rapid but safe delivery of pathology test results from on-line POCT services. Bearing in mind that ICE is highly prevalent throughout the NHS (approximately 200 placements), a huge trained user group is available to take advantage of on-line POCT services. Also, of significant interest to community polyclinics and large GP practices in the community. The results of this project were presented at a sponsored meeting on the 2nd July 2012. Hopefully further dissemination will follow though the usual channels including -presentations, posters and publication.

POCT services. Also, of significant interest to community polyclinics and large GP practices in the community. The results of this project were presented at a sponsored meeting on the 2nd July 2012. Hopefully further dissemination will follow though the usual channels including -presentations, posters and publication. Results The study showed that patients receiving test profiles from the POCT devices experienced a 31 minute reduction in waiting time compared to a control group receiving the same test profiles from the main laboratory. Waiting time was defined as the time elapse between patient registration to and discharge from the A&E department. The time to produce test results (turnaround time) was 24 minutes for the POCT devices and 60 minutes for the equivalent laboratory tests (FBC; sodium, potassium, chloride, urea and creatinine). Turnaround time was defined as the time elapse between submitting a request on ICE to receiving all test results on ICE. The A&E clinicians stated that compared to the conventional laboratory service, the rapid availability of POCT test results facilitated patient care in several respects:

loride, urea and creatinine). Turnaround time was defined as the time elapse between submitting a request on ICE to receiving all test results on ICE. The A&E clinicians stated that compared to the conventional laboratory service, the rapid availability of POCT test results facilitated patient care in several respects: 1) Rapid, safe discharge of patients with less serious complaints 2) Very rapid management of patients with sepsis. Where cases caused concern, the proximity of the POCT devices was exploited with delivery of a full blood count within 3 minutes of delivery of the blood sample. This produced the necessary information to confirm the clinical diagnosis and institute antibiotic treatment without delay. 3) Similarly, the management of patients presenting with dangerous cardiac arrhythmias was expedited by the rapid (three minute delay) availability of serum potassium results. Lessons and limitations Communications with the supplier in the USA, the BT supplier, the lead Clinicians and hospital staff was deemed effective including the resolution of interface and HL7 messaging issues by the ICE and Midlynx suppliers. The work performed by both suppliers and the funding body NHS London being highly commendable. Another success being the testing of POCT devices in terms of speed of operation and accuracy of results. Additional training support was maintained by Quest diagnostics staff and suppliers regarding use of the Sysmex and Abbott analysers.

rmed by both suppliers and the funding body NHS London being highly commendable. Another success being the testing of POCT devices in terms of speed of operation and accuracy of results. Additional training support was maintained by Quest diagnostics staff and suppliers regarding use of the Sysmex and Abbott analysers. Limitations to the project included the time in obtaining the correct IP address information for the Hospital N3 network so firewall changes could be made requiring Liaison with suppliers at all levels. Also, the length of time taken for IT staff to address network and project issues and the length of time taken for ICE supplier to address interface and project issues could have fared better which included a lack of support from the ICE supplier in terms of some requested tasks. There was a definite lack of availability and cooperation of some clinical staff and engaging the Lead Clinicians was a major hurdle that we managed to eventually overcome. The initiative was supported by a grant from the NHS London Innovation Fund. A significant amount unspent due to unexpected levels of support received from industry partners.

f availability and cooperation of some clinical staff and engaging the Lead Clinicians was a major hurdle that we managed to eventually overcome. The initiative was supported by a grant from the NHS London Innovation Fund. A significant amount unspent due to unexpected levels of support received from industry partners. The initiative not designed to demonstrate savings but to ascertain whether on-line POCT can contribute safely and reliably to the clinical process in a demanding environment such as an A&E department. As part of these objectives, a financial estimate was carried out (5 year ‘whole life approach’) showing that the cost of a FBC produced by the Sysmex XS was close to that observed for the main laboratory while the I-Stat profile was more expensive than the laboratory equivalent. The financial model not taking into account savings that might accrue from the reduction in waiting times leading to generation of income through an increase in the number of managed clinical cases. Further work in this area is therefore required to assist decision makers choose whether to invest in on-line POCT services. Sophisticated modelling techniques are needed to balance the demonstrable clinical advantages against the costs involved. This analyses also needs to take into account the rapid evolution of POCT technology. Devices are becoming smaller, more accurate and safer to use with a test repertoire expanding into most clinical areas. Standards (ISO22870) covering the operational aspects of POCT, but the evaluation of benefit although intuitively obvious, needs assessment.

o take into account the rapid evolution of POCT technology. Devices are becoming smaller, more accurate and safer to use with a test repertoire expanding into most clinical areas. Standards (ISO22870) covering the operational aspects of POCT, but the evaluation of benefit although intuitively obvious, needs assessment. Conclusion The main objectives of the study were realized in firstly, establishing an ‘on-line’ configuration of validated POCT devices in the A&E department and subsequently linking these devices to an electronic order communications system (ICE) allowing electronic test requesting and reporting which was the innovative aspect of the study. Generally, where POCT devices are interfaced, the connection is usually only between POCT and a laboratory computer system. Data capture enabled accurate measurement of the effect of on-line POCT on patient waiting times.

E) allowing electronic test requesting and reporting which was the innovative aspect of the study. Generally, where POCT devices are interfaced, the connection is usually only between POCT and a laboratory computer system. Data capture enabled accurate measurement of the effect of on-line POCT on patient waiting times. On-line POCT is a safe, effective and robust method of operating diagnostic equipment located remotely from the clinical laboratory.Interfacing POCT devices overcomes the main disadvantage (potentially unsafe clinical data handling) of deploying ‘standalone’ analytical equipment. The quality of POCT generated results is suitable for the clinical environment and this case study shows that POCT, when focused on a discrete group of patients, can be very advantageous in reducing patient waiting times significantly when a small repertoire of diagnostic tests is required for the management of cases in an A&E department. Online POCT is thus cost effective, improves the patient experience and reduces patient waiting times in well defined circumstances, for example, patients with Sepsis to enable rapid diagnosis and insitution of treatment without delay, the management of patients presenting with dangerous arrythmias expedited by the rapid (3 minute) availability of serum potassium results, the safe and rapid discharge of patients with less serious complaints and is also useful in specialist clinics e.g. an anti-coagulation clinic. Misha Piracha - MSc student Ladan Jama - MSc student Declaration of interests: Nothing to declare

Problem This audit was carried out at a DGH serving a population of 320,000 for general services with a 24-hour, seven days a week consultant-led trauma service. A daily Trauma Meeting (TM) occurs during which the previous 24-hour take is discussed, relevant imaging reviewed and a management plan is decided by the consultant on-take. The post-take ward round (PTWR) usually follows this trauma meeting. Junior doctors are relied upon to document the discussions of the TM and the PTWR. Previously there was no set system to document these discussions and the interaction with the patient. There were clinical incidences related to patient ownership and handing-over of care. After a systematic evaluation it was apparent that the PTWR documentation were suboptimal in these cases. Background Post take ward rounds can be high pace and there is a lot of pressure on junior doctors to document discussions and plans made by the clinician leading the ward round. It is vital that documentation of the PTWR and management plan is clear and readily available to all members of staff to help ensure the correct treatment plan is implemented efficiently with minimal chances of clinical incidences. Many hospitals now use a proforma to enable clear, yet concise documentation of post take ward rounds. They enable other members of the multi disciplinary team to gain an understanding of the rational behind admission, the treatment plan for the patient and to identify the team who are responsible for the patient.

Background Post take ward rounds can be high pace and there is a lot of pressure on junior doctors to document discussions and plans made by the clinician leading the ward round. It is vital that documentation of the PTWR and management plan is clear and readily available to all members of staff to help ensure the correct treatment plan is implemented efficiently with minimal chances of clinical incidences. Many hospitals now use a proforma to enable clear, yet concise documentation of post take ward rounds. They enable other members of the multi disciplinary team to gain an understanding of the rational behind admission, the treatment plan for the patient and to identify the team who are responsible for the patient. Baseline measurement We identified gold standards using the GMC and the Royal College of Physicians recommendations (1,2). 50 trauma cases were selected randomly and the hospital notes were reviewed retrospectively. Audited variables included; presence of a clearly documented PTWR, date and time of admission, consultant on-take, clinician leading the ward-round and documenting, a clear documentation of the patient's presenting compliant and a management plan.

selected randomly and the hospital notes were reviewed retrospectively. Audited variables included; presence of a clearly documented PTWR, date and time of admission, consultant on-take, clinician leading the ward-round and documenting, a clear documentation of the patient's presenting compliant and a management plan. 72% were seen on a PTWR and 47% of these had clearly labeled PTWR. 64% of the cases, which were not seen on a PTWR, had been admitted during the weekend. In 19% of cases there was no identifiable consultant on take, in 78% of cases the presenting complaint was not documented and there was no clear plan in 3%. The entries were not dated in 3% of cases and not timed in 17% of cases. Details of the person documenting were also poor with 19% of case having no name of person documenting, 14% no signature; 50% no grade and 25% no contact details. Design From the initial audit, it was clear that documentation was not acceptable. We therefore developed a Trauma Meeting/Post-Take Ward Round Proforma consisting of template for documentation of TM/PTWR including: patient details, date of admission, consultant and registrar on call, presenting complaint, management plan, details of the person documenting, and date and time. Strategy PDSA Cycle 1 The design of the proforma was discussed with Consultants, Registrars and Junior Doctors in orthopaedics, along with the trauma co-ordinator and other members of the multidisciplinary team who would be referring to the proforma on the wards.

Design From the initial audit, it was clear that documentation was not acceptable. We therefore developed a Trauma Meeting/Post-Take Ward Round Proforma consisting of template for documentation of TM/PTWR including: patient details, date of admission, consultant and registrar on call, presenting complaint, management plan, details of the person documenting, and date and time. Strategy PDSA Cycle 1 The design of the proforma was discussed with Consultants, Registrars and Junior Doctors in orthopaedics, along with the trauma co-ordinator and other members of the multidisciplinary team who would be referring to the proforma on the wards. PDSA Cycle 2 The results of the initial audit and the proforma were presented at the monthly Departmental Educational Half Day. Discussions from the meeting were positive but it was suggested that the proforma was on yellow paper, so that it would stand out in the notes. PDSA Cycle 3 All surgical junior doctors who cover orthopaedics during weekends were informed of the new proforma and the need to attend trauma meeting when on call and to complete the profomas for the trauma admissions. Subsequently, the proforma was implemented and a second prospective audit was carried out 2 weeks later. Results A prospective re-audit was conducted two weeks after the intervention. 50 cases were reviewed whilst observing the same variables and the presence or absence of a TM/PTWR proforma.

PDSA Cycle 3 All surgical junior doctors who cover orthopaedics during weekends were informed of the new proforma and the need to attend trauma meeting when on call and to complete the profomas for the trauma admissions. Subsequently, the proforma was implemented and a second prospective audit was carried out 2 weeks later. Results A prospective re-audit was conducted two weeks after the intervention. 50 cases were reviewed whilst observing the same variables and the presence or absence of a TM/PTWR proforma. The number of patients not seen on a PTWR decreased from 28% to 18%; 4% of these were weekend admissions. 88% of patients seen on a PTWR had a proforma completed. 18% of all cases did not have a proforma. 67% of these were weekend admissions. In 4% of cases it was not possible to identify the responsible consultant. None of these had a proforma completed. In addition, 44% of the patients who were not seen on a PTWR had a clear consultant-formulated plan documented on the Trauma Meeting section of the proforma. Of those cases seen on a PTWR, 2% did not have a clearly documented plan and 10% did not have the presenting complaint documented. In none of these cases was a proforma used to document the PTWR. All PTWR entries had been signed and dated. 12% did not have a name, 15% had no contact details and 10% had no grade. None of those without a name or grade had a PTWR proforma.

arly documented plan and 10% did not have the presenting complaint documented. In none of these cases was a proforma used to document the PTWR. All PTWR entries had been signed and dated. 12% did not have a name, 15% had no contact details and 10% had no grade. None of those without a name or grade had a PTWR proforma. Lessons and limitations The introduction of the PTWR proforma when used greatly improved the level and quality of documentation of the post-take ward round. The introduction of a Trauma Meeting proforma not only established a system to document the discussion occurring at the meeting, but also meant that when patients were not seen on a PTWR, there was at least a clear documentation of management plan decided by a consultant. Completion of the proformas during weekends still needs to be improved. Conclusion The post-take surgical ward round is usually a very busy time for the junior doctors. Clear documentation in the notes serves as an important communication tool to the multiduciplinary team, it improves continuity with the handover system and it has increasing legal significance. A simple too such as a proforma and staff awareness can improve the overall care of patients and potentially protect staff. Fran Hole Declaration of interests: Nothing to declare

Problem Tamoxifen and fluoxetine are two of the most commonly prescribed medicines in the UK and as such there is likely to be some overlap of the two drugs in individual patients. A recent study has shown that fluoxetine could actually reduce the action and effectiveness of tamoxifen in preventing the growth of breast cancer. Background Some breast cancer requires oestrogen to grow. Tamoxifen is an endocrine therapy that inhibits the oestrogen-receptor in breast tissue, and thus effectively stops the growth of the cancer. It is currently used in both pre- and post-menopausal women with oestrogen receptor-positive breast cancer and since it came off patent in 2002 it has become the world's largest selling hormonal drug for breast cancer. Fluoxetine, meanwhile, is approved for the treatment of major depression as well as other psychological disorders. It is currently the third most prescribed antidepressant. In 2010 a population-based cohort study showed that there was an increased risk of death from breast cancer in patients on both tamoxifen and fluoxetine (SSRI) as opposed to tamoxifen alone (Andersohn & Willich, 2010). The risk of death was also shown to increase the longer the patient was taking both drugs. This is because tamoxifen is a pro-drug that requires conversion to an active metabolite via the cytochrome P450 system. Thus drugs such as fluoxetine, that inhibit this system, also reduce the amount of active drug, endoxifen. The study showed that other drugs that could have similar interactions are paroxetine, bupropion, quinidine and cinacalcet.

pro-drug that requires conversion to an active metabolite via the cytochrome P450 system. Thus drugs such as fluoxetine, that inhibit this system, also reduce the amount of active drug, endoxifen. The study showed that other drugs that could have similar interactions are paroxetine, bupropion, quinidine and cinacalcet. Baseline Measurement The problem was quantified across two GP practices in Clevedon, Bristol (The Riverside Practice and the Green Practice). This was done by auditing the active patient population to seek those patients on both tamoxifen and one of the drugs above. This was done using the EMIS computer system used at both practices with the search terms Tamoxifen [AND] Fluoxetine [OR] Paroxetine [OR] Bupropion [OR] Quinidine and [OR] Cinacalcet. In the Green Practice there were 7,424 registered patients, of whom five were on tamoxifen. One of these patients was on both tamoxifen and fluoxetine. Meanwhile in the Riverside Practice there were 9,228 active patients, 13 of whom were on tamoxifen. Two of these patients were on both tamoxifen and fluoxetine. Thus in total in our cohort there were three patients on both tamoxifen and fluoxetine. Design It was clear from a baseline data and process flow that changes were required to firstly alter the medication of those patients at risk of the drug interactions. Furthermore there was a need to implement a system to ensure no further prescriptions would create such risk.

In the Green Practice there were 7,424 registered patients, of whom five were on tamoxifen. One of these patients was on both tamoxifen and fluoxetine. Meanwhile in the Riverside Practice there were 9,228 active patients, 13 of whom were on tamoxifen. Two of these patients were on both tamoxifen and fluoxetine. Thus in total in our cohort there were three patients on both tamoxifen and fluoxetine. Design It was clear from a baseline data and process flow that changes were required to firstly alter the medication of those patients at risk of the drug interactions. Furthermore there was a need to implement a system to ensure no further prescriptions would create such risk. Three interventions were decided upon. Firstly the three patients found to be on both tamoxifen and fluoxetine would be called in for a review of medication. Secondly a warning message would be put onto the EMIS computer system that is used for drug prescriptions; this both flashes and makes a sound when an attempt is made to prescribe tamoxifen with one of the above drugs (or visa versa). Finally the drug interactions and this audit would be discussed at a staff meeting. Strategy PDSA Cycle 1 Those patients on both tamoxifen and fluoxetine were called into the surgery. The relevant new information was discussed and change from fluoxetine to sertraline was recommended and accepted by all. This achieved the goal of removing those currently at risk but did not deal with the possibility of future recurrences. PDSA Cycle 2

Those patients on both tamoxifen and fluoxetine were called into the surgery. The relevant new information was discussed and change from fluoxetine to sertraline was recommended and accepted by all. This achieved the goal of removing those currently at risk but did not deal with the possibility of future recurrences. PDSA Cycle 2 Two interventions were performed to stop future co-prescriptions. Firstly a prompt was put on the EMIS computer system used by the GPs at both practices. This will appear and make a sound when an attempt is made to prescribe the two drugs together. Furthermore the GPs were informed about the new data. See supplementary file: ds1557.doc Post-Measurement Our intervention has provided a 100% reduction in those at risk from the interaction of the two drugs in our population. A further check was performed using the same EMIS system four weeks after the intervention and showed that there were no new cases on both tamoxifen and fluoxetine. This will be re-checked in 12 months time. Lessons and Limitations This project had few problems. The GP practices were fortunate enough to have a computer technician who was comfortable with the EMIS system to implement the new prompt, although this would be a consideration for other practices.

Post-Measurement Our intervention has provided a 100% reduction in those at risk from the interaction of the two drugs in our population. A further check was performed using the same EMIS system four weeks after the intervention and showed that there were no new cases on both tamoxifen and fluoxetine. This will be re-checked in 12 months time. Lessons and Limitations This project had few problems. The GP practices were fortunate enough to have a computer technician who was comfortable with the EMIS system to implement the new prompt, although this would be a consideration for other practices. A further theoretical problem would be encouraging the patients to attend the clinic to have their medication changed, but this was not the case in the project. A further consideration for other practices would be the wording of the letter or phone call that goes out to their affected patients. This is a delicate situation as the implication is the patient has not been receiving the optimum treatment for their breast cancer during the time they have been on fluoxetine. This project is definitely scaleable and should be implemented in all GP practices in the UK. We have outlined a template that worked across these two practices; however, given the small number of affected patients there may be further unforeseen complications if implemented in a larger practice.

A further theoretical problem would be encouraging the patients to attend the clinic to have their medication changed, but this was not the case in the project. A further consideration for other practices would be the wording of the letter or phone call that goes out to their affected patients. This is a delicate situation as the implication is the patient has not been receiving the optimum treatment for their breast cancer during the time they have been on fluoxetine. This project is definitely scaleable and should be implemented in all GP practices in the UK. We have outlined a template that worked across these two practices; however, given the small number of affected patients there may be further unforeseen complications if implemented in a larger practice. Conclusion The problem that we started with was the recent discovery of an interaction between fluoxetine and tamoxifen that caused the latter to be less effective. This has a large implication on affected patients as it means they are receiving substandard treatment for their breast cancer. We implemented two quality improvement cycles. The first helped us identify those patients that were affected and change their medication to eradicate the problem. The second allowed us to put in place measures that should stop the co-prescription of these two drugs in the future.

Conclusion The problem that we started with was the recent discovery of an interaction between fluoxetine and tamoxifen that caused the latter to be less effective. This has a large implication on affected patients as it means they are receiving substandard treatment for their breast cancer. We implemented two quality improvement cycles. The first helped us identify those patients that were affected and change their medication to eradicate the problem. The second allowed us to put in place measures that should stop the co-prescription of these two drugs in the future. The project was successful in that at the current time there are no people across the active databases for the two GP practices who are at risk of the interaction. There is plenty of scope for this project to be implemented in all GP practices in the UK and we strongly encourage this. Furthermore the database will be re-checked for these two practices in one year to ensure the ongoing success of our interventions, reflecting the continual nature of quality improvement. Supplementary Material Web supplement

Problem We felt that when we worked on the weekend on-call cover team, a lot of time was spent responding to bleeps requesting work that should have been completed within normal working hours. These actions included such tasks as re-writing expired drug cards and prescribing IV fluids, warfarin and laxatives. Not only did this work reduce our time available for direct patient care but it also meant that nursing staff were spending time bleeping us or waiting for a response to bleeps. In addition, the necessity to perform this sort of work at weekends suggested that patients were not getting all their routine care in a timely manner.

did this work reduce our time available for direct patient care but it also meant that nursing staff were spending time bleeping us or waiting for a response to bleeps. In addition, the necessity to perform this sort of work at weekends suggested that patients were not getting all their routine care in a timely manner. Background It is well-recognised that doctors often have to interrupt patient care to answer a bleep. It has also been demonstrated that a large proportion of those bleeps are not urgent and may even be inappropriate and/or incorrect. A group in Dublin found that 40% of bleeps to Junior Doctors were inappropriate or unnecessary in some way (1) whilst an American study documented that approximately 50% of bleeps interrupted doctors' patient care time (2). It isn't only the doctors' time being wasted. Nurses also have to interrupt their work to bleep doctors and await a response. A study in 2005 showed that, overall, nurses spent 8% of their time on the telephone. This varied according to shift. Nurses on the late shift spent nearly 18% of their time on the telephone (3). Furthermore, our Junior Doctors have to cover a wide physical area. Half a mile separates the furthest two wards and it takes ten minutes to walk from one to the other. It can be easily seen that returning to a ward to perform work that could have been done on a previous visit is not the most effective use of time.

3). Furthermore, our Junior Doctors have to cover a wide physical area. Half a mile separates the furthest two wards and it takes ten minutes to walk from one to the other. It can be easily seen that returning to a ward to perform work that could have been done on a previous visit is not the most effective use of time. Baseline Measurement First, we needed to assess the size and nature of the problem. To do this, we made some baseline measurements on two of our acute medical wards. We elected to record the number of bleeps received by the on-call doctor in the 12 hour daytime shift on Saturday and Sunday. Both are medical wards, one is a Diabetic & Endocrine ward (W1) and the other is Care of the Elderly Rehabilitation ward (W2). Both have 28 beds and both accept patients from the hospital's three Medical Assessment Units. We measured: - Number of bleeps from each ward in both weekend 12 hour daytime shifts (via switchboard records) for three weekends. - The reason for the calls (from a nursing staff log). Results showed that more bleeps originated from W1 than W2. In addition, there were more requests for routine work from W1 than W2. This seemed to be because W2 batched Junior Doctors' tasks together, rather than issuing a bleep for each individual request. See supplementary file: ds1877.xls - “Baseline measurment” Design The analysis of the baseline measures suggested two possible areas of fruitful work: Reduce the amount of routine work left undone by weekday medical teams. Improve the batching of jobs on W1.

Results showed that more bleeps originated from W1 than W2. In addition, there were more requests for routine work from W1 than W2. This seemed to be because W2 batched Junior Doctors' tasks together, rather than issuing a bleep for each individual request. See supplementary file: ds1877.xls - “Baseline measurment” Design The analysis of the baseline measures suggested two possible areas of fruitful work: Reduce the amount of routine work left undone by weekday medical teams. Improve the batching of jobs on W1. Brainstorming sessions were held with various stakeholders - quality improvement staff, nursing staff, junior and senior medical staff. A number of ideas were generated from which we selected two simple tests of change to try. These two ideas were implemented as two PDSAs. Our measures for improvement remained the number of bleeps issued by each ward and the reasons for each call. Strategy PDSA 1 - We designed an A4 poster to act as a visual reminder of the need to complete routine work before the weekend. This was discussed with the ward managers and approval was obtained to display the posters in the doctors' offices and the nurses' stations on each ward. - The aim of the project and the purpose of the poster were explained to the junior doctors and nurses on both wards. PDSA 2

- We designed an A4 poster to act as a visual reminder of the need to complete routine work before the weekend. This was discussed with the ward managers and approval was obtained to display the posters in the doctors' offices and the nurses' stations on each ward. - The aim of the project and the purpose of the poster were explained to the junior doctors and nurses on both wards. PDSA 2 - Our second PDSA tried to improve job-batching on W1. We decided to replicate the system already in place on W2 and implemented a Doctors' Book, i.e. a note book that contained requests for all the non-urgent tasks to be done by doctors. Requests were recorded by staff nurses during the day and the book was checked regularly by junior doctors on both wards. - The idea was explained to staff nurses and junior doctors and was given the green light from both ward managers. Results Following the first intervention, the total number of bleeps fell for one weekend but climbed back to baseline levels by the next weekend. The number of inappropriate bleeps did not decrease at all. Ward staff commented that, after two weeks, the posters were ‘just another piece of furniture’ and that their effect was tailing off. Two of the posters went missing from one of the wards and were never found.

imbed back to baseline levels by the next weekend. The number of inappropriate bleeps did not decrease at all. Ward staff commented that, after two weeks, the posters were ‘just another piece of furniture’ and that their effect was tailing off. Two of the posters went missing from one of the wards and were never found. It seemed clear that this first test of change was not sufficient to produce a sustained change and so we implemented the second PDSA. After introducing the Doctors' Job Book on W1, the number of inappropriate bleeps fell below baseline and has stayed at this new level. The idea was widely accepted by staff and we received positive feedback from both wards. It was felt that the book reminded doctors to complete routine tasks and saved both nursing and medical staff time by reducing the need for repetitive calls to the ward. Following the success of the second intervention, a meeting was arranged with junior doctors on both wards to explain and embed the work. An explanation of the Doctors' Book was also added to the wards' induction information for the benefit of future cohorts of junior doctors. We will revisit the wards in eight weeks to ensure that improvements are embedded with the staff. See supplementary file: ds1879.xls - “Charts showing 1. the total number of bleeps from both wards over the study period. 2. Chart showing bleeps for routine work” Lessons and Limitations We have learned several lessons from carrying out our project: Simple changes can result in improvement.

Following the success of the second intervention, a meeting was arranged with junior doctors on both wards to explain and embed the work. An explanation of the Doctors' Book was also added to the wards' induction information for the benefit of future cohorts of junior doctors. We will revisit the wards in eight weeks to ensure that improvements are embedded with the staff. See supplementary file: ds1879.xls - “Charts showing 1. the total number of bleeps from both wards over the study period. 2. Chart showing bleeps for routine work” Lessons and Limitations We have learned several lessons from carrying out our project: Simple changes can result in improvement. However, the process is iterative. More than one test may be necessary and repeated measurement is needed to demonstrate improvement. Engagement and feedback from stakeholders is vital for the design and implementation of a successful project. Team work is important. This project would probably not have been successful without the input of both clinical and improvement staff. Close involvement is necessary in the early stages of a project, if it is not to falter. We acknowledge our lack of balance measures for this project i.e. a measure to ensure that the changes did not also have unwanted results.

Team work is important. This project would probably not have been successful without the input of both clinical and improvement staff. Close involvement is necessary in the early stages of a project, if it is not to falter. We acknowledge our lack of balance measures for this project i.e. a measure to ensure that the changes did not also have unwanted results. Conclusion Reducing the time that Junior Doctors spend on routine tasks is a worthwhile goal of improvement work as it may increase the time available to both nursing and medical staff for direct patient care. Our implementation of two small changes resulted in such a reduction on two of our medical wards at the weekends. We feel that this project was simple and could be easily implemented in other wards and hospitals. Our challenge now is to ensure that the improvements we have seen are sustained and handed over to the next cohort of junior doctors. Supplementary Material Web supplement Web supplement Huge thanks to Dr. Anna Girolami for the invaluable guidance and the inspiring remarks. Thanks are also extended to Dr. Sally Davies, the entire team of service improvement at Sheffield Teaching Hospitals and the nursing and medical staff who have willingly implemented these changes so effectively despite working in an extremely challenging environment. Declaration of interests: Nothing to declare

Problem Patients are often subjected to distressing investigations and treatments, inappropriate to their presentation, by on-call doctors who are forced to make treatment escalation decisions without detailed knowledge of the patient's circumstances. This problem arises because of difficulties in documenting treatment limits in the medical notes, and inherent lack of continuity as a result of on-call cover. At the RUH, there was no standardised method for recording these important decisions in the medical notes. Background Treatment escalation describes an increasing the complexity of care for patients up to a designated ‘ceiling of treatment’. An experienced clinician, with knowledge of both the patient and problem, often after discussion with the patient and family, can designate an appropriate ceiling to treatment. A quality improvement project was undertaken to improve decision making and documentation of escalation of treatment, in line with the recent NCEPOD report (1). The work took place at the RUH, a medium sized district general hospital in South West England. The RUH previously used a DNAR form - an intervention at the very end of a spectrum of treatment options. Often no ceiling of treatment decision was documented in patients' medical notes, leading to inappropriate treatment/investigation and difficult decisions for out-of-hours doctors.

Problem Until about 7 years ago, the poor outcome for patients with malignant brain tumours, predominantly glioblastoma (GBM), meant that therapeutic nihilism pervaded the management of brain tumour patients in the United Kingdom. Radical resection of tumours was inevitably followed by recurrence within the resection bed, despite post-operative adjuvant therapy. This lead to generations of surgeons questioning the role of glioma resection (1). As a result, the surgical management of brain tumours was considered part of general neurosurgery and subspecialised services for managing these patients were poorly developed.

l hospital in South West England. The RUH previously used a DNAR form - an intervention at the very end of a spectrum of treatment options. Often no ceiling of treatment decision was documented in patients' medical notes, leading to inappropriate treatment/investigation and difficult decisions for out-of-hours doctors. The first-hand experience of the authors - having to make difficult out-of-hours treatment decisions without clear guidance from the medical team caring for the patient – was a key motivator for this project. One study documented 96% of patients regarded treatment escalation planning as a positive component of their care (2), and current guidelines advocate the use of a ceiling of treatment approach in acute care (3). Baseline Measurement Alternate sets of notes on the care of the elderly wards were analysed for presence or absence of a documented treatment escalation decision. At baseline, these were mostly weekend plans or specific overnight instructions based on outstanding investigations. The documentation rate for the 57 patients included was 30%. See supplementary file: ds2024.pdf - “figure_one” Design The intervention was an easy to use form, clearly showing a ceiling of treatment for each patient (see figure one). The appearance and content of the form was created after discussion with trainees, consultants, nurses and allied healthcare professionals.

Baseline Measurement Alternate sets of notes on the care of the elderly wards were analysed for presence or absence of a documented treatment escalation decision. At baseline, these were mostly weekend plans or specific overnight instructions based on outstanding investigations. The documentation rate for the 57 patients included was 30%. See supplementary file: ds2024.pdf - “figure_one” Design The intervention was an easy to use form, clearly showing a ceiling of treatment for each patient (see figure one). The appearance and content of the form was created after discussion with trainees, consultants, nurses and allied healthcare professionals. The form was made widely available on the care of the elderly wards and data were again collected for presence of a documented ceiling of treatment decision in the medical notes of each patient. Questionnaire data, collected via email to all medical trainees in the Trust, provided formative feedback for evolution of the form. The results of improved documentation rates, and a refined form incorporating DNAR decisions, were presented to the care of the elderly consultant team and a special interest consultant panel. After further changes at these levels, the form was discussed by the Documents and Legal Review Panel and subsequently instituted as trust protocol for all patients. Strategy PDSA Cycle 1

The results of improved documentation rates, and a refined form incorporating DNAR decisions, were presented to the care of the elderly consultant team and a special interest consultant panel. After further changes at these levels, the form was discussed by the Documents and Legal Review Panel and subsequently instituted as trust protocol for all patients. Strategy PDSA Cycle 1 The initial documentation rate for a treatment escalation decision was 30% for patients on the care of the elderly wards. The plan was to derive an easy to use document for describing treatment escalation decisions. The form was made available on the intervention wards with verbal instructions to all medical staff at the weekly meeting “to use the form if they considered it helpful”. No training was given about its use. After 6 weeks of intervention, documentation rates on the intervention wards improved to 57% (n=113 patients). PDSA Cycle 2 A ‘Survey Monkey’ questionnaire was sent to all trust medical trainees via email. There were 70 respondents to this questionnaire. 67% of trainees (46) had seen the ceiling of treatment form during their on-call shifts. 100% of respondents who had seen the form considered it ‘useful’. Feedback was predominantly positive, mainly describing ease of decision making and time saved when reviewing patients.

ere were 70 respondents to this questionnaire. 67% of trainees (46) had seen the ceiling of treatment form during their on-call shifts. 100% of respondents who had seen the form considered it ‘useful’. Feedback was predominantly positive, mainly describing ease of decision making and time saved when reviewing patients. The main negative feedback concerned replication of information on existing proformas (for example, post-take ward round proforma) and potential overlap with the established DNAR paperwork. The actions during this cycle of change were to combine the DNAR and ceiling of treatment forms and include detailed instructions for use on the reverse. Results The refined and merged form was modified and reviewed at trust legal and consultant level. This was then published as trust protocol for recording resuscitation and treatment escalation decisions (see figure two). Data were collected from the same intervention wards after change of the trust protocol, for the presence or absence of a treatment escalation decision in the medical notes. The observed documentation rate increased to 90% (n=113 patients). See supplementary file: ds2023.pdf - “figure_two”

Results The refined and merged form was modified and reviewed at trust legal and consultant level. This was then published as trust protocol for recording resuscitation and treatment escalation decisions (see figure two). Data were collected from the same intervention wards after change of the trust protocol, for the presence or absence of a treatment escalation decision in the medical notes. The observed documentation rate increased to 90% (n=113 patients). See supplementary file: ds2023.pdf - “figure_two” Lessons and Limitations A key lesson from the project was the inclusion of questionnaire data. The data provided invaluable formative feedback for improvement of the form and also gave specific examples and accounts to illuminate its use. When presenting to senior clinicians and decision makers, accounts from the trainee perspectives provided great insight. Presenting data on improved documentation was key; however individuals accounts of the improvements the form had made to patient care were both emotive and enlightening. The evolution of the ceiling of treatment form is not specific to the RUH; many trusts in the UK are now adopting similar approaches (4). The approach and findings of this project are widely applicable to trusts across the UK.

Lessons and Limitations A key lesson from the project was the inclusion of questionnaire data. The data provided invaluable formative feedback for improvement of the form and also gave specific examples and accounts to illuminate its use. When presenting to senior clinicians and decision makers, accounts from the trainee perspectives provided great insight. Presenting data on improved documentation was key; however individuals accounts of the improvements the form had made to patient care were both emotive and enlightening. The evolution of the ceiling of treatment form is not specific to the RUH; many trusts in the UK are now adopting similar approaches (4). The approach and findings of this project are widely applicable to trusts across the UK. An important limitation to this work is a lack of evidence about the impact on patients and carers. Questionnaire testimony described reduced patient anxiety and eased decision making for doctors, based solely on the opinion of doctors. This study did not collect feedback from the patients' perspective and whether the advent of the ceiling of treatment form improved their experience. This was considered outside the remit of this study but is an important consideration when striving to include patients and carers in the decision-making process.

octors. This study did not collect feedback from the patients' perspective and whether the advent of the ceiling of treatment form improved their experience. This was considered outside the remit of this study but is an important consideration when striving to include patients and carers in the decision-making process. Conclusion Using a designated ceiling of treatment form, and ultimately combining it with a DNAR form, improved the documentation rates of treatment escalation decisions. Rates increased from 30% to 90%, which implies more patients will receive an appropriate level of care in a timely manner. The change of policy has had a lasting effect on patient care at the RUH as out of hours doctors now have consultant endorsed treatment plans for the majority of patients, thus improving patient safety and care. Supplementary Material Web supplement Declaration of interests: Nothing to declare

Problem The two Lead Providers of Postgraduate Medical Education in North West London, Imperial College Healthcare NHS Trust (ICHT) and Central and North West London Mental Health Foundation Trust (CNWL), have assumed responsibility for ensuring that medical trainers are competently trained. Assessment of the training of trainers showed that: Too few trainers were being trained to the required standards. There was widespread local dissatisfaction with existing Train the Trainers provision. There was evidence to indicate poor Trainer performance. Background Professional development of medical trainers has been recommended by the London Deanery and is now a requirement of GMC revalidation. The London Deanery Professional Development Framework (PDF) incorporates 7 domains of competence and is compatible with the GMC requirements (London Deanery, 2012: see Figure 1). The aim is to ensure all medical trainers are appropriately skilled to enhance the quality of postgraduate training and, in turn, attract high calibre trainees who become well trained. Effective training will improve patient safety and quality of service, and avoid sanctions for poorly performing organisations such as the removal of training status. Figure 1: 7 Domains of the London Deanery Professional Development Framework (London Deanery, 2012) London Deanery PDF Framework Ensuring safe and effective patient care through training Establishing and maintaining an environment for learning Teaching and facilitating learning Enhancing learning through assessment Supporting and monitoring educational progress

Figure 1: 7 Domains of the London Deanery Professional Development Framework (London Deanery, 2012) London Deanery PDF Framework Ensuring safe and effective patient care through training Establishing and maintaining an environment for learning Teaching and facilitating learning Enhancing learning through assessment Supporting and monitoring educational progress Guiding personal and professional development Continuing professional development as an educator Local education provider Trusts in London had been encouraged and supported by the London Deanery to build a database of clinical and educational supervisors and their training in order to comply with the GMC's Standards for Trainers (GMC, 2010). Training was accessed from a number of sources. Some supervisors had accessed training provided by the Deanery and other providers, some local education providers had brought in training packages for their staff, and some had developed in-house programmes. Baseline Measurement The assessment by the Lead Providers demonstrated that Too few trainers were being trained to the required standards. The 2011 and 2012 London Deanery census of training showed that coverage fell short of the target of 100% attendance at training in all 7 domains of the Professional Development Framework. Most aspects of required training achieved coverage of 30-80%, training of Educational Supervisors being higher than for Clinical Supervisors. In outlier cases, training attendance in some domains was 0% and in some 100%.

target of 100% attendance at training in all 7 domains of the Professional Development Framework. Most aspects of required training achieved coverage of 30-80%, training of Educational Supervisors being higher than for Clinical Supervisors. In outlier cases, training attendance in some domains was 0% and in some 100%. There was widespread local dissatisfaction with existing Train the Trainers provision. This was evident from feedback in the sector medical educational network where it was reported that uptake of training had been patchy, there was variable engagement of medical staff in the drive for educational excellence, and there were barriers to staff attending training away from their work place. Some consultants' experience of previous training was perceived to be too theoretical and not sufficiently based in the real-life clinical environment There was evidence to indicate poor Trainer performance, with, for example, Red Flags on National Trainee Surveys. This was considered to be consistent with patchy training of trainers as above. See supplementary file: ds1709.docx - “BMJ article v2 figures” Design The T4 programme target is for 100% of trainers to have attended training in the 7 domains of the PDF (London Deanery, 2012) and GMC requirements for approval of trainers (GMC, 2012) as a baseline, with evidence of ongoing professional development thereafter.

See supplementary file: ds1709.docx - “BMJ article v2 figures” Design The T4 programme target is for 100% of trainers to have attended training in the 7 domains of the PDF (London Deanery, 2012) and GMC requirements for approval of trainers (GMC, 2012) as a baseline, with evidence of ongoing professional development thereafter. Stakeholder engagement has been crucial (see Figure 2 for summary of stakeholders). In 2011, the Lead Providers held focus groups across the sector to develop a way forward and secure buy-in. Two strong themes emerged. A course that met GMC standards, and a new model of delivery, was required; it also had to be locally responsive, clinically focused, integrative, sustainable and offer value for money. Figure 2: T4 stakeholder map Responding to this local feedback, T4 builds on 3 essential requirements for a future shape of training: Clinical Leadership and a Collaborative Approach

Stakeholder engagement has been crucial (see Figure 2 for summary of stakeholders). In 2011, the Lead Providers held focus groups across the sector to develop a way forward and secure buy-in. Two strong themes emerged. A course that met GMC standards, and a new model of delivery, was required; it also had to be locally responsive, clinically focused, integrative, sustainable and offer value for money. Figure 2: T4 stakeholder map Responding to this local feedback, T4 builds on 3 essential requirements for a future shape of training: Clinical Leadership and a Collaborative Approach The T4 design builds on an approach of “by Trainers for Trainers”. The programme has been led and designed by experienced Trainers (Lead and Specialty Tutors) to ensure it is based in real-life and relevant to clinical practice. The team emulates collaborative leadership with close working between clinicians, the two Lead Provider organisations, educationalists from the London Deanery, and the sector wide Medical Education leadership network. It recognises the needs of the “expert learner" (Dreyfus & Dreyfus, 1986), utilising discursive and reflective teaching styles. It is designed as a 3 level course (see Figure 3). The content of Levels 1 & 2 is designed to address all 7 areas of the Professional Development Framework. The Level 3 programme, designed for experienced and aspiring local leaders in medical education, is flexible and will address needs responsively. The first workshop, for example, focuses on appraisal and revalidation as it pertains to medical education.

to address all 7 areas of the Professional Development Framework. The Level 3 programme, designed for experienced and aspiring local leaders in medical education, is flexible and will address needs responsively. The first workshop, for example, focuses on appraisal and revalidation as it pertains to medical education. Figure 3: T4 Module Programme Design Cross-Specialty Design and Participation T4 has from the outset combined both Teachers and Learners drawn from Medicine, Surgery and Psychiatry to promote integration of the learning pathway. This brings many benefits - for example, networking, sharing experience and learning from different settings and specialties. The modules above can be taken in any order and attended at any of the local education provider sites across the sector. This further encourages cross specialty training, with consultants and higher trainees from all specialties attending any of the advertised sessions. Local Delivery and Governance Networks

T4 has from the outset combined both Teachers and Learners drawn from Medicine, Surgery and Psychiatry to promote integration of the learning pathway. This brings many benefits - for example, networking, sharing experience and learning from different settings and specialties. The modules above can be taken in any order and attended at any of the local education provider sites across the sector. This further encourages cross specialty training, with consultants and higher trainees from all specialties attending any of the advertised sessions. Local Delivery and Governance Networks T4 has been delivered by the two local Lead Providers at all 11 Provider sites across the sector. To ensure coverage of training across this large geographical area, and at the same time maintain stakeholder engagement, a cascade model of training was adopted. This model, used favourably by the East of England Deanery and commended by the GMC (GMC, 2011), is embedded in the design to maximise sustainability. Factors known to influence a positive outcome of cascade training include: ensuring the training of cascade trainers is contextually appropriate; creating a milieu that supports post-training implementation (Weddell, 2005); providing leadership and accountability for the success of delivery and quality assurance (Draper et al 2009); the training of cascade trainers being experiential and reflective, with materials that are open to reinterpretation without expectation of rigid adherence to prescribed ways of working, diffusion of expertise throughout the system, and engagement of a cross-section of stakeholders in the preparation of training materials (Hayes 2000).

ascade trainers being experiential and reflective, with materials that are open to reinterpretation without expectation of rigid adherence to prescribed ways of working, diffusion of expertise throughout the system, and engagement of a cross-section of stakeholders in the preparation of training materials (Hayes 2000). To date, 14 consultants and higher trainees have volunteered as Local Faculty Development Trainers. Transfer of skill has been cascaded through workshops, observation of Specialty Tutors, micro-teaching sessions, individual coaching, ready access to Specialty Tutors and educational bursaries. The Local Trainers exercise expertise in their service and are local champions for excellence in training. They provide a communication flow between the programme and local providers, and trouble shoot local barriers to engagement. Quality assurance will be provided through direct observation of sessions and ongoing participant feedback. Workshops will be held quarterly to develop the network, gain feedback on the experience of delivering training and to iteratively develop the training materials.

, and trouble shoot local barriers to engagement. Quality assurance will be provided through direct observation of sessions and ongoing participant feedback. Workshops will be held quarterly to develop the network, gain feedback on the experience of delivering training and to iteratively develop the training materials. Strategy Penetration of training coverage is continually monitored by the Lead Providers through attendance data provided to the employee provider Trust. There is regular 3 monthly reporting to a standing item for Faculty Development at the Lead Provider Committee including representation from all Providers and both Lead Providers. A plan of sessions and delivery sites is developed every 3 months. Each plan takes into account recorded demand for each module, waiting lists for attendance, popularity of sites, and feedback from the provider Trusts about training needs. Attendance by specialty is also reviewed, the Specialty Tutors trouble shooting wherever attendance is low in a particular group. This has, for example, led to training modules being delivered as part of specialty meetings in order to facilitate attendance. The modules are delivered as half-day sessions in order to facilitate clinical work for the other half day. However, in response to feedback, some whole day sessions are now provided.

r group. This has, for example, led to training modules being delivered as part of specialty meetings in order to facilitate attendance. The modules are delivered as half-day sessions in order to facilitate clinical work for the other half day. However, in response to feedback, some whole day sessions are now provided. In addition, attendance by grade is reviewed every 3 months. Sixty seven percent of attendees have been consultants, the remainder higher trainees, thus creating the educational workforce of the future. The high consultant workforce attendance was achieved by engaging with our Training Programme Director (TPD), Medical Education Managers (MEM) and Director of Medical Education (DME) network across the sector, with recruitment assisted by their postgraduate departments. Content of the modules and delivery methods have also evolved through an iterative process to ensure the training is meeting the needs of the trainer workforce. This is achieved through 3 monthly reviews of participant feedback in addition to observations from the independent coaches, a survey evaluation conducted in July 2012, and an external evaluation of Level 1 undertaken in August-October 2012. This has led to changes in content with more information available on-line, more emphasis in-session on interactive delivery and the modelling of a dynamic learning environment. Results Outcomes of the programme have been evaluated by attendance numbers, session feedback, a survey of attendees at Level 1 modules, and external evaluation of Level 1.

Content of the modules and delivery methods have also evolved through an iterative process to ensure the training is meeting the needs of the trainer workforce. This is achieved through 3 monthly reviews of participant feedback in addition to observations from the independent coaches, a survey evaluation conducted in July 2012, and an external evaluation of Level 1 undertaken in August-October 2012. This has led to changes in content with more information available on-line, more emphasis in-session on interactive delivery and the modelling of a dynamic learning environment. Results Outcomes of the programme have been evaluated by attendance numbers, session feedback, a survey of attendees at Level 1 modules, and external evaluation of Level 1. Evaluation of penetration has been extremely positive with 834 attendances in 11 months, exceeding the 12 month project target of 350 attendances. Design and delivery commenced with Level 1, modules 1 & 2 (see Figure 4). Figure 4: T4 Attendance May 2012 - March 2013 Figure 5: T4 Attendance by Specialty Cluster Attendance has also been achieved from across all specialities as summarised in Figure 5. Evaluation of content May 2012 to March 2013 via participant feedback demonstrates Level 1 (modules 1 & 2) have 87% & 93% rating as “good\excellent” respectively, and Level 2 (modules 3 & 4) content rating 96% and 98% “good\excellent”. Quality of delivery of the two levels overall has rated 89-98% “good\excellent”.

Attendance has also been achieved from across all specialities as summarised in Figure 5. Evaluation of content May 2012 to March 2013 via participant feedback demonstrates Level 1 (modules 1 & 2) have 87% & 93% rating as “good\excellent” respectively, and Level 2 (modules 3 & 4) content rating 96% and 98% “good\excellent”. Quality of delivery of the two levels overall has rated 89-98% “good\excellent”. The above findings demonstrate high engagement and satisfaction with the training, achieving the aim of improving uptake and focus on medical education excellence across the sector. Further evidence of engagement can be drawn from the volunteering of 14 consultants and higher trainees to join the programme as Local Faculty Development Trainers.

rate high engagement and satisfaction with the training, achieving the aim of improving uptake and focus on medical education excellence across the sector. Further evidence of engagement can be drawn from the volunteering of 14 consultants and higher trainees to join the programme as Local Faculty Development Trainers. Impact on quality of training has been assessed by changes the trainer participants have stated they have made. This has mostly related to learning styles and the learning environment. Indicative comments include: “Think more about training as a process that should be flexible/adaptable but dogmatically done”; “More structured plan for learning”; “Ensure I make time for trainees”; “Find ways to engage the trainees with the rest of the team in innovative ways”; “Many things around induction”; “Adapt and learn from trainees and their styles”. In the on-line survey of attendees (July 2012), responses from trainers evidenced improved confidence, improved knowledge of educational roles, improved clinical supervision skills, and increased skill in recognition of the trainee in difficulty, careers advise resources, use of feedback and completion of workplace based assessments.

survey of attendees (July 2012), responses from trainers evidenced improved confidence, improved knowledge of educational roles, improved clinical supervision skills, and increased skill in recognition of the trainee in difficulty, careers advise resources, use of feedback and completion of workplace based assessments. An external evaluation of Level 1 modules using in-depth interviews showed that new trainers were excited by the programme and emerged with many ideas about how different trainees learn. The changes in behaviour they reported included enhanced supervision skills, use of reflection as a learning method, and the value of goal setting. The training was also reported to have provided a valuable space for moderation of practice. See supplementary file: ds1710.docx - “BMJ article V2 Figure 4 & 5” Lessons and Limitations Regular review of module content, delivery and attendance is needed to ensure the programme remains responsive to need. This has taken place as above with input from participant feedback, live-observation of sessions, consultation with the Deanery Faculty Development team and experience of the Specialty Tutors. The modules will continue to be developed iteratively with increasing input from the Local Faculty Development Trainers as they gather experience of session delivery.

t from participant feedback, live-observation of sessions, consultation with the Deanery Faculty Development team and experience of the Specialty Tutors. The modules will continue to be developed iteratively with increasing input from the Local Faculty Development Trainers as they gather experience of session delivery. Establishment of and communication with an educational network is required to shape and drive the uptake of training. As stated in a recent review of networks in healthcare (Randall, 2013), networks are useful for delivering services in ways that make the most of network members' capability and resources, in this case defining and delivering training standards. Ongoing communication and awareness of the programme in the network will be essential to its sustainability. It is anticipated that developing the voice of trainees within the Local Trainer group will assist by providing focus on the purpose and importance of Faculty Development. The cascade of skills and support has proved invaluable resulting in considerably improved teaching skills, coaching skills and support across a network of trainers. Repeat census data is not yet available to provide comparison from the baseline. The London Deanery 2013 Census of Faculty Development training is awaited. The T4 attendance data would, however, indicate there will have been improvement in uptake of training.

s, coaching skills and support across a network of trainers. Repeat census data is not yet available to provide comparison from the baseline. The London Deanery 2013 Census of Faculty Development training is awaited. The T4 attendance data would, however, indicate there will have been improvement in uptake of training. Whilst the programme has developed with considerable energy and enthusiasm in the first 12 months, maintaining consistent quality of delivery and the commitment and drive of the Faculty team will require attention. This is particularly relevant as we move into a new phase of delivery with extended membership and a more diffuse group of trainers. Focus will be needed on the structure, leadership and management of the Faculty network (Randall, 2013). The ultimate test of improvement is the experience of trainees. Whilst this is difficult to capture in a meaningful way, the GMC Trainee Survey data will provide an indicator of change and will be reviewed year on year. Further development of quality metrics are needed to identify the impact and complexity of Faculty Development interventions. The use of Kirkpatrick's model for evaluating educational outcomes might provide a way forward (Kirkpatrick, 1994).

ey data will provide an indicator of change and will be reviewed year on year. Further development of quality metrics are needed to identify the impact and complexity of Faculty Development interventions. The use of Kirkpatrick's model for evaluating educational outcomes might provide a way forward (Kirkpatrick, 1994). Conclusion T4 has demonstrated that Lead Provider partnership initiatives can improve quality of training through creation of sector-wide educational networks. One outcome that we underestimated was the enthusiasm for and usefulness of the network. We intend building on this. Making training relevant through design and delivery by clinicians, and easily accessible by delivery at the work place, enhances the engagement of medical trainers. Supplementary Material Web supplement The T4 programme was initially sponsored by the London Deanery. The Faculty Development team at the London Deanery have been of huge support in developing this programme. The input of Dr Catherine O'Keefe and Dr John Launer, in particular, has been greatly valued. Declaration of interests: Nothing to declare

Problem Progression to end-stage renal disease (ESRD) is a major issue for heath care systems both clinically and financially. There are currently over a million patients worldwide on dialysis, with the number increasing by ~7% yearly, particularly in the elderly, many of whom have significant extra-renal comorbidities and will do poorly on dialysis. [1] Furthermore, dialysis is expensive costing ~£30,000 per patient per year in the UK. [2] Given dialysis may not prolong life and may indeed impair quality of life alternative options for these patients such as conservative care are urgently needed. Background Chronic kidney disease (CKD) is a major health problem affecting 10-16% of the world's general adult population. [3–8] Progression to ESRD remains a major clinical problem and there are currently over a million patients worldwide on dialysis, with the number increasing by ~7% yearly, particularly in the elderly, many of whom are dependent and frail. [1] Furthermore, survival once on dialysis is poor.

d's general adult population. [3–8] Progression to ESRD remains a major clinical problem and there are currently over a million patients worldwide on dialysis, with the number increasing by ~7% yearly, particularly in the elderly, many of whom are dependent and frail. [1] Furthermore, survival once on dialysis is poor. The benefits of dialysis for elderly, dependent patients with ESRD have been questioned. The prospects for rehabilitation in such patents tend to be slim, and prognosis is often poor. [9, 10] Dialysis in such circumstances can pose huge additional burdens for patients and their carers. In recent years, the concept of the “Conservative Care Programme” (CCP) has gained sway in an attempt to provide a comprehensive package of care to patients who have chosen to forego dialysis. Conservative management of ESRD involves a shift from efforts to prolong life to those that focus on care, quality of life and symptom control. Baseline Measurement Our assessment of the scale of the problem was qualitative. Many of us have many years of experience working as part of a multi-disciplinary team looking after patients on dialysis. We have all witnessed first-hand how difficult dialysis could be for the elderly and their families and were thus moved to instigate a CCP in our unit. Design Intervention: appointment of a Conservative Care Programme (CCP) Nurse Specialist

Baseline Measurement Our assessment of the scale of the problem was qualitative. Many of us have many years of experience working as part of a multi-disciplinary team looking after patients on dialysis. We have all witnessed first-hand how difficult dialysis could be for the elderly and their families and were thus moved to instigate a CCP in our unit. Design Intervention: appointment of a Conservative Care Programme (CCP) Nurse Specialist We appointed a dialysis charge nurse who had many years of experience of working with patients on dialysis to spearhead the newly set up CCP in Edinburgh. The rationale was to work as part of the renal multidisciplinary team to support patients and their families to make an informed shared decision whether to opt for dialysis or to follow the CCP. The CCP targets the active treatment of symptomatic anaemia, fluid overload, blood pressure control and management of uraemic symptoms to promote the best quality of life. The programme allows these patients to receive the best quality of care but without having to attend the hospital on a regular basis to receive this care. The CCPI also aims to provide bereavement counselling for families and carers. Challenges to setting up a CCP

The CCP targets the active treatment of symptomatic anaemia, fluid overload, blood pressure control and management of uraemic symptoms to promote the best quality of life. The programme allows these patients to receive the best quality of care but without having to attend the hospital on a regular basis to receive this care. The CCPI also aims to provide bereavement counselling for families and carers. Challenges to setting up a CCP The CCP nurse specialist is the key figure involved in setting up, and in the success of, a CCP. This individual should have extensive experience of working with patients with advanced renal failure and those on dialysis but also possess the key qualities essential for the CCP, namely excellent communication skills, the ability to liaise with other health care professionals in both primary and secondary care, and the ability to work as part of a multi-disciplinary team.

ng with patients with advanced renal failure and those on dialysis but also possess the key qualities essential for the CCP, namely excellent communication skills, the ability to liaise with other health care professionals in both primary and secondary care, and the ability to work as part of a multi-disciplinary team. The engagement of other members of the renal unit (especially the medical team) in the CCP is important. Patients with CKD can only choose conservative care as the management of their ESRD if this is an option offered by their nephrologist. In order to engage others, the CCP nurse specialist needs to have a positive attitude to conservative care. To raise the profile of the CCP we have had positive feedback from patients and their families directly to their nephrologist showing them directly the utility of this programme. We have also provided in-house education to all members of the renal team as well as education days to GPs and health care professionals in primary care to raise awareness of the CCP.

d positive feedback from patients and their families directly to their nephrologist showing them directly the utility of this programme. We have also provided in-house education to all members of the renal team as well as education days to GPs and health care professionals in primary care to raise awareness of the CCP. Strategy Given the qualitative parameters of the role of the CCP Nurse Specialist the strategy for improvement was experience based with each patient (and their family) encounter informed by those preceding it. The role of the CCP Nurse Specialist has developed from solely being involved in hospital care to working in partnership with the multidisciplinary team both in primary and secondary care. In primary care, they interface directly with the patient, their carers and family and provide education and support. They also discuss the patient's care with their GP, district nurses, and community palliative care team, with an emphasis on advance care planning. When the patient is in hospital they are involved in discussions with the medical team, occupational therapists, physiotherapists, social workers, nursing staff, palliative care team and the members of the spiritual care team. At the centre of these discussions is the patient along with their family and other carers. The CCP Nurse Specialist supports patients “opting out” of dialysis initiation as well as those withdrawing from dialysis. Importantly, they provide a strong communication link between the primary and secondary care givers as well as providing a voice for the patient and their families through their independent reviews. The focus of their discussion is centred around the importance of symptom control and quality over quantity of life.

sis. Importantly, they provide a strong communication link between the primary and secondary care givers as well as providing a voice for the patient and their families through their independent reviews. The focus of their discussion is centred around the importance of symptom control and quality over quantity of life. Results Qualitative Results From the perspective of the patients, their families and carers we have received positive feedback since starting the CCP - thank you cards; phone calls both to the CCP Nurse Specialist and the renal unit affirming the positive experience patients had during the conservative management of their renal failure. We have also had money donated to the renal unit to support future work in this area. Phrases used by families and carers of patients include: “Professional, dedicated, source of friendship, moral support, help, understanding, kindness, Loved one allow to die with dignity, Patient's wishes met, Good death, A special person, Wonderful support, Thanks for keeping loved one as well as possible to the end" Quantitative Results

Phrases used by families and carers of patients include: “Professional, dedicated, source of friendship, moral support, help, understanding, kindness, Loved one allow to die with dignity, Patient's wishes met, Good death, A special person, Wonderful support, Thanks for keeping loved one as well as possible to the end" Quantitative Results Whilst continuing to provide the best quality of care to renal patients in NHS Lothian and Borders, the number of prevalent dialysis patients in our catchment area has fallen significantly over the last few years as demonstrated by Scottish Renal Registry (SRR) data (see Figure 1). According to the SRR reports the median age of incident patients starting dialysis in Lothian in 2004 was 64 years and this has fallen to 58 in 2012. Furthermore, the age-standardised incidence of new patients starting dialysis in 2007-2011 in NHS Lothian was 8.9 per 100,000 population, compared to 10.4/100,000 for Scotland as a whole. At any one time we have ~100 patients on the CCP casebook, ~25% of whom have an estimated GFR >10ml/min so who would otherwise be on dialysis. In addition, the CCP Nurse Specialist is involved in the care of 3-5 patient deaths/month. See supplementary file: ds1693.docx - “Figure 1” Lessons and Limitations Our experiences in NHS Lothian of a CCP are potentially more widely applicable to the UK. We plan to use the data and experiences accrued in our centre to improve health care provision for those patients not wishing to pursue dialysis as a treatment option for their ESRF. We will plan to do this in a number of ways:

ns Our experiences in NHS Lothian of a CCP are potentially more widely applicable to the UK. We plan to use the data and experiences accrued in our centre to improve health care provision for those patients not wishing to pursue dialysis as a treatment option for their ESRF. We will plan to do this in a number of ways: Continued presentations at national renal meetings Teaching sessions for nursing, medical and allied health professionals both locally and nationally – the latter through workshops at national meetings Continued dialogue with the standard palliative care teams both locally and through presentations and workshops at national meetings – this will improve renal-specific knowledge for these health care professionals Working towards anticipatory care planning for selected dialysis patients with a view to planning for a ‘good death’ Given the increasing use of the CCP in Edinburgh, as well as the expanding role of the CCP nurse specialist, we have now employed another full-time CCP nurse specialist which allows for succession planning.

Working towards anticipatory care planning for selected dialysis patients with a view to planning for a ‘good death’ Given the increasing use of the CCP in Edinburgh, as well as the expanding role of the CCP nurse specialist, we have now employed another full-time CCP nurse specialist which allows for succession planning. Conclusion Progression to ESRD is a major issue for heath care systems both clinically and financially. Given dialysis may not prolong life and indeed impair quality of life alternative options for these patients, such as conservative care, are urgently needed. The introduction of a CCP in our unit has not only improved patient care and quality of life but, whilst continuing to provide the best quality of care to renal patients in NHS Lothian and Borders, the number of prevalent dialysis patients in our catchment area has also fallen. These benefits are potentially applicable to other renal units across the UK. Supplementary Material Web supplement Declaration of interests: None of the authors have any declaration of interests.

Problem For current UK junior doctors learning how to write discharge letters is very much a ‘see one, do one, teach one’ approach, and judgement and experience dictate the information written in such letters. For patients undergoing complex medical procedures, such as permanent pacemaker insertion, important information regarding the procedure needs to be documented within the interim discharge letter sent to the patient's GP. Copies of this letter are also kept in the patients notes and a copy is sent home with the patient. A lack of easily accessible guidelines meant that junior doctors struggled to identify the required information that should be documented in a patient's discharge letter after pacemaker insertion. As a result they were discharging patients with substandard discharge summaries that were of little use to GPs and follow up clinicians post-procedure. This was evident when a local GP had to phone the cardiology ward because the discharge letter they had received contained no explanation of the indication or follow up details for a pacemaker implanted in one of their practice's patients.

ummaries that were of little use to GPs and follow up clinicians post-procedure. This was evident when a local GP had to phone the cardiology ward because the discharge letter they had received contained no explanation of the indication or follow up details for a pacemaker implanted in one of their practice's patients. Background The Royal College of Physicians outlines essential headings that should be included in hospital discharge documentation in its April 2013 guideline ‘Consistent structure and content standards for admission, handover, discharge, outpatient and referral records and communications’. This guideline does not, however, outline recommended information for specific procedures such as permanent pacemaker insertion. There are currently no national guidelines from the European Society of Cardiology regarding the information that should be contained within interim discharge letters written by hospital ward doctors. Patients, GPs and follow up clinicians need comprehensive documentation of their patient's previous care to elicit an accurate past medical history. This is even more essential in the acute setting, where medical professionals need clear information regarding previous surgery such as a permanent pacemaker insertion. Failure to do so may result in needless expenditure of time and resources with compromise of patient care.

to elicit an accurate past medical history. This is even more essential in the acute setting, where medical professionals need clear information regarding previous surgery such as a permanent pacemaker insertion. Failure to do so may result in needless expenditure of time and resources with compromise of patient care. Baseline Measurement In this project, ten ward discharge letters were audited prior to the introduction of the discharge proforma on the cardiology ward. The letters were reviewed by hand to evaluate the information they contained. The following details were required to be included according to the local trust guidance. These included: date and indication for insertion, pacemaker type, make and model, access route, complications, chest x-ray and device check results, and follow-up details. Finally, a copy of the letter was to be sent to the cardiology department for clinic follow-up. The results showed that all ten of the audited letters were missing significant and important pieces of information. See supplementary file: ds1859.docx - “Percentage of discharge letters containing required information prior to introduction of proforma.”

Baseline Measurement In this project, ten ward discharge letters were audited prior to the introduction of the discharge proforma on the cardiology ward. The letters were reviewed by hand to evaluate the information they contained. The following details were required to be included according to the local trust guidance. These included: date and indication for insertion, pacemaker type, make and model, access route, complications, chest x-ray and device check results, and follow-up details. Finally, a copy of the letter was to be sent to the cardiology department for clinic follow-up. The results showed that all ten of the audited letters were missing significant and important pieces of information. See supplementary file: ds1859.docx - “Percentage of discharge letters containing required information prior to introduction of proforma.” Design After discussion with the cardiology ward's junior doctors it was highlighted that the swift four month rotation of trainee medical staff was contributing to the problem. Junior doctors, sometimes in their first medical job, were required to produce discharge letters for pacemaker patients containing all of the relevant information stipulated in the trust guidelines. The problem was that these doctors did not know that these guidelines existed or where to find them.

ting to the problem. Junior doctors, sometimes in their first medical job, were required to produce discharge letters for pacemaker patients containing all of the relevant information stipulated in the trust guidelines. The problem was that these doctors did not know that these guidelines existed or where to find them. The easiest method to improve this problem was to create a discharge template for junior doctors writing letters for patients having permanent pacemakers implanted. This would be permanently located next to the computer that was used to type the summaries. The template would essentially be a published version of the guidelines giving ward doctors a quick and easy to follow document when typing discharge summaries. Strategy The proforma was discussed with and approved by the hospital's consultant cardiologists. It was then put up on the cardiology ward next to the computer used to type discharge letters. A random selection of ten discharge letters in the month following the proforma's introduction were audited against the criteria highlighted in the guidelines to gauge its effectiveness. The ward's junior doctors gave very positive feedback regarding the simple yet comprehensive document. The proforma's results were so positive that it was left on the ward for re-audit in one year's time.

proforma's introduction were audited against the criteria highlighted in the guidelines to gauge its effectiveness. The ward's junior doctors gave very positive feedback regarding the simple yet comprehensive document. The proforma's results were so positive that it was left on the ward for re-audit in one year's time. One year later and the original proforma had been lost and retyped by one of the junior doctors on the ward at that time. The proforma had been incorrectly transcribed and one of the important criteria (copying discharge summaries to the cardiology department) was no longer at the foot of the document. As a result, the original proforma was re-issued and also published onto the trust intranet so that it could be quickly re-printed if the original was lost. It was also decided that for patients who had to be boarded to other medical wards, a copy of the proforma would be printed and attached to the patients notes by the catheterisation laboratory staff. This would enable the junior doctors from other medical wards to produce discharge letters to the same standard as the cardiology ward. The ward clerks were also informed at this point that they needed a fourth copy of each letter to send to the cardiology department. The audit cycle will be completed again for a third time in October 2014.

One year later and the original proforma had been lost and retyped by one of the junior doctors on the ward at that time. The proforma had been incorrectly transcribed and one of the important criteria (copying discharge summaries to the cardiology department) was no longer at the foot of the document. As a result, the original proforma was re-issued and also published onto the trust intranet so that it could be quickly re-printed if the original was lost. It was also decided that for patients who had to be boarded to other medical wards, a copy of the proforma would be printed and attached to the patients notes by the catheterisation laboratory staff. This would enable the junior doctors from other medical wards to produce discharge letters to the same standard as the cardiology ward. The ward clerks were also informed at this point that they needed a fourth copy of each letter to send to the cardiology department. The audit cycle will be completed again for a third time in October 2014. Results Evaluation of the intervention was initially measured at one month post introduction of proforma and then at one year post introduction. Ten discharge letters were audited in the month following the proforma being placed on the cardiology ward. Each letter was accessed from the departments online discharge database to assess which pieces of information it contained against the recommendations set out in the trust guidelines.

one year post introduction. Ten discharge letters were audited in the month following the proforma being placed on the cardiology ward. Each letter was accessed from the departments online discharge database to assess which pieces of information it contained against the recommendations set out in the trust guidelines. This initial audit revealed that all ten letters in the month following the introduction of the proforma contained 100% of the required information as set out in the guidelines. This included 1) Date of insertion 2) Indication for insertion Pacemaker type (DDDR VVIR etc) 4) Manufacturer and model 5) Route 6) Complications 7) Post op CXR and check results 8) Follow-up details and finally whether a copy of the letter was received by the cardiology department. One year following the introduction of the proforma, 70 discharge letters were again audited via the same method as 11 months previously. Again all 70 letters contained 100% of the required content. However only 37 letters (53%) had been copied across and received by the cardiology department secretaries. Please see discussion for how this is going to be addressed for the next cycle of improvement. See supplementary file: ds1860.docx - “Proforma Results”

One year following the introduction of the proforma, 70 discharge letters were again audited via the same method as 11 months previously. Again all 70 letters contained 100% of the required content. However only 37 letters (53%) had been copied across and received by the cardiology department secretaries. Please see discussion for how this is going to be addressed for the next cycle of improvement. See supplementary file: ds1860.docx - “Proforma Results” Lessons and Limitations The life of a ward junior doctor in the NHS is a very busy one. They frequently have to multi-task, which can lead to errors. The impact of this can vary from minor to life threatening. Training rotations every four months means that these doctors have to learn new and rotation specific skills very quickly. This project has shown that a simple document can dramatically improve the quality of discharge letters by giving these doctors a quick and easy guide to the information that needs to be contained in such documents. The one year cycle has shown that only half of the letters are being copied to the cardiology department despite the effectiveness of the proforma in the other eight areas. This has highlighted that change and improvement is a gradual process; sometimes all areas cannot be targeted at once. Clinical audit is invaluable in this process, enabling healthcare professionals to evaluate their department's performance in specific areas against local and national standards.

the other eight areas. This has highlighted that change and improvement is a gradual process; sometimes all areas cannot be targeted at once. Clinical audit is invaluable in this process, enabling healthcare professionals to evaluate their department's performance in specific areas against local and national standards. Conclusion A set of guidelines in the form of a simple published document on the cardiology ward has enabled regularly rotating junior doctors to produce consistently high quality e-discharge letters for patients leaving hospital after undergoing permanent pacemaker implantation. The project has highlighted that clinical guidelines need to be readily accessible to those using them in order to be as effective as possible. Supplementary Material Web supplement Dr Honey Thomas, Dr Daniel Higham, Dr Craig Runnett, Dr Andrew Mcleod. Declaration of interests: Nothing to declare.

Problem Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness.[1] Over the last 10 years, one of the key themes of public policy in palliative care has been achievement of choice in place of death. [2,3] A YouGov survey conducted on behalf of Marie Curie Cancer Care in 2005, reported that up to 75 per cent of the general public would choose to die at home; Marie Curie Cancer Care used this and other information in their UK campaign for greater support for people's choice in place of death. In Marie Curie Hospice Edinburgh, a baseline audit relating to the period November 2005 to March 2006 showed that less than one fifth of patients cared for by the hospice services died at home (30/164 patients). Given the relatively low proportion of home deaths in comparison to the high proportion of preferences for a home death reported in national reports, it became clear that a better understanding of patient preference and improvements in achievement of preference was required. This difference between public campaign and local practice led the hospice senior management team to initiate a programme of quality improvement to improve achievement of patient wishes for place of death.

lear that a better understanding of patient preference and improvements in achievement of preference was required. This difference between public campaign and local practice led the hospice senior management team to initiate a programme of quality improvement to improve achievement of patient wishes for place of death. Three key issues were found to compound the difference. Firstly, existing documentation needed to be improved. The preferred place of death assessment form needed to be reformatted so that more detailed information on patient preferences could be collected and reviewed. Secondly, the challenging nature of assessing place of death preferences meant that some staff avoided initiating discussions about preferred place of death. There was clearly a need to develop the skills of staff in this area. Thirdly, resources needed to be balanced to support dying at home where this was preferred by the patient and family. It was clear that there were sufficient inpatient beds to support a preference to die at the hospice, but not the same resource to support patients who wished to be at home. The lack of rapid access to support at home needed to be addressed. Background To have choice and control over where death occurs is important for a good quality of end of life.[4, 5] Consequently, national end of life care strategies recommend that healthcare professionals involve patients approaching end of life, and their carers, in discussions about preferred place of death in order to identity and meet their wishes.[2, 3]

where death occurs is important for a good quality of end of life.[4, 5] Consequently, national end of life care strategies recommend that healthcare professionals involve patients approaching end of life, and their carers, in discussions about preferred place of death in order to identity and meet their wishes.[2, 3] Much evidence over the last decade has suggested that the majority of the general public would choose home as their preferred place.[6] Findings from studies examining the preferences of patients with advanced illness are mixed, with some reporting that most patients have a home preference [7, 8] and others revealing patient preferences for hospice.[9, 10] Given that preferences will vary depending on a range of patient, carer, environmental and informational factors, systems that support discussions about preferences are required, and quality measures that emphasize the proportion of patients dying in their preferred place need to be prioritised.

ces for hospice.[9, 10] Given that preferences will vary depending on a range of patient, carer, environmental and informational factors, systems that support discussions about preferences are required, and quality measures that emphasize the proportion of patients dying in their preferred place need to be prioritised. Open discussion about preferences facilitates anticipatory care planning for patients and helps reduce inappropriate hospital admission at the end of life.[11] Patients who express a preference are less likely to die in hospital compared with those who do not;[10] and are more likely to die at home than in any other location.[12] Congruence between preferred and actual place of death varies greatly with congruence rates (percentage of met preferences for all locations of death) ranging from 30% to 91% being reported.[13] Interventions that promote congruence between preferred and actual place of death are required in many settings.

ocation.[12] Congruence between preferred and actual place of death varies greatly with congruence rates (percentage of met preferences for all locations of death) ranging from 30% to 91% being reported.[13] Interventions that promote congruence between preferred and actual place of death are required in many settings. The Preferred Priorities for Care (PPC) tool was developed in 2006 in order to facilitate discussions around end of life care wishes and preferences and to enable communication of care planning and decisions across care contexts (NHS Support Sheet 18). The PPC documentation asks patients to record their preferences and priorities for their future care, and where they would like to be cared for. The document is usually completed by the patient, who then shares it with anyone who is, or likely to be, involved in their care. Recent evaluative studies suggest that this tool is helpful in communicating patient's wishes across care settings.[14] While the PPC is a useful tool, documentation emphasizing continual and proactive review of preferences was deemed more useful for identifying preferences of patients in a specialist palliative care setting. In this context, Marie Curie Hospice Edinburgh began a programme of improvement to develop systems to support preference identification; and to increase the overall proportion of patients under the care of any hospice service, who die in their place of choice. Baseline Measurement Baseline audit:

The Preferred Priorities for Care (PPC) tool was developed in 2006 in order to facilitate discussions around end of life care wishes and preferences and to enable communication of care planning and decisions across care contexts (NHS Support Sheet 18). The PPC documentation asks patients to record their preferences and priorities for their future care, and where they would like to be cared for. The document is usually completed by the patient, who then shares it with anyone who is, or likely to be, involved in their care. Recent evaluative studies suggest that this tool is helpful in communicating patient's wishes across care settings.[14] While the PPC is a useful tool, documentation emphasizing continual and proactive review of preferences was deemed more useful for identifying preferences of patients in a specialist palliative care setting. In this context, Marie Curie Hospice Edinburgh began a programme of improvement to develop systems to support preference identification; and to increase the overall proportion of patients under the care of any hospice service, who die in their place of choice. Baseline Measurement Baseline audit: All patients referred to Marie Curie Hospice Edinburgh between 1st November 2005 and 7th March 2006 were included from the outset (181 patients). Seventeen patients died before the hospice had contact with them and were excluded, leaving 164 patients. Of the 164 patients, 70% died in the hospice, 18% died at home, 10% died in hospital and 2% died in a nursing home. (Supplementary Material – Table 1)

All patients referred to Marie Curie Hospice Edinburgh between 1st November 2005 and 7th March 2006 were included from the outset (181 patients). Seventeen patients died before the hospice had contact with them and were excluded, leaving 164 patients. Of the 164 patients, 70% died in the hospice, 18% died at home, 10% died in hospital and 2% died in a nursing home. (Supplementary Material – Table 1) In terms of preference for place of death, there was no record of any assessment for 29% of patients. Of the 116 patients who had a recorded preference, 60% expressed a preference to die at home, 37% expressed a preference to die at the hospice; 2% chose a nursing home and 1% chose a hospital setting. (Supplementary Material – Table 2) Overall 56% of patients with a recorded preference died in their preferred place (65/116). Of those who nominated the hospice or care home as their preference, 91% died in their preferred setting. Only 31% of those who expressed a preference to die at home actually died at home. See supplementary file: ds2074.JPG - “Table 1”

Overall 56% of patients with a recorded preference died in their preferred place (65/116). Of those who nominated the hospice or care home as their preference, 91% died in their preferred setting. Only 31% of those who expressed a preference to die at home actually died at home. See supplementary file: ds2074.JPG - “Table 1” Design First, the senior management team reviewed and revised the existing documentation relating to preferred place of death (PPoD) assessment. The structure of the original documentation meant that staff only felt able to record a categorical preference - this made it difficult during subsequent review to identify whether a discussion about preferences had happened, and any reasons why it might not have taken place. The documentation did not differentiate between discussions not taking place and situations in which patients had said that they were unsure about preference. Introducing some descriptors of reasons for not discussing PPoD (e.g. ‘not known the patient for long enough’, or ‘it may cause the patient too much distress’) reflected the reality of the process of an emerging shared understanding of a plan. Serial recording of ‘assessments’ reinforced this sense of a continuing process of discussion and planning, reducing the times where there was no recorded preference.

nt for long enough’, or ‘it may cause the patient too much distress’) reflected the reality of the process of an emerging shared understanding of a plan. Serial recording of ‘assessments’ reinforced this sense of a continuing process of discussion and planning, reducing the times where there was no recorded preference. Secondly, the team decided to introduce an expectation of discussing PPoD at each inpatient multidisciplinary team meeting, emphasising the importance of making plans for each patient and enabling clarification when team members held different views or perspectives. Similar processes for review were adopted in the community and day services provided by the hospice. Making the process a routine part of the multidisciplinary meeting also enabled problems to be anticipated and solutions identified. Next, we emphasised the need to discuss ‘preferred place of death’ with patients and families rather than ‘preferred place of care’ as place of death discussions seemed to lead to clearer plans when patients deteriorated. Leadership from senior members of the team was necessary to engage all members of the team in this important difference. Discussions where a patient wanted something that the staff thought was not achievable was initially a challenge. As our team's understanding developed we became more comfortable with the idea that we would not be able to achieve the preference for all our patients. It became possible to share our concerns or problems with the patient and family and arrive at a consensus as each patient's story unfolded. Strategy PDSA cycle 1

Next, we emphasised the need to discuss ‘preferred place of death’ with patients and families rather than ‘preferred place of care’ as place of death discussions seemed to lead to clearer plans when patients deteriorated. Leadership from senior members of the team was necessary to engage all members of the team in this important difference. Discussions where a patient wanted something that the staff thought was not achievable was initially a challenge. As our team's understanding developed we became more comfortable with the idea that we would not be able to achieve the preference for all our patients. It became possible to share our concerns or problems with the patient and family and arrive at a consensus as each patient's story unfolded. Strategy PDSA cycle 1 Our first aim was to increase the proportion of patients who had a recorded place of death preference; or a reason why preference was not known. The senior management team designed and introduced a structured preferred place of death assessment form. This new form included a section allowing the clinician to select reasons why a preference was not recorded. The form also included space for multiple assessments to point towards a process of regular review. A reaudit six months after the introduction of the new documentation showed that it was still being used inconsistently. Staff had found some of the wording and concepts difficult to use. PDSA cycle 2

the resection bed, despite post-operative adjuvant therapy. This lead to generations of surgeons questioning the role of glioma resection (1). As a result, the surgical management of brain tumours was considered part of general neurosurgery and subspecialised services for managing these patients were poorly developed. Cambridge was no different from the rest of the United Kingdom. Patients were admitted to the neurosurgical unit as an emergency under the care of the on-call consultant who then decided on their management. This made treatment variable and dependent on the day the patient presented. Patients were often kept in the referring hospital until operating slots were available, and were therefore kept for a long time as inpatients. They were often transferred for neurosurgery late in the evening and only had the opportunity to discuss the operation on the morning of surgery. There was a lack of information for the patient and their family. Regularly, patients with resectable tumours were offered a tumour biopsy to make a diagnosis. They were often kept in hospital until a histological report was ready and told of their diagnosis on the ward. The lack of interest also led to lack of recruitment to clinical trials. Overall care was consultant-centred rather than patient-centred.

Our first aim was to increase the proportion of patients who had a recorded place of death preference; or a reason why preference was not known. The senior management team designed and introduced a structured preferred place of death assessment form. This new form included a section allowing the clinician to select reasons why a preference was not recorded. The form also included space for multiple assessments to point towards a process of regular review. A reaudit six months after the introduction of the new documentation showed that it was still being used inconsistently. Staff had found some of the wording and concepts difficult to use. PDSA cycle 2 A need still existed to increase the proportion of patients who had their preferences for place of death recorded, or a clear reason for an unknown preference. Consequently the senior management team further revised the preferred place of death assessment form to improve the visual ease of use and simplify some of the language. The section that listed reasons why preference might not be achieved was removed as this seemed to cause particular confusion. On reaudit, although assessments were carried out more often there were still some patients who did not seem to have had an adequate discussion of their wishes. The senior management team recognised that discussion of patient preferences needed to become embedded into routine clinical assessment. PDSA cycle 3

A need still existed to increase the proportion of patients who had their preferences for place of death recorded, or a clear reason for an unknown preference. Consequently the senior management team further revised the preferred place of death assessment form to improve the visual ease of use and simplify some of the language. The section that listed reasons why preference might not be achieved was removed as this seemed to cause particular confusion. On reaudit, although assessments were carried out more often there were still some patients who did not seem to have had an adequate discussion of their wishes. The senior management team recognised that discussion of patient preferences needed to become embedded into routine clinical assessment. PDSA cycle 3 To further increase the proportion of patients with a recorded preference, the senior management team agreed with the service leads (inpatient, community and day services) to introduce regular review of PPoD into the multidisciplinary review meetings, supporting regular MDT discussion and planning. This allowed clinical staff to raise important questions about the purpose of PPoD discussions which in time led to greater buy in from all staff. Discussing patient preferences at the end of life became ‘something that we do’ and something that is seen to benefit enough patients to make it worthwhile. The proportion of patients with a recorded preference, or a recorded reason why preference was unknown increased. The focus then turned to increasing the proportion of patients dying in their place of choice. PDSA cycle 4

To further increase the proportion of patients with a recorded preference, the senior management team agreed with the service leads (inpatient, community and day services) to introduce regular review of PPoD into the multidisciplinary review meetings, supporting regular MDT discussion and planning. This allowed clinical staff to raise important questions about the purpose of PPoD discussions which in time led to greater buy in from all staff. Discussing patient preferences at the end of life became ‘something that we do’ and something that is seen to benefit enough patients to make it worthwhile. The proportion of patients with a recorded preference, or a recorded reason why preference was unknown increased. The focus then turned to increasing the proportion of patients dying in their place of choice. PDSA cycle 4 The development of good assessment and recording of PPoD allowed the senior management team to identify specific issues which prevented patient's from dying in their preferred place. For instance, a preference to die at home was often difficult to achieve when a patient deteriorated more rapidly than expected and a care package could not be arranged quickly enough to enable discharge home. When an opportunity arose to bid for service development money, the senior management team were able to use PPoD audit data to demonstrate that rapid access to health and social care was needed to increase the number of patients able to die in their place of choice. A fast-track discharge service was commissioned and is now used when required. This has contributed to an increase in the proportion of patients wishing to die at home who achieve their wish.

that rapid access to health and social care was needed to increase the number of patients able to die in their place of choice. A fast-track discharge service was commissioned and is now used when required. This has contributed to an increase in the proportion of patients wishing to die at home who achieve their wish. Results Reaudit: One hundred and ninety seven patients died under the care of Marie Curie Hospice Edinburgh during the re-audit period (1 November 2012 to 7 March 2013). One patient died before they were seen by the hospice team leaving 196 eligible patients for the audit. All 196 patients had a PPoD or a documented reason for an unclarified preference. Of the 196 patients, 51% died in the hospice, 33% died at home, 13% died in hospital; 3% died in a nursing home and 0.5% died in a relatives home. (Supplementary material – Table 3) Eighty-one per cent of patients had a categorical preference (159 patients) – home was the preferred place for 52% of patients, hospice was preferred by 43%; while 5% chose other locations. (Supplementary Material – Table 4). Critically, 71% of all patients who chose to die at home actually died there – an increase from 31% during the initial audit in 2005-06. Furthermore, the vast majority of patients who chose to die at the hospice achieved their wish and died there (88%). (Supplementary Material – Table 5).

lementary Material – Table 4). Critically, 71% of all patients who chose to die at home actually died there – an increase from 31% during the initial audit in 2005-06. Furthermore, the vast majority of patients who chose to die at the hospice achieved their wish and died there (88%). (Supplementary Material – Table 5). Data on reasons for an unclarified preference was also available following the introduction of a more detailed PPoD assessment form. Overall, 19% of patients (37 patients) had an unclarified preference. The main reasons were that the patient was unable to communicate (11 patients); the patient wasn't known for long enough to have the discussion (10 patients) and the clinician felt that the discussion might cause the patient too much distress (10 patients); other reasons (6 patients). See supplementary file: ds2075.JPG – “Table 3” Lessons and Limitations This project shows that it is possible to systematically assess, record and review patient preferences for place of death in a specialist palliative care setting. Following this programme of quality improvement, preference information became available for all patients who died under the care of the hospice. The vast majority of patients (81%) had a categorical preference; for the remaining 19% a clear reason for an unclarified preference was available. The revised documentation also allowed for recording and communication of preference changes; so that all clinicians could see how preferences were evolving for the individual patient over time.

atients (81%) had a categorical preference; for the remaining 19% a clear reason for an unclarified preference was available. The revised documentation also allowed for recording and communication of preference changes; so that all clinicians could see how preferences were evolving for the individual patient over time. Over the course of this quality improvement programme, the number of patients involved in a discussion about their end of life care preferences increased. Critically, better identification and communication of preferences for patients, in conjunction with the introduction of a new fast-track discharge service, contributed to a substantial increase in preference achievement for all patients, in particular those who wanted to die at home. Overall, the number of patients dying at home doubled during the reaudit period compared with the baseline audit. This increase in the number of patients dying at home is potentially cost effective, with recent reports suggesting that the cost of palliative care at home is considerably less than the cost of palliative care in hospital or hospice settings.[15,16]

e doubled during the reaudit period compared with the baseline audit. This increase in the number of patients dying at home is potentially cost effective, with recent reports suggesting that the cost of palliative care at home is considerably less than the cost of palliative care in hospital or hospice settings.[15,16] The communication skills of staff also developed over time. The discussion of PPoD at weekly MDT meetings provided an opportunity for more experienced staff members to offer advice and support to staff who sometimes found the initiation of discussions about preferred place of death difficult. Over time staff became more confident in their skills and developed their own communication strategies to sensitively explore the patient's preferences. Such discussions generally took place in context of anticipatory care planning discussions. Our reaudit data showed that patients choosing to die at home who actually died at home increased to 71%; however patients with a preference to die at home still remain less likely to achieve their wish compared with patients who choose the hospice or a care home. Further increases in preference achievement for home deaths may be difficult unless the structures are in place to support this. Further studies examining the reasons why some patients who choose to die at home end up dying elsewhere, would shed light on the factors that influence the lack of congruence between preferred and actual place of death for this group.

for home deaths may be difficult unless the structures are in place to support this. Further studies examining the reasons why some patients who choose to die at home end up dying elsewhere, would shed light on the factors that influence the lack of congruence between preferred and actual place of death for this group. Routine assessment of place of death has enabled more of our patients to engage in discussions about future deterioration and has facilitated better planning and delivery of one important aspect of palliative care. It is not, however, the only measure of quality of a palliative care service. We have not assessed our ability to deliver preference for place of care. It is important that patients are able to die where they wish, but perhaps more important that they are able to live in their preferred setting. Finally, efficiency measures such as reduction in hospital stays (and hospital deaths) should not be conflated with achievement of preference for place of death - a quality measure. Conclusion In 2006 the hospice started to seriously consider the local delivery of national policy on preference for place of death. A Quality Improvement Programme with multiple cycles of PDSA has continued up until 2013. This focus on preference for place of death has been associated with a substantial increase in achievement of preference for patients wishing to die at home (from 31% to 71%). It has also been linked with an increase in the proportion of patients who actually die at home (18% to 33%).

PDSA has continued up until 2013. This focus on preference for place of death has been associated with a substantial increase in achievement of preference for patients wishing to die at home (from 31% to 71%). It has also been linked with an increase in the proportion of patients who actually die at home (18% to 33%). Supplementary Material Web supplement We would like to thank all the staff at Marie Curie Hospice Edinburgh who have contributed to this team effort. Declaration of interests: DO, LA, PBR and AF are employees of Marie Curie Cancer Care, an end of life care charity who campaign for choice of place of death and provide end of life care for people in their own homes and in Marie Curie Hospices.

h resectable tumours were offered a tumour biopsy to make a diagnosis. They were often kept in hospital until a histological report was ready and told of their diagnosis on the ward. The lack of interest also led to lack of recruitment to clinical trials. Overall care was consultant-centred rather than patient-centred. Background The variation in practice and low levels of tumour resection were a concern to the clinical oncologists managing these patients. This was further highlighted by the EORTC/NCIN study in which 80% of patients had a tumour resected, setting the standard of clinical care for glioblastomas (2). Although common in the USA and in parts of Europe since the early 1990s, subspecialisation in neurosurgical oncology was rare in the UK. There were a couple of subspecialists, usually with an academic interest, who were virtually always single handed and could manage only some of the patients in their region. Subspecialisation in surgical oncology had been shown to improve outcome in both breast and colonic cancer (3, 4) and also in paediatric brain tumours (5). Similar data does not exist in adult brain tumours. In fact, a single centre study from Edinburgh showed no improvement in survival in patients treated by a single-handed specialist neurosurgical oncologist (6).

shown to improve outcome in both breast and colonic cancer (3, 4) and also in paediatric brain tumours (5). Similar data does not exist in adult brain tumours. In fact, a single centre study from Edinburgh showed no improvement in survival in patients treated by a single-handed specialist neurosurgical oncologist (6). Baseline Measurement All data in our study was obtained retrospectively from the Eastern Cancer Registration and Information Centre (ECRIC) database and from the MDT database. Between 1997 and 2006 685 glioblastomas were treated. In the first four years of this period only 40% of patients underwent tumour resection. This increased to 55% in the last four years. By 2006, before these changes had been made, the median length of stay was 8 days, and 35% of patients received the results of their histology outwith a clinic setting. The median time between imaging showing a tumour and the post-operative MDT meeting was 23 days, most of which were spent in hospital.

last four years. By 2006, before these changes had been made, the median length of stay was 8 days, and 35% of patients received the results of their histology outwith a clinic setting. The median time between imaging showing a tumour and the post-operative MDT meeting was 23 days, most of which were spent in hospital. Design It was clear that to improve consistency of management it would be necessary to limit the number of surgeons operating on adult glioma patients. The key to this was to establish a pathway of care in which all patients were discussed pre-operatively in an MDT meeting and then directed into the surgical neuro-oncology service. An outpatient surgical neuro-oncology clinic was set up as a first point of specialist contact and to aid recruitment into research studies. Support from oncology colleagues provided the pressure to ensure patients were managed in this way and strengthened links between neurosurgery and oncology within the Anglian Cancer Network. The changes in the process of care allowed us to better counsel patients and their families and provide them with appropriate information throughout the patient journey.

d the pressure to ensure patients were managed in this way and strengthened links between neurosurgery and oncology within the Anglian Cancer Network. The changes in the process of care allowed us to better counsel patients and their families and provide them with appropriate information throughout the patient journey. Our major concern was how other neurosurgical consultants would accept such a proposal. Most were happy to allow oncology patients to be managed in this way. A few were not and would block attempts to change practice. For that reason we set about change by ‘evolution’ rather than ‘revolution’. We needed to demonstrate that we could provide ‘added value’ for patient care. The publication of the Improved Outcomes Guidelines in Brain Tumours in June 2006 provided justification and support this development (7).

empts to change practice. For that reason we set about change by ‘evolution’ rather than ‘revolution’. We needed to demonstrate that we could provide ‘added value’ for patient care. The publication of the Improved Outcomes Guidelines in Brain Tumours in June 2006 provided justification and support this development (7). Strategy Some baseline changes were made in the previous 10 years that provided the environment required to allow the neuro-oncology service to develop. In the mid 1990's Cambridge started to move toward subspecialisation within neurosurgery - earlier than many other units. Consultants with interests in pituitary tumours, paediatric neurosurgery, skull base tumours, neurovascular surgery and complex spinal surgery were appointed and were able to clearly show the value of providing specialised services to patient care. The second change was the development of a neuro-oncology MDT, was prompted by the publication of the Calman-Hine report (8) and NHS Cancer Plan produced in 2000 (9). The purpose of the MDT meeting was to ensure patients were treated in multidisciplinary teams according to recognised guidelines (10). This started in 2000 but did not discuss all patients - especially at the time of presentation. The publication of the Improving Outcomes Guidance (IOG) in 2006 was a major driver for changing and enhancing MDT working. It also introduced the controversial requirement for surgeons treating these patients to be subspecialists, spending more than 50% of their programmed activities in neurosurgical oncology. This was used as a major driver and justification for service reconfiguration. Videoconferencing these MDT meetings between the neurosurgical and oncology teams (based at Addenbrooke's Hospital in Cambridge) and our two regional oncology centres (at,Ipswich Hospital and the Norfolk and Norwich University Hospital) has developed closer links between the three centres.

for service reconfiguration. Videoconferencing these MDT meetings between the neurosurgical and oncology teams (based at Addenbrooke's Hospital in Cambridge) and our two regional oncology centres (at,Ipswich Hospital and the Norfolk and Norwich University Hospital) has developed closer links between the three centres. In 2006 a specialist neuro-oncology clinic was set up on alternate weeks, in the afternoon following the MDT meeting. Initially established to aid recruitment to research studies, patients were soon directed to this clinic to facilitate their clinical care. A number of neurosurgical consultants were keen for patients referred under their care to be managed by this service. The growth of this service led to this clinic being run weekly and the appointment of a clinical lead for surgical neuro-oncology in September 2007 and an additional neurosurgeon with a subspecialist interest in April 2008. The three consultants running this service and clinic fulfil the IOG requirement for spending >50% of programmed activities in neuro-oncology. The referral pathway initially allowed for other consultants to retain neuro-oncology patients, but over time the numbers dropped, as this was seen to be outside the normal pathway, until 2008 when all malignant tumours were brought into this service. The development of awake surgery and intra-operative stimulation brain mapping, the use of intra-operative carmustine wafers and 5-aminolevulinic acid (5-ALA)-guidance to maximise the degree of surgical resection of these tumours all confirmed the need for subspecialisation.

nant tumours were brought into this service. The development of awake surgery and intra-operative stimulation brain mapping, the use of intra-operative carmustine wafers and 5-aminolevulinic acid (5-ALA)-guidance to maximise the degree of surgical resection of these tumours all confirmed the need for subspecialisation. Nursing support has been critical to provide an integrated service. The surgical neuro-oncology service is supported by a clinical nurse specialist and a clinical nurse practitioner who act as key workers for these patients. They work closely with clinical nurse specialists in oncology in the three Cancer Centres (Addenbrooke's, Ipswich and Norfolk and Norwich Hospitals). These specialist nurses provide information to patients, can help signpost patients to relevant rehabilitation/supportive services, and act as point of contact to the service. Over time each unit has put together a library of information for patients so they are kept informed at all stages on the treatment pathway.

s). These specialist nurses provide information to patients, can help signpost patients to relevant rehabilitation/supportive services, and act as point of contact to the service. Over time each unit has put together a library of information for patients so they are kept informed at all stages on the treatment pathway. One major advantage we found from the reconfigured service was the provision of access to patients for research. When patients were admitted as an emergency there was insufficient time to obtain informed consent for research and give patients sufficient time to think about participation. This was a major limitation to surgical/pre-operative research. Reviewing patients pre-operatively the MDT meeting can highlight potential patients who could be approached in the surgical neuro-oncology clinic. Patients then have at least a week to think about participating in these studies. This model has allowed an increased recruitment to clinical trials and the development of new studies such as an NIHR-funded observational study of tumour invasion (MALTINGS study, UKCRN 8596) as well as innovative Phase I trials examining questions such as penetration of a hypoxia-targeting prodrug into GBM (11) or the safety of combining 5-ALA guided fluorescence resection with intraoperative local delivery of chemotherapy (carmustine wafers) funded by Cancer Research UK/Samantha Dickson Brain Tumour Trust (GALA-5; CRUK/10/009). This has been presented as a platform for developing surgical research (figure 1) (12).

o GBM (11) or the safety of combining 5-ALA guided fluorescence resection with intraoperative local delivery of chemotherapy (carmustine wafers) funded by Cancer Research UK/Samantha Dickson Brain Tumour Trust (GALA-5; CRUK/10/009). This has been presented as a platform for developing surgical research (figure 1) (12). Introduction of day of surgery admission (DOSA) and the opening of a DOSA unit in 2011 lead to the need to pre-admit patients. This has provided another opportunity to discuss the operation with patients and answer questions. It also provides opportunity to consent to clinical trials and has further reduced length of stay. Results The full results of this intervention have been described in detail previously (11). In summary we compared the results of a six-month period in 2006 before the introduction of the service and two time points after the introduction in 2008 and 2009. Our analysis showed that the introduction of this service has led to an increase in patients discussed pre-operatively in an MDT (66% rising to 87%; P=0.027), an increase in the rate of surgical resection (from 40% to 80%) and more patients being admitted electively (from 25% to 80%; P<0.001). There was a reduction in the median length of stay (8 days reduced to 4.5 days; P<0.001). Patients were now told their diagnosis in the private surroundings of a clinic room (up to 100% from 65% in 2006; P<0.001). The total time from diagnostic imaging to post-operative MDT remained unchanged (median = 23 days) showing that this system had not introduced delays.

f stay (8 days reduced to 4.5 days; P<0.001). Patients were now told their diagnosis in the private surroundings of a clinic room (up to 100% from 65% in 2006; P<0.001). The total time from diagnostic imaging to post-operative MDT remained unchanged (median = 23 days) showing that this system had not introduced delays. For the cohort of GBM patients with the best prognostic factors who went on to have chemoradiotherapy, median survival was 18 months, with 35% of patients alive at two years. These figures are comparable with the EORTC/NCIN study (2) and show how service reconfiguration can optimise patient care leading to improved clinical outcomes in a routine setting that are similar to those in a clinical trial. See supplementary file: ds1932.jpg - “FIGURE - pathway” Lessons and Limitations From our experiences we have learnt that implementing a specialist neurosurgical oncology service begins with understanding the patient care pathway. Our experience shows that very few of these patients need to be in hospital once they have had appropriate investigations and have been medically stabilised. Patients and their families prefer to stay out of hospital and welcome the idea of being managed as an outpatient. Patients who require in-patient care and are too unwell to be seen as an outpatient rarely have a good enough performance status to consider aggressive therapy, and often best served with supportive care.

Patients and their families prefer to stay out of hospital and welcome the idea of being managed as an outpatient. Patients who require in-patient care and are too unwell to be seen as an outpatient rarely have a good enough performance status to consider aggressive therapy, and often best served with supportive care. Moving to an outpatient-based practice we have shown a reduced length of stay together with reduced treatment costs. In 2006 the median cost of in-patient care was £2096 reducing to £1316 in 2009 after our service reconfiguration.. This extra money has been used in Cambridge to reinvest in patient care. It helps to fund 5-ALA-guided surgery, which improves the extent of resection, which has been demonstrated to improve survival in this patient group. Conclusion It is clear that our service and our patients have benefited from subspecialisation. This means that most glioblastoma patients are now treated by a dedicated surgical neuro-oncology service. Demonstrating ‘added value’ in the form of specialist surgical techniques and volume and quality of clinical research has ensured that the service has continued to evolve. One major factor that has ensured success of this process is the excellent inter-disciplinary working relationships that have developed. Supplementary Material Web supplement We would like to thank the staff at ECRIC for their help in preparing this manuscript. Stephen Price is funded by a Clinician Scientist Award from the National Institute for Health Research. Declaration of interests: Nothing to declare

Problem Bronchoscopies at our unit at Southend University Hospital are carried out by four consultants and one associate specialist who operate for three sessions a week between them. There are also up to three trainee doctors who may perform the procedure with assistance from a senior clinician. This results in up to eight different individuals and a maximum of 15 procedures each week. Additional bronchoscopies are carried out on the critical care unit as and when needed. All procedures are recorded by the bronchoscopist using a standard written proforma which incorporates the type and amount of local anaesthetic and sedation given, any abnormalities seen in the bronchial tree and the site of where samples are taken from. In addition, nursing staff have their own checklist for each patient including ensuring that the correct patient is identified and that wristband identification tags are used. A number of verbal checks are made by the bronchoscopist but these are user dependent. They are not uniformly performed and vary in their level of assessment. These checks include inspection of the relevant radiology prior to the procedure, checking of anticoagulation status and determining which samples may need to be taken. Post procedure checks including measurement of oxygen saturations and heart rate are also made but again these are user dependent and there is no formal recording of these observations. Crucially, the communication between the different members of the team is not formalised which can potentially lead to delays and difficulties with patient management.

easurement of oxygen saturations and heart rate are also made but again these are user dependent and there is no formal recording of these observations. Crucially, the communication between the different members of the team is not formalised which can potentially lead to delays and difficulties with patient management. Background In the 12 months leading up to May 2013, we carried out 269 bronchoscopies in our hospital and no major adverse events were reported. Over the past five years there have been a number of minor events but no reported major adverse events. The British Thoracic Society guidelines for the use of flexible bronchoscopy is due to be updated later in 2013 but the current guidance confirms that flexible bronchoscopy is a relatively safe procedure (1). The largest study to date in the UK analysed retrospective data from 40,000 procedures and concluded that the mortality rate was 0.04% and the major complication rate was 0.12% (2). However, the complication rate is higher in patients at higher risk (e.g. those with co-existing cardiac or renal disease) and is also higher with specific procedures e.g. the overall mortality rate when taking transbronchial biopsies has been reported as being 0.1% with the rate of major complications as high as 6.8% (3). Major complications associated with the procedure include respiratory failure, cardiac dysrhythmias and bleeding whereas minor complications include vasovagal reactions and adverse effects of the local anaesthetic or sedation (4).

has been reported as being 0.1% with the rate of major complications as high as 6.8% (3). Major complications associated with the procedure include respiratory failure, cardiac dysrhythmias and bleeding whereas minor complications include vasovagal reactions and adverse effects of the local anaesthetic or sedation (4). The World Health Organisation has developed a surgical checklist template which is adapted and in use in most hospitals in the United Kingdom (5). This simple list ensures good communication between members of the surgical team and has a series of pre- and post-operative checks. Variations have been adapted for use in non-surgical procedures e.g. at Johns Hopkins the use of a checklist for inserting central lines has been shown to dramatically reduce the incidence of line associated complications such as line-associated infections and ventilator-associated pneumonia, thus improving patient safety and dramatically reducing cost (6). There is no such list available in widespread use for endoscopic procedures of any nature in the United Kingdom.

to dramatically reduce the incidence of line associated complications such as line-associated infections and ventilator-associated pneumonia, thus improving patient safety and dramatically reducing cost (6). There is no such list available in widespread use for endoscopic procedures of any nature in the United Kingdom. Baseline Measurement A review of the notes from 20 patients having bronchoscopies between December 2012 and February 2013 revealed a wide variation in the standard of record keeping. In all cases, bronchoscopy forms were filled in appropriately and no major or minor complications appear to have occurred for any case. However, in only 3 patients, post procedure observations were recorded in the medical notes and in one case, a direct communication to the ward was recorded in order to hand over care to the team looking after the patient post procedure. In none of the 20 cases was a record made of acknowledgement of reviews of the CT scans, spirometry or blood clotting profile prior to the procedure. Although it is likely, based on current practice, that this was routinely checked, there is no written record of this having been carried out.

the patient post procedure. In none of the 20 cases was a record made of acknowledgement of reviews of the CT scans, spirometry or blood clotting profile prior to the procedure. Although it is likely, based on current practice, that this was routinely checked, there is no written record of this having been carried out. Design The decision to create a bronchoscopy checklist was made after discussions with our consultants regarding the standardisation of pre and post-bronchoscopy checks. Although there had been no major complications in recent years, it was generally felt that better documentation and a more rigorous system of checks would be to our patients' benefit. A review of the literature confirmed that very few endoscopy checklists are routinely used by clinicians either in the United Kingdom or worldwide. This is stark contrast with the WHO surgical checklists which were devised less than a decade ago and are now in routine practice for operations across the world. The WHO surgical checklist was reviewed when creating a draft bronchoscopic checklist. Endoscopy checklists themselves are not in routine use worldwide but we assessed a number of these prior to writing our own draft e.g. the bronchoscopy checklist used in Vancouver, Canada (7).

ractice for operations across the world. The WHO surgical checklist was reviewed when creating a draft bronchoscopic checklist. Endoscopy checklists themselves are not in routine use worldwide but we assessed a number of these prior to writing our own draft e.g. the bronchoscopy checklist used in Vancouver, Canada (7). Prior to the creation of our first draft, a detailed consultation period commenced which involved the four consultants and one associate specialist as well as the head nurse of our endoscopy unit and the two endoscopy nurses who had the greatest experience with bronchoscopy. A number of important objectives were agreed in this initial period. Firstly, we decided that the checklist should be confined to a single piece of paper and filed in the notes of all patients having the procedure. It should be filled in by the bronchoscopist and countersigned by a senior physician if the procedure was performed by a doctor in training. It was also decided that the checklist would have one section for checks prior to the procedure and one section for the post-procedure checks. It should be simple to use there should be no ambiguity about the checklist boxes. Finally, as with the WHO surgical checklist, it was decided that at the beginning of each bronchoscopy list there should be an opportunity for all members of the team to introduce themselves at the beginning of the list and voice any concerns that they may have before starting. Strategy PDSA Cycle 1

Prior to the creation of our first draft, a detailed consultation period commenced which involved the four consultants and one associate specialist as well as the head nurse of our endoscopy unit and the two endoscopy nurses who had the greatest experience with bronchoscopy. A number of important objectives were agreed in this initial period. Firstly, we decided that the checklist should be confined to a single piece of paper and filed in the notes of all patients having the procedure. It should be filled in by the bronchoscopist and countersigned by a senior physician if the procedure was performed by a doctor in training. It was also decided that the checklist would have one section for checks prior to the procedure and one section for the post-procedure checks. It should be simple to use there should be no ambiguity about the checklist boxes. Finally, as with the WHO surgical checklist, it was decided that at the beginning of each bronchoscopy list there should be an opportunity for all members of the team to introduce themselves at the beginning of the list and voice any concerns that they may have before starting. Strategy PDSA Cycle 1 Through the use of the hospital email and intranet system, a virtual board of experts was created which consisted of all the Respiratory Physicians, Specialist Registrars and relevant endoscopy nurses at Southend Hospital. The board was initially consulted on what they felt would be the most valuable additions to the checklist. These were then compiled into an adapted version of the standardised WHO Surgical Checklist. This was then made to concisely fit into one single sheet of A4 paper which would fit into the medical notes. This formed the first draft of the checklist.

n what they felt would be the most valuable additions to the checklist. These were then compiled into an adapted version of the standardised WHO Surgical Checklist. This was then made to concisely fit into one single sheet of A4 paper which would fit into the medical notes. This formed the first draft of the checklist. PDSA Cycle 2 The first draft of the checklist was then sent to all board members and initial comments were assessed and changes to the checklist made where needed. These changes included the decision to have a specific section for infection control measures in cases of suspected tuberculosis, ensuring that nursing staff have labelled the sample pots correctly and deciding whether the clinician looking after the patient would need to be informed in cases of suspected lung cancer so that the patient is added for discussion at the next available lung cancer multidisciplinary meeting. PDSA Cycle 3 After the amendments were made, the checklist was again circulated amongst the board to ask for minor amendments. These included a change in the size of the boxes to ensure that they were large enough to be ticked with ease and an explanation that that ticking a box meant that the point had been considered, even if it was not relevant e.g. ticking the box for ‘clotting profile (if applicable)’ would mean that the user had thought about this point, even if the patient was not on anticoagulants and had not therefore had a clotting profile checked as standard prior to the procedure. PDSA Cycle 4

After the amendments were made, the checklist was again circulated amongst the board to ask for minor amendments. These included a change in the size of the boxes to ensure that they were large enough to be ticked with ease and an explanation that that ticking a box meant that the point had been considered, even if it was not relevant e.g. ticking the box for ‘clotting profile (if applicable)’ would mean that the user had thought about this point, even if the patient was not on anticoagulants and had not therefore had a clotting profile checked as standard prior to the procedure. PDSA Cycle 4 Up until this point the checklist had only existed in an electronic version. The latest draft was then printed onto paper and this was circulated to all board members. This allowed for final minor comments to be made which would only have been made on inspection of the actual checklist on paper e.g. it was felt that there was not enough space in between the tick boxes and this was addressed to make the checklist easier to use. PDSA Cycle 5 The bronchoscopy checklist was then trialled for two weeks in the endoscopy department ensuring that all respiratory physicians and relevant endoscopy staff had the opportunity to use it. This ensured that comments made from a real world use of the checklist were incorporated into the next version of the checklist e.g. it was felt that the area for the patient identification sticker should be made larger and bolder to ensure that it was easily accessible to all members of staff. PDSA Cycle 6

The bronchoscopy checklist was then trialled for two weeks in the endoscopy department ensuring that all respiratory physicians and relevant endoscopy staff had the opportunity to use it. This ensured that comments made from a real world use of the checklist were incorporated into the next version of the checklist e.g. it was felt that the area for the patient identification sticker should be made larger and bolder to ensure that it was easily accessible to all members of staff. PDSA Cycle 6 After taking on board these further comments, a final version of the checklist was produced. The official logo of the hospital was sought from the hospital communications department and this was added to the checklist. The decision made to use the checklist as a standard was then made at the monthly Respiratory Governance Meeting. Results Figure 1 shows the final version of the bronchoscopy checklist. This has been in circulation for two months and is now used routinely for all bronchoscopies in the department as well as those carried out by Respiratory Physicians on patients in intensive care. There have been no reported problems with it to date but a record will be kept of any difficulties encountered by either the medical team or the endoscopy nursing staff and this will be fed back to us at a later date. Any major issues will be collated and we will discuss them at a Respiratory Medicine Governance meeting 6 months after starting the list. See supplementary file: ds1911.pdf - “Figure 1: Final version of the bronchoscopy checklist”

Results Figure 1 shows the final version of the bronchoscopy checklist. This has been in circulation for two months and is now used routinely for all bronchoscopies in the department as well as those carried out by Respiratory Physicians on patients in intensive care. There have been no reported problems with it to date but a record will be kept of any difficulties encountered by either the medical team or the endoscopy nursing staff and this will be fed back to us at a later date. Any major issues will be collated and we will discuss them at a Respiratory Medicine Governance meeting 6 months after starting the list. See supplementary file: ds1911.pdf - “Figure 1: Final version of the bronchoscopy checklist” Lessons and Limitations We have learnt a number of lessons from this project. Firstly, when implementing a new protocol it is important to get views from all members of the clinical team involved with the procedure. In this case we canvassed the view of our four consultants and one associate specialist as well as trainee doctors. It is also vital to get views from clinical staff who are from a non-medical background-in this case we took on board written comments by the head nurse in endoscopy as well as those from other nurses in the department. Finally, we learnt that use of the checklist in the real world is important as it acts as a ‘post-deployment’ assessment of the work. The implementation of the checklist over the two week pilot period allowed us to incorporate comments from users and discover unseen issues that were only uncovered once the checklist was in use.

we learnt that use of the checklist in the real world is important as it acts as a ‘post-deployment’ assessment of the work. The implementation of the checklist over the two week pilot period allowed us to incorporate comments from users and discover unseen issues that were only uncovered once the checklist was in use. There are however a number of limitations with this strategy. Firstly, the low incidence of mortality or major complications associated with bronchoscopies means that it will be difficult to tell initially whether our checklist has improved patient safety. However, it will allow for assessment of whether routine checks are carried out e.g. checking of the clotting profile and spirometry prior to bronchoscopy. As with the creation of the checklist, we will need to rely on qualitative reporting from the users and we have put in place a framework for this to begin. Additionally, we will need to continue to use the checklist on a regular basis in order to see if any further difficulties arise. Finally, it is important that we devise an accurate method of auditing use of the checklist to ensure that it is properly used by all bronchoscopists and that any difficulties which arise with it's use are properly documented and acted upon.

hecklist on a regular basis in order to see if any further difficulties arise. Finally, it is important that we devise an accurate method of auditing use of the checklist to ensure that it is properly used by all bronchoscopists and that any difficulties which arise with it's use are properly documented and acted upon. Conclusion Bronchoscopies at Southend University Hospital are currently carried out by up to eight individuals i.e. four Respiratory Consultants, one Associate Specialist and three trainees. Until the development of a checklist there was no standardised method for pre and post-procedure checks. If such checks were carried out, they were done so on an individualised basis and no written record was kept. Despite having had no major adverse effects in the five years leading up the development of a checklist, it was widely felt that the introduction of a checklist would be beneficial to patients and ensure good clinical practice. The standardised WHO surgical checklist was adapted to our use and a number of specific changes were made after a series of consultations with all members of staff who use the checklist.

checklist, it was widely felt that the introduction of a checklist would be beneficial to patients and ensure good clinical practice. The standardised WHO surgical checklist was adapted to our use and a number of specific changes were made after a series of consultations with all members of staff who use the checklist. We feel that the creation and implementation of a bronchoscopy checklist is not simply about reducing the risks involved with the procedure but also in ensuring best practice for our patients. The checklist has been in regular use since May 2013 and feedback from both the users and the nursing staff in endoscopy indicate that it is a worthwhile measure to ensure a high level of safety for the procedures. The use of the checklist will be audited and these results collated with any difficulties encountered with the checklist. These will be fed back to our Respiratory Medicine Governance meeting and if needed, the checklist will be further modified. Supplementary Material Web supplement We would like to thank all who were involved with designing the checklist, specifically: Masood Ali, Sohail Ansari, Peter Bailey, Philip Branch, Farag Eltaie, Vera Gummer, Alicia Howe, Ganes Lingam and Abigail Moore. Declaration of interests: None declared

Problem The traditional notes trolley is stationary and kept outside the patient bay during ward round (WR), it is therefore not uncommon for notes to be drawn by other MDT members during the round, leading to inevitable interruption whilst these notes are tracked down. During this time the rest of the WR team wait idly or wander off looking for the notes, potentiating further delay. Therefore if the trolley was re-designed to be portable and brought along on the WR it would theoretically reduce non-productive time and overall WR duration. It would also eliminate the time spent retrieving and replacing each patients notes from outside the bay. Background A joint statement released in October 2012 by the RCP and RCN entitled “Ward Rounds in Medicine Principles for Best Practice” called for the medical ward round (WR) to become the cornerstone of inpatient care [1]. The statement describes “a clear paucity of quality indicators and evidence guiding best practice for medical ward rounds.” Critical analysis of changes and innovations are required to guide improvements in Medical WRs. Any changes that improved efficiency whilst preserving effectiveness would be welcome, as this would free more professional time to complete any subsequent tasks.

Background A joint statement released in October 2012 by the RCP and RCN entitled “Ward Rounds in Medicine Principles for Best Practice” called for the medical ward round (WR) to become the cornerstone of inpatient care [1]. The statement describes “a clear paucity of quality indicators and evidence guiding best practice for medical ward rounds.” Critical analysis of changes and innovations are required to guide improvements in Medical WRs. Any changes that improved efficiency whilst preserving effectiveness would be welcome, as this would free more professional time to complete any subsequent tasks. The impact of better efficiency can be demonstrated in the paradigm of a 600-bedded hospital. Every weekday, each patient has a daily clinical review by at least one doctor on a WR, if each review could be conducted one minute quicker, whilst maintaining quality, safety and patient reported outcomes; this would release a minimum of 600 minutes of professional time. If there were two doctors on the round, 1200 minutes, or two doctors and a nurse 1800 minutes etc. 600 minutes is 10 hours of professional time. This would have substantial practical and financial implications.

lity, safety and patient reported outcomes; this would release a minimum of 600 minutes of professional time. If there were two doctors on the round, 1200 minutes, or two doctors and a nurse 1800 minutes etc. 600 minutes is 10 hours of professional time. This would have substantial practical and financial implications. Baseline Measurement The problem of inefficiency secondary to ward trolley structure has been identified in previous literature and has been documented as a source of dissatisfaction by senior medical staff [3]. An audit performed at a district general hospital in West Sussex, UK found that up to 250 ‘doctor journeys’ (trips from patient bedside to patient notes) were being performed on a single ward round of 25 patients per day by 5 doctors (see figure attached). The time spent on these journeys is not clinically useful and so any reduction in this would free up more time for subsequent clinical tasks. The impact of the problem was difficult to quantitatively assess as many factors contribute to the extent of delay resulting from a stationary ward trolley. These include: the number of patients on a WR the number of doctors on the WR the number of notes absent from the ward trolley during WR Therefore, we decided to assess the scale of the problem in a retrospective manner; as a comparison to the efficiency of a WR with the Vista 90. Therefore, we would be able to determine the relative scale of the problem by comparing a WR with one trolley versus another. See supplementary file: ds1990.pdf - “Poster was accepted and presented at International Forum on Safety & Healthcare”

Therefore, we decided to assess the scale of the problem in a retrospective manner; as a comparison to the efficiency of a WR with the Vista 90. Therefore, we would be able to determine the relative scale of the problem by comparing a WR with one trolley versus another. See supplementary file: ds1990.pdf - “Poster was accepted and presented at International Forum on Safety & Healthcare” Design The decision was taken to install a new ward trolley that would target these shortcomings. The decision was taken by Dr Gordon Caldwell, a senior Consultant physician at Worthing Hospital, West Sussex Hospital Trust. The issue was discussed with other team members working on Dr Caldwell's medical ward as well as other senior medical and managerial staff. After initially using an old electrician trolley, UK-based medical furniture designers, Sunflower Medical, were commissioned to create a trolley to fit Dr Caldwell's objectives. The outcome was the Sunflower V90 trolley, which was implemented on Erringham Medical Ward in Worthing Hospital in 2011 (figure 1) [2]. Each V90 has 8 drawers for notes and one containing forms and instruments often required on the WR, a modification called for in previous work [3]. This re-design gave the opportunity for other modifications to be made to its frame, including an ergonomic writing surface- improving comfort and legibility during WR documentation and translucent horizontal note trays- allowing all folders to be seen at a glance. Even outside of WRs these modifications could be time saving.

-design gave the opportunity for other modifications to be made to its frame, including an ergonomic writing surface- improving comfort and legibility during WR documentation and translucent horizontal note trays- allowing all folders to be seen at a glance. Even outside of WRs these modifications could be time saving. On Erringham Ward there are 3 bays of 6 patients and a total of 5 cubicles. Therefore four V90s were implemented, one for each bay and one for the five patients in cubicles. Strategy It was important to determine whether these theoretically beneficial changes would translate to a practical improvement in efficiency. This was assessed by a qualitative evaluation. It is important to re-iterate that any improvement in efficiency is only valid if the effectiveness of the WR is preserved. Therefore this was assessed too. The decision for assessment via qualitative evaluation was taken after conceeding that quantitative evaluation would be unreliable and subject to significant bias (see Baseline Measurement). The format and flow of a WR varies from Consultant to Consultant, and their personality and style are reflected in the nature of their WR. Therefore we felt qualitative analysis was a better method for assessing the impact of the V90. As we also wanted to retrospectively determine a baseline measurement of the problem with the original ward trolleys, we felt it necessary to incorporate questions that directly compared the Vista 90 trolley with the original ward round trolley.

litative analysis was a better method for assessing the impact of the V90. As we also wanted to retrospectively determine a baseline measurement of the problem with the original ward trolleys, we felt it necessary to incorporate questions that directly compared the Vista 90 trolley with the original ward round trolley. The second decision was to identify the impacted cohort to interview. The initial decision was to interview only doctors as this discipline is most heavily involved with the medical ward round. However, it became apparent that the ward trolley had a greater role on the ward than simply on the ward round. Multi-disciplinary team members interacted with the ward trolley throughout the day and night and so the impacted cohort was much greater than initially anticipated. Therefore, the decision was taken to expand the interviewee cohort to all MDT staff interacting with the trolley and expand the interview to ascertain the impact on non-ward round medical activity too.

the ward trolley throughout the day and night and so the impacted cohort was much greater than initially anticipated. Therefore, the decision was taken to expand the interviewee cohort to all MDT staff interacting with the trolley and expand the interview to ascertain the impact on non-ward round medical activity too. Results A semi-structured interview was conducted with a variety of doctors who had regularly used the V90 trolley and had previously also used the standard medical trolley (table 1). The doctors interviewed ranged from senior registrar to foundation year 1 doctors. Senior, junior and specialist nurse interviews were also sought. As well as health care professionals (HCPs) based on the ward, we also interviewed those who served the hospital as a whole, i.e. consulted doctors and therapists (table 2). These members of staff accessed the V90 trolley to perform ward tasks and this was confirmed prior to interview. A framework questionnaire was used that can be found in Appendix A. The responses to the semi-structured interviews can be divided into several common areas of impact. A full transcript of the interviews can be obtained from the author. Impact on the ward round

Results A semi-structured interview was conducted with a variety of doctors who had regularly used the V90 trolley and had previously also used the standard medical trolley (table 1). The doctors interviewed ranged from senior registrar to foundation year 1 doctors. Senior, junior and specialist nurse interviews were also sought. As well as health care professionals (HCPs) based on the ward, we also interviewed those who served the hospital as a whole, i.e. consulted doctors and therapists (table 2). These members of staff accessed the V90 trolley to perform ward tasks and this was confirmed prior to interview. A framework questionnaire was used that can be found in Appendix A. The responses to the semi-structured interviews can be divided into several common areas of impact. A full transcript of the interviews can be obtained from the author. Impact on the ward round Opinion regarding the impact of the V90 on the daily WR was positive across the interviewed cohort. Both junior and senior doctors felt the V90 helped improve efficiency by minimising disruptions both during a consultation and between consecutive ones. The latter was attributed by two doctors directly to the fact that one can “take the trolley into the bay, so there's no reason to leave the bay” thus making the transition from one patient to another more fluid. Another doctor directly contrasted this to the former system, which often involved a junior doctor “traipsing [wandering] around with 3 or 4 sets of notes and trying to write on them at the same time as hold them.” All interviewees felt the WRs were “smoother and quicker” without the need to leave the bay to exchange notes.

er doctor directly contrasted this to the former system, which often involved a junior doctor “traipsing [wandering] around with 3 or 4 sets of notes and trying to write on them at the same time as hold them.” All interviewees felt the WRs were “smoother and quicker” without the need to leave the bay to exchange notes. All interviewed doctors felt the tangible accompaniment of the trolley at the bedside did not detract from the doctor-patient relationship as “one of you [doctor] is talking to the patient and one of you [another doctor] is writing.” However, this was qualified by adding that it is only if “you position it [the trolley] in the right place, i.e. at the end of the bed.” A nurse commented that it “makes you feel more involved as the nurses are on one side and the doctors on another and it gives you [both] somewhere to write.” However another MDT member felt that “they [the trolleys] form a barrier and doctors can hide behind them” thus stressing the potential risk of formalising the consultation if placed inappropriately.

feel more involved as the nurses are on one side and the doctors on another and it gives you [both] somewhere to write.” However another MDT member felt that “they [the trolleys] form a barrier and doctors can hide behind them” thus stressing the potential risk of formalising the consultation if placed inappropriately. The most significant limitation of the V90, which arose in three interviews, was their incompatibility with wards that have multiple teams providing “shared care for a single bay.” At Worthing Hospital, surgical wards have such a layout, with two or more teams sharing a single bay and were quoted as those that were unlikely to gain full benefit of the V90 during WR. Interviewed doctors speculated that “they'll all be hunting for notes at the same time…[as] you can have up to half a dozen teams on the ward.” However, each interviewee recognized that “for a ward that has a dedicated team like Erringham, there aren't any disadvantages.” Ergonomic structure The ‘portable’ writing surface was the most commended feature of the V90. It was utilized both, whilst note-taking during the WR and whilst working throughout the day, with the former function receiving greater appreciation. Two doctors commented how it was much easier than “trying to rest it on your arm or bending your back” and a third noted how “now you can hold the drug chart in your other hand, be much more efficient and be much more legible” whereas previously one would “write less because it was so difficult.”

greater appreciation. Two doctors commented how it was much easier than “trying to rest it on your arm or bending your back” and a third noted how “now you can hold the drug chart in your other hand, be much more efficient and be much more legible” whereas previously one would “write less because it was so difficult.” These empirical benefits are in correlation with the expected benefits of having an ergonomic writing surface available throughout the WR. Facilitating the ease of writing was intended to improve the legibility of any documentation as well as to encourage a doctor to provide a more comprehensive written account due to both increased scribing speed and greater comfort. However, one aspect that was questioned twice was the height of the surface. The surface is 122cm above the ground, which one HCP found “a bit high, so can't [couldn't] write on it as I'm [she is] a bit shorter.” The aesthetic impact of the V90 was contentious; whereas some staff described it as “cool” and “classy” others found it “chunky” and “a lot bigger.” Extra-WR functionality In a traditional in-patient care setting, the WR is followed by the completion of subsequent tasks throughout the rest of the morning and afternoon. HCPs require access to notes to identify patient needs and co-ordinate care. The input of both ward-based and visiting staff (therapists and consulted doctors) was sought to explore this important aspect of team working.

is followed by the completion of subsequent tasks throughout the rest of the morning and afternoon. HCPs require access to notes to identify patient needs and co-ordinate care. The input of both ward-based and visiting staff (therapists and consulted doctors) was sought to explore this important aspect of team working. A repeated theme was the positive impact that the V90 had on efficiency in this context too. Almost half the interviewees made direct comparisons with the functionality of the V90 and the traditional ward trolley with one doctor commenting that generally “coming to Erringham ward seems a lot easier, and a lot less frustrating than being on [a ward with traditional trolleys].” A quoted reason was the improved structural integrity. Whereas a traditional ward trolley has vertical note sleeves acting as dividers, the V90 has horizontally-stacked transparent plastic trays to hold notes. One doctor felt the V90 was “much, much better because with the old trolleys, they [the sleeves] break all the time and notes are going everywhere.” Despite the hyperbole, this demonstrates an appreciation of the robustness of the V90 contrasting with “the old trolleys…[which are] completely disorganized, none of the tabs say what number bed it is and…wallets drop off and the notes fall down.”

, they [the sleeves] break all the time and notes are going everywhere.” Despite the hyperbole, this demonstrates an appreciation of the robustness of the V90 contrasting with “the old trolleys…[which are] completely disorganized, none of the tabs say what number bed it is and…wallets drop off and the notes fall down.” Another explanation for the greater efficiency was the functionality of the V90 making it easier to find a specific set of notes. One doctor explained, “people know exactly where to put them [notes] back, therefore less time is wasted wandering round the ward, looking in different trolleys or round the wards.” One doctor compared this to the traditional trolleys “with old style notes, [where] you could spend 60 seconds trying to work out where to put them back.” See supplementary file: ds1983.docx - “interviewed cohorts and quote selection and appendix A” Lessons and Limitations 100% of interviewed HCPs stated that they prefer the V90 to the traditional ward trolley and would not switch back if given the option. Qualitative results are often measured by three parameters; effectiveness, efficiency and enjoyment. The results above demonstrate a subjective greater efficiency of WR and ward work as a direct result of the V90 without detracting from efficacy. Also, one doctor explicitly stated that the trolleys help create a “less frustrating” work environment which could be translated to an improved mood.

fficiency and enjoyment. The results above demonstrate a subjective greater efficiency of WR and ward work as a direct result of the V90 without detracting from efficacy. Also, one doctor explicitly stated that the trolleys help create a “less frustrating” work environment which could be translated to an improved mood. The V90 costs about £600. As per ‘Unit Costs of Health & Social Care’ an independent report commissioned by the Department of Health, a Consultant costs the NHS about £2 per minute, an SPR about £1, and a Nurse and Foundation Year One Doctor about 50p each [4]. Thus a WR involving a Consultant, a specialist registrar, an F1 and a nurse costs £3 per minute to run. If the round involves 20 patients, and it is half a minute quicker to find and replace each set of notes, the round would be completed 10 minutes earlier, releasing £30 of professional time, to be used productively elsewhere e.g. in writing the discharge summary and reducing length of stay. If each of the 20 sets of notes is handled 10 times a day by HCPs (200 ‘findings and replacings’ of notes a day) using the V90 would save 100 minutes of HCP time a day, or £50 per day of released resource. On a day with a Consultant WR the V90 would release at least £80 of professional resource. Thus using the V90 releases cost efficiency savings to cover the purchase cost within 8 working days.

gs and replacings’ of notes a day) using the V90 would save 100 minutes of HCP time a day, or £50 per day of released resource. On a day with a Consultant WR the V90 would release at least £80 of professional resource. Thus using the V90 releases cost efficiency savings to cover the purchase cost within 8 working days. The most frequently quoted limitation of the V90 was its' incompatibility with multi-team wards. The V90 was implemented as best to compliment the anatomical structure of Erringham Ward; a single team ward. However, the V90 is versatile and can be adapted to such a situation too. A ward managed by multiple teams could choose to arrange their trolleys according to the functional structure instead i.e. one trolley per team. This would enable a team to take one trolley per WR without the need for interrupting other teams to get hold of notes. The other issue that was raised was that for shorter individuals, the writing surface was too high. The height of 122cm was chosen with consideration of the average HCP. A lower writing surface may improve accessibility amongst this cohort but would cause backache and discomfort for taller people. 122cm was chosen as a compromise. However, the V90 has two additional foldout writing surfaces at a lower height that could be of used to overcome this problem (figure 1). Therefore the issue here may simply be one of unawareness.

essibility amongst this cohort but would cause backache and discomfort for taller people. 122cm was chosen as a compromise. However, the V90 has two additional foldout writing surfaces at a lower height that could be of used to overcome this problem (figure 1). Therefore the issue here may simply be one of unawareness. A limitation of this audit was an inability to measure the quantitative impact of this referenced improvement in efficiency. Despite not being an aim of this piece of work, it could have added numerical support to this qualitative finding. We felt that to achieve significant quantitative results, the time saved by the trolley would have to be prospectively measured across multiple wards over multiple days to minimise intra- and inter-team variability. Therefore, if additional wards and hospitals take up the V90 trolley, we recommend this be performed, as any quantitative results can be more easily translated into financial implications and thus provide a more convincing argument to support their further use. Conclusion We feel the V90 is a significant improvement over the pre-existing notes trolley however larger prospective, qualitative analysis is required to identify any areas for further improvement. Implementing the V90 on additional wards would therefore have the additional benefit of enabling this by providing a larger cohort to interview. This audit strongly supports the implementation and use of the Vista 90 trolley to improve WR efficiency, saving time, money and notes.

tify any areas for further improvement. Implementing the V90 on additional wards would therefore have the additional benefit of enabling this by providing a larger cohort to interview. This audit strongly supports the implementation and use of the Vista 90 trolley to improve WR efficiency, saving time, money and notes. Supplementary Material Web supplement I would like to acknowledge the help of Dr Gordon Caldwell in the design of the evaluation for which I am very grateful. Declaration of interests: nothing to declare

Problem Admitting doctors are often criticised for the inappropriate use of investigations in the early stages of diagnosis. This not only wastes resources, but it delays correct diagnosis and can in some cases be harmful to the patient. The unnecessary measurement of d-dimer in cases of pulmonary embolism (PE) is particularly high. Background Symptomatic pulmonary embolism has a >10% mortality rate in the early stages if left untreated.[1] Patients presenting with the symptom complex including pleuritic chest pain, dyspnoea, haemoptysis and evidence of venous thromboembolic disease may warrant investigation. A serum d-dimer measurement has high sensitivity and low specificity and thus is useful for ruling out PE as a cause of these symptoms if the diagnosis is unlikely. A CT pulmonary angiogram (CTPA) is both sensitive and specific and is thus ideal for definitive diagnosis of PE. CTPA is limited by a lack of resources and the high dose of radiation required for this test. The National Institute of Clinical Excellence (NICE) guideline on venous thromboembolic diseases (published June 2012)[2] advises the use of a 2-level Well's score to determine which of these diagnostic tests is required. A low score (unlikely PE) should be investigated with d-dimer first, and CTPA in the event of a positive d-dimer. A high score (likely PE) should be investigated with a CTPA as soon as possible. In either case, if a CTPA is indicated but has been delayed, an interim therapeutic dose of low molecular weight heparin (LMWH) should be given.

ly PE) should be investigated with d-dimer first, and CTPA in the event of a positive d-dimer. A high score (likely PE) should be investigated with a CTPA as soon as possible. In either case, if a CTPA is indicated but has been delayed, an interim therapeutic dose of low molecular weight heparin (LMWH) should be given. Close adherence to this guideline is important for quality of care for several reasons: Patients with likely PE who have an inappropriate d-dimer test will delay treatment with LMWH significantly. Urgent blood tests can take more than one hour from deciding to take the sample to having the result Efficiently ruling out PE in patients allows for timely investigation of alternative diagnoses Needless d-dimer tests in patients with high Well's scores is a waste of resources. Likewise, any CTPA without preceding d-dimer test in cases of low likelihood PE is both a waste of resources and a large inappropriate dose of radiation. Baseline Measurement Baseline measurement of this problem took the form of an audit into the current adherence to the NICE guideline on diagnosis and early management of pulmonary embolism (guideline CG144). The sample included any patients admitted to the emergency admissions unit (EAU) in a 2 week period where any of the GP, the A&E doctor, the clerking junior doctor or the medical consultant had suspected PE. Measures of adherence to the guidelines included use of 2-level Well's score, appropriate use of d-dimer in cases with a Well's score suggesting unlikely PE and inappropriate use of d-dimer in cases with Well's score suggesting likely PE.

&E doctor, the clerking junior doctor or the medical consultant had suspected PE. Measures of adherence to the guidelines included use of 2-level Well's score, appropriate use of d-dimer in cases with a Well's score suggesting unlikely PE and inappropriate use of d-dimer in cases with Well's score suggesting likely PE. Our sample found that of 646 patients admitted to EAU in this 2 week period, 51 had a suspected PE. A 2-level Well's score was calculated and recorded in only 6 patients (12%). Well's scores were calculated in retrospect to determine where investigations had been used appropriately. Fourteen of 56 patients were calculated to have a likely PE according to retrospective Well's scoring. Of these patients, 12 (86%) had an inappropriate d-dimer taken prior to LMWH or CTPA investigation. In every case (12 out of 12), interim LMWH was given while waiting for CTPA. In the case of unlikely PE, two patients underwent inappropriate diagnostic CTPA following negative d-dimer tests in this period. Clearly there was a very low use of the 2-level Well's score in this baseline study. This appeared to be leading to a large number of inappropriate d-dimer tests and in turn delaying the early administration of LMWH. Additionally, the inappropriate use of CTPA is both a drain on resources and potentially harmful to patients. See supplementary file: ds1831.pptx - “Baseline data” Design It is clear that structured adherence to guidelines and in particular the 2 level Well's score would be the key element in improving this problem.

Clearly there was a very low use of the 2-level Well's score in this baseline study. This appeared to be leading to a large number of inappropriate d-dimer tests and in turn delaying the early administration of LMWH. Additionally, the inappropriate use of CTPA is both a drain on resources and potentially harmful to patients. See supplementary file: ds1831.pptx - “Baseline data” Design It is clear that structured adherence to guidelines and in particular the 2 level Well's score would be the key element in improving this problem. When investigating suitable interventions with colleagues three issues became apparent: Many do not use 2 level Well's scores because they either forget altogether, or because they cannot remember the components of the score. The trust wide introduction of a mandatory proforma for every patient with suspected PE would be an unpopular addition to the workload of admitting doctors. This strategy would fail as a result. Many doctors believed that the radiology department in our hospital would not perform a CTPA on any patient prior to having a d-dimer result. For these reasons we selected education and access to Well's scores as the key strategies for promoting change. Short presentations were made at the hospital audit meeting and at teaching sessions for the junior doctors in accident and emergency department. These aimed to highlight the guideline and detail the results of our baseline measurements. We also discussed the Well's score and how it should be used.

or promoting change. Short presentations were made at the hospital audit meeting and at teaching sessions for the junior doctors in accident and emergency department. These aimed to highlight the guideline and detail the results of our baseline measurements. We also discussed the Well's score and how it should be used. Strategy PDSA cycle 1: The use of a proforma was discussed with acute medical physicians and admitting doctors. A standardised design was available from the National Institute of Clinical Excellence website. The outcome was that an extra piece of paperwork would not be popular and would be difficult to implement for every patient. PDSA cycle 2: The importance of using the Well's score and following NICE guidelines was discussed at multiple hospital meetings. We left Well's score proformas in A&E and the emergency assessment unit for reference and advertised their availability. Example Well's scores were pinned to the walls in the emergency assessment unit. These interventions were evaluated in a prospective re-audit 2 months later. Improvements between audits were determined using a CHI square test where p<0.05 was considered significant. See supplementary file: ds1834.docx - “PDSA Cycles (1)” Post-Measurement Data was collected over 2 weeks and used identical inclusion/exclusion criteria to the baseline study. Six hundred and ninety-seven patients were admitted during this period. Pulmonary embolus had been suspected in a total of 64 patients.

These interventions were evaluated in a prospective re-audit 2 months later. Improvements between audits were determined using a CHI square test where p<0.05 was considered significant. See supplementary file: ds1834.docx - “PDSA Cycles (1)” Post-Measurement Data was collected over 2 weeks and used identical inclusion/exclusion criteria to the baseline study. Six hundred and ninety-seven patients were admitted during this period. Pulmonary embolus had been suspected in a total of 64 patients. Two level Well's scores were calculated significantly more often in the post intervention measurement compared to the baseline measurement (46% vs 11%, p<0.001). Unnecessary tests: D-dimer tests were performed in fewer cases of likely PE in the post intervention measurement, however this result was not statistically significant (65% vs 86%, p = 0.18). Where a Well's score had been calculated, significantly fewer d-dimers were performed for cases of likely PE (45% vs 100%, p<0.05). In cases of unlikely PE, only one patient underwent a CTPA following a negative d-dimer test in the post intervention measurement (n=44). This occurred in 2 out of 37 patients in the baseline measurement. Necessary tests: The number of CTPA's performed in cases of likely PE were similar in both the baseline and post interventional measurements (71% for both). There were significantly more CTPA's performed in cases of likely PE where a Well's score had been calculated, compared to cases where no Well's score was used (91% vs 33%, p<0.05).

The number of CTPA's performed in cases of likely PE were similar in both the baseline and post interventional measurements (71% for both). There were significantly more CTPA's performed in cases of likely PE where a Well's score had been calculated, compared to cases where no Well's score was used (91% vs 33%, p<0.05). D-dimer tests were performed in 100% of cases of unlikely PE in the post interventional study, compared to 96% in the baseline study. In cases of unlikely PE where the d-dimer was positive the post intervention study found a higher number of patients being offered CTPA (55% vs 33%, p = 0.18). This figure increased to 83% where a Well's score was calculated (Well's score vs no Well's score p value = 0.003). See supplementary file: ds1835.pptx - “PE audit comparative data graphs” Lessons and Limitations The introduction of a proforma is a common way to stimulate change and improve quality. One lesson from this study was that this approach can be unpopular to the point of inhibiting the main goals of the project. The first PDSA cycle revealed that time pressured doctors were unwilling to increase their work load by filling out forms. As such it was integral to this intervention to avoid increasing paperwork for admitting doctors. Our alternative was to promote the use of a two level Well's score and advertise where to find information if required through educational reminders. This had a notable effect on clinical practice.

ad by filling out forms. As such it was integral to this intervention to avoid increasing paperwork for admitting doctors. Our alternative was to promote the use of a two level Well's score and advertise where to find information if required through educational reminders. This had a notable effect on clinical practice. The most encouraging outcome measure from our project was that the use of a Well's score clearly correlated with appropriately targeted initial investigation. This provides us the confidence to continue promoting the use of Well's scores in our trust. This should also be used as evidence in other hospitals that appropriate education and use of scoring systems will translate to better adherence to national guidelines and thus improved patient care. This study was limited by the wide differential diagnoses which can accompany suspected pulmonary embolism. The relatively low specificity of d-dimer tests make them positive in cases where other markers (eg clinical indications or inflammatory blood markers) point to an alternative diagnoses. In the light of other more convincing evidence a patient may not be offered a CTPA despite a positive d-dimer as it is no longer indicated. This example would be counted as contradicting the national guideline in our study. As a result any future measurements will be adjusted using pre-specified objective evidence which strongly suggests an alternative diagnosis, (for example consolidation on a chest xray in addition to raised blood inflammatory markers).

This example would be counted as contradicting the national guideline in our study. As a result any future measurements will be adjusted using pre-specified objective evidence which strongly suggests an alternative diagnosis, (for example consolidation on a chest xray in addition to raised blood inflammatory markers). Conclusion Investigations for suspected PE were not being used appropriately in our hospital. This was revealed in an audit which demonstrated poor adherence to national guidelines. Two level Well's scores were being used infrequently leading to unnecessary investigation in some instances, and delays to necessary investigation in other cases. In particular, the inappropriate use of d-dimer tests in cases of likely PE was causing delays in potentially live saving management. We publicised the use of Well's scores through educational meetings and advertised where to find reference materials on the acute wards. These measures significantly increased the use of Well's scores and improved targeting of initial investigation and management. Cases where a Well's score was used showed a significant improvement in investigation targeting compared to cases where no Well's score was performed. This confirmed that our approach of promoting the use of a scoring system was impacting on patient care. It gives us the confidence to continue with this intervention in the future. Supplementary Material Web supplement Web supplement Web supplement Authors would like to acknowledge Steven Thompson for his role in the team. Declaration of interests: None

Problem Effective handover is becoming an increasingly important aspect of hospital medicine with the introduction of shift-based rotas and the European working time directive (E.W.T.D) (2). Despite this, there is as yet no clear evidence regarding the most effective handover system. (3) It is an area that, when done badly, increases the likelihood of errors occurring, which may result in patient harm. (4) Robust systems must be in place to ensure successful handover is possible so that the teams taking over patient care are aware of potential problems and the jobs that are required. (5) The original weekend handover between medical SHOs at this tertiary referral centre was very informal, with no structured system in place to facilitate the process. Handover involved the eight subspecialty teams putting their patient lists into a folder, which the on-call SHO collected at the beginning of their weekend shift. Ward rounds, therefore, involved having to browse through many different sheets of paper.

rmal, with no structured system in place to facilitate the process. Handover involved the eight subspecialty teams putting their patient lists into a folder, which the on-call SHO collected at the beginning of their weekend shift. Ward rounds, therefore, involved having to browse through many different sheets of paper. Having experienced weekends on-call, the authors felt the handover system was chaotic and prone to error. This was supported with anecdotal evidence from the other medical SHOs, prompting further analysis of the system. Patient lists were ordered by sub-speciality team, rather than ward, and each list was formatted differently with different information included on it. Despite no known serious untoward incident occurring as a result of the handover system, the SHOs raised concerns that the chances of jobs being missed was high, and that it was difficult to find the correct patient under time pressures. These problems potentially increase the likelihood of errors occurring that could impact on patient safety.

untoward incident occurring as a result of the handover system, the SHOs raised concerns that the chances of jobs being missed was high, and that it was difficult to find the correct patient under time pressures. These problems potentially increase the likelihood of errors occurring that could impact on patient safety. Background A definition of a clinical handover, developed by the UK-based National Patient Safety Agency (NPSA) (6), has been used across the world: ‘The transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or a permanent basis.’ In the UK, the GMC says, ‘You must be satisfied that, when you are off duty, suitable arrangements have been made for your patients' medical care. These arrangements should include effective hand-over procedures, involving clear communication with healthcare colleagues.’ (1) Baseline Measurement In order to confirm the authors' beliefs in the dangers of the original handover system, a questionnaire was given to each of the 11 current medical SHOs to survey their views and their experiences of working a weekend rotation. The qualities of the current systems were assessed and suggestions for improvement were requested. The same group of SHOs were then questioned with a modified questionnaire after implementing the changes to assess whether they subjectively felt there has been an improvement in the handover system. The response rate on each occasion was 100%.

rrent systems were assessed and suggestions for improvement were requested. The same group of SHOs were then questioned with a modified questionnaire after implementing the changes to assess whether they subjectively felt there has been an improvement in the handover system. The response rate on each occasion was 100%. Both pre- and post-implementation questionnaires used yes/no, Likert scales, and free text questions, to assess the opinions of the SHOs and can be seen attached to this report. The results of the baseline questionnaire affirmed the authors opinions that the current handover system was inadequate. 100% of the medical SHOs felt that the system could be improved, with 72% stating that it was disorganised. 55% did not feel they could ever find patients' details in a hurry and only 36% felt that they had a clear idea of the jobs required of them during the weekend on-call. Equally, only 9% felt they were able to easily identify sick or unstable patients. See supplementary file: ds1884.doc - “Initial Questionnaire” Design The planned intervention involved a single handover proforma designed by the authors that is available centrally on a shared drive. Each team is able to copy and paste their patient details onto this single list so that the weekend SHO has one patient list that is organised by ward, rather than team, and contains all the relevant information for handover.

ingle handover proforma designed by the authors that is available centrally on a shared drive. Each team is able to copy and paste their patient details onto this single list so that the weekend SHO has one patient list that is organised by ward, rather than team, and contains all the relevant information for handover. Having this unified handover proforma also allows the information to be provided to the on-call SHO in a standardised way. Columns are provided to specify if an SHO or registrar review is required, whether the patient is a clinical or medical oncology patient and which consultant is in charge of their care. This allows the on-call SHO to have easy access to the information needed to direct and respond to inquiries about inpatients over the weekend. As the original system required the SHOs to update their own lists and create a job list for the weekend before printing a copy for the weekend handover folder, this new system should not add to their workload on a Friday afternoon. The new proforma should, however, significantly reduce the workload of the on-call SHO, who would no longer need to organise the individual lists before starting the weekend ward round. It would also reduce printing costs as the unified list would require fewer pages.

ld not add to their workload on a Friday afternoon. The new proforma should, however, significantly reduce the workload of the on-call SHO, who would no longer need to organise the individual lists before starting the weekend ward round. It would also reduce printing costs as the unified list would require fewer pages. The medical department in this hospital is relatively small with only 11 medical SHOs. It was possible, therefore, to verbally inform all of the staff members of the intervention when it was implemented, as well as communicating via email. The proposal was discussed with senior medical management and also approved by the local audit committee. The new intervention should be sustainable as it provides a solution for an ongoing and relevant issue. Weekend medical SHO shifts can be incredibly busy and so any intervention to reduce the paper work load is unlikely to be opposed by the SHO team. Although SHO turnover in these posts is high, the SHO pattern of rotation is variable with four and six month posts. There are also four regular trust grade SHOs who are permanently employed and are able to facilitate the changeover period, allowing continuity of the handover system to be maintained. The support from the senior management will also encourage a change in the culture of handover in this institution.

nd six month posts. There are also four regular trust grade SHOs who are permanently employed and are able to facilitate the changeover period, allowing continuity of the handover system to be maintained. The support from the senior management will also encourage a change in the culture of handover in this institution. Strategy The proforma was implemented following approval from the trust audit committee. Minor alterations to the formatting of the proforma were suggested to improve its ease of use. These suggested changes were subsequently incorporated into the proforma with good effect. Results Following approval of the intervention by the audit committee, the new proforma was rolled out and trialled for four weekends before the SHO group were re-questioned about the new handover process. The results of the questionnaire demonstrated that the proforma was a successful intervention with 100% of the SHOs stating that the handover system had been improved. 100% felt that the new system was more structured. The perception of safety during an on-call shift also increased with the new handover proforma. Using a scale of 1 (poor safety) to 6 (excellent safety) the majority of SHOs thought the process was unsafe pre-implementation (81% scoring between 1 to 3). Using the same scale, 100% of SHOs scored either 5 or 6 in the post-implementation questionnaire, demonstrating and increased perception in patient safety.

forma. Using a scale of 1 (poor safety) to 6 (excellent safety) the majority of SHOs thought the process was unsafe pre-implementation (81% scoring between 1 to 3). Using the same scale, 100% of SHOs scored either 5 or 6 in the post-implementation questionnaire, demonstrating and increased perception in patient safety. During a verbal feedback session, the medical SHOs informed the authors that the proforma allowed jobs to be be prioritised easily and patients were less likely to be missed. Similar discussions were had with the registrars, who also found the proforma to be useful as it presented the patients in a logical fashion and often also had their jobs listed on it. See supplementary file: ds1885.doc - “Re-questionnaire” Lessons and Limitations The major lesson learnt during the implementation of this handover process was the importance of involving all the relevant stakeholders when making a change, in this case, the medical SHOs. By utilising the experienced audit committee and senior medical management, potential problems were highlighted early on and solutions created before implementation. For a change in handover to be successful, all of the SHOs would have to accept its use as if one team did not put their patients on the list then the handover would be as unsafe as the old system. The authors, therefore, involved all of the medical SHOs in the process of developing the proforma and made minor adjustments to it as suggested.

r to be successful, all of the SHOs would have to accept its use as if one team did not put their patients on the list then the handover would be as unsafe as the old system. The authors, therefore, involved all of the medical SHOs in the process of developing the proforma and made minor adjustments to it as suggested. The limitations associated with this project were mainly associated with having a small sample number to question (ie only 11 medical SHOs) and the fact that it is so specific to the trust in which it was designed. Both of these factors meant that the proforma could be easily customised to the requirements of the hospital and those who work in it but it does limit its wider use. A similar model could be used in a different circumstance or hospital but should ideally be adapted for its specific use. A further limitation revealed by the post-implementation questionnaire is that the SHO workload on a Friday is increased in the new system compared to the original one, with only 27% saying that it never increased their workload. Although this is a drawback to the system, it did not prevent the proformas utilisation as the SHOs were aware of its positive impact on weekend workload.

nnaire is that the SHO workload on a Friday is increased in the new system compared to the original one, with only 27% saying that it never increased their workload. Although this is a drawback to the system, it did not prevent the proformas utilisation as the SHOs were aware of its positive impact on weekend workload. Having initially implemented this new system, the trust planned to roll it out across other hospitals within the same trust. The IT team are currently investigating the possibility of integrating it with the current electronic patient manager system. This would overcome the main concern from SHOs that only one person is able to access the list at any one time and would also potentially reduce the time spent entering the data. Conclusion The problem identified was that the SHO weekend handover system originally in place when the authors commenced their rotation at this tertiary referral centre was unstructured and could potentially pose a threat to patient safety. By implementing a new weekend handover proforma, the structure of the system and the SHOs perceptions of patient safety increased dramatically (from 81% generally unsafe to 100% generally safe). Whilst the results of our repeated SHO questionnaire are encouraging, the authors are aware of this project's limitations; that of a small sample size and its specificity to the trust for which the handover system was designed. The main issues highlighted and the solutions to the original problem however, could be translated to other trusts to improve handover systems.

e are encouraging, the authors are aware of this project's limitations; that of a small sample size and its specificity to the trust for which the handover system was designed. The main issues highlighted and the solutions to the original problem however, could be translated to other trusts to improve handover systems. Another very relevant issue not specifically measured or considered within this study, is the actual impact on patient safety. All medical SHOs completed a pre- and post-implementation questionnaire with the perceived impact of the handover system on patient safety but no formal measure into this was made. Supplementary Material Web supplement Web supplement Royal Marsden Hospital, Dr Jayne Wood, Dr Orla Lacey, Sylvia Tan Dr Rachel Fisher and Dr Olivia Curtis have contributed equally to this project and would like to be listed as co-authors. Declaration of interests: Nothing to declare

Problem Most of the patients with cancer were not getting access to Palliative care services at an appropriate time in their disease trajectory. There was no standard measure to identify the prospective palliative care patients. Consultation of patients and their families about palliative care was not done except for terminally ill patients, just before transfer to palliative care services, which compromised quality of life.This Improvement project was done at specialist cancer hospital in Qatar. Background This project was done under the guidance of the Clinical Care Improvement Training program (CCITP). A multidisciplinary team was formed and a literature review was carried out to prepare a business case to clearly define our project. A data collection plan was prepared for our project which started in February 2012. While being treated for cancer, challenging situations, like insurmountable physical distress, inadequate coping patterns and unanswered spiritual issues, leads to a debilitating Quality of life. The Palliative Care team approach addresses all these issues and also sees the patient to go through the protocols of Palliative care management as well as Oncology treatment plan. Further, this facilitates a smooth transition from the hospital to home and hospice care. (1)

ues, leads to a debilitating Quality of life. The Palliative Care team approach addresses all these issues and also sees the patient to go through the protocols of Palliative care management as well as Oncology treatment plan. Further, this facilitates a smooth transition from the hospital to home and hospice care. (1) In a randomised controlled study conducted in Lebanon, 322 patients newly diagnosed with advanced cancer from November 2003 through May 2008, who received palliative care interventions, had higher scores of Quality Of Life (QOL) and mood, compared to patients who received only oncology care. (2) One study found that palliative care consultations were associated with an average saving of $1700 per admission for patients who were discharged, and $4900, on average, for every patient who died in the hospital.(3) Patients with advanced lung cancer who received integrated palliative care early on during treatment had a better QOL and survived for two months longer (11.6 months versus 8.9 months) compared to patients receiving standard care (chemotherapy) according to a study published in the August 19, 2010 issue of New England Journal of Medicine. (4)

ung cancer who received integrated palliative care early on during treatment had a better QOL and survived for two months longer (11.6 months versus 8.9 months) compared to patients receiving standard care (chemotherapy) according to a study published in the August 19, 2010 issue of New England Journal of Medicine. (4) Baseline Measurement The multidisciplinary team developed a palliative care referral screening tool based on the National Cancer Care Network guideline (5). A score of more than five meant the patient should have a Palliative care consultation and seven meant palliative care transfer. Retrospective medical record reviews were done from January 2012 to April 2012 and showed a mean of 68% patients who scored more than five were not consulted and 32% patient who scored more than seven were not transferred to palliative care. Seven percent of them died without any consultation or transfer to palliative care. See supplementary file: ds1620.ppt - “Attachment 1 showing pie chart with shortfall, palliative care referral tool and bar graph showing problem” Design A process flow map was created and waste analysis carried out. In the process there were 6 wastes, 5 enablers, 4 values added and 2 hands off activities. Value add is a Lean term; a value added step is a step that the patient is willing to pay, for example diagnosis of cancer, starting first line treatment and transfer to palliative care set up.

ted and waste analysis carried out. In the process there were 6 wastes, 5 enablers, 4 values added and 2 hands off activities. Value add is a Lean term; a value added step is a step that the patient is willing to pay, for example diagnosis of cancer, starting first line treatment and transfer to palliative care set up. Enabler are step that are considered necessary by organization for the quality and safety reason but the patient see it as waste for example multidisciplinary team assessment, staging, plan of care, policy, screening tool, consent form etc. Waste is the step in process which is considered as non value adding in the process map for example unnecessary exposure of patients to radiotherapy and chemotherapy with second line and third line therapy. Hands off is handing over to another department (for example from acute care to palliative care). The team brainstormed to prepare a Cause and Effect diagram for the delayed referral and consultation of cancer patients to palliative care.

Waste is the step in process which is considered as non value adding in the process map for example unnecessary exposure of patients to radiotherapy and chemotherapy with second line and third line therapy. Hands off is handing over to another department (for example from acute care to palliative care). The team brainstormed to prepare a Cause and Effect diagram for the delayed referral and consultation of cancer patients to palliative care. The two most important causes identified were that there was no availability of Palliative care referral criteria and patients and family were resisting referral to palliative care. A survey was done among physicians to buy in physician support and identify the causes of non referrals. Pareto's principle was used to analyse the survey results and to identify the cumulative percentage of 20% of barriers leading to 80% of the problem. The most important cause identified from the survey was that doctors not being aware of how to assess and manage palliative care needs. Among their common comments the most stated were ‘It's too early’ or ‘Let's give it some more time’ etc. Feedback from the physicians during the survey were supportive and positive about our palliative care referral screening tool. Process redesign was carried out by implementing the palliative care referral screening tool (with referral criteria) to be filled in at every admission for all patients with cancer.

The two most important causes identified were that there was no availability of Palliative care referral criteria and patients and family were resisting referral to palliative care. A survey was done among physicians to buy in physician support and identify the causes of non referrals. Pareto's principle was used to analyse the survey results and to identify the cumulative percentage of 20% of barriers leading to 80% of the problem. The most important cause identified from the survey was that doctors not being aware of how to assess and manage palliative care needs. Among their common comments the most stated were ‘It's too early’ or ‘Let's give it some more time’ etc. Feedback from the physicians during the survey were supportive and positive about our palliative care referral screening tool. Process redesign was carried out by implementing the palliative care referral screening tool (with referral criteria) to be filled in at every admission for all patients with cancer. Strategy A great amount of time was dedicated in educating physicians, residents, nurses, medical record staff and admitting clerks on this subject and the suggested improvement. Baseline data were presented to physicians during morning reports. Patient and family education materials/brochures were prepared in collaboration with the palliative care team to overcome barriers in palliative care referral.

ses, medical record staff and admitting clerks on this subject and the suggested improvement. Baseline data were presented to physicians during morning reports. Patient and family education materials/brochures were prepared in collaboration with the palliative care team to overcome barriers in palliative care referral. After implementing the new referral process, there were extensive consultations and transfers of patients to palliative care. There was a sudden increase in the demands of services and a decrease in the supply (beds, staff and other resources). Through a collaborative effort among Haematology, Oncology and Palliative care teams, this was successfully managed. There were a series of meetings, discussions and data presentations and it was mutually agreed to gradually transfer patients to palliative care. Each team would transfer one patient per week until additional resources were allocated and arranged to handle more patients. By implementing early screening of patients for palliative care consultation and transfer it allowed us to provide better quality of life to the cancer patients and reduce waste. Our referral tool allowed us to reduce waste of resources and and minimise unnecessary exposure of patients to radiation and chemotherapy, while improving pain management and end of life care. Standardisation of process allowed us to identify patients' needs for palliative services at admission.

ients and reduce waste. Our referral tool allowed us to reduce waste of resources and and minimise unnecessary exposure of patients to radiation and chemotherapy, while improving pain management and end of life care. Standardisation of process allowed us to identify patients' needs for palliative services at admission. Results Prospective and retrospective data were collected through 30 medical record reviews done monthly to identify the percentage of patients who scored more than, five or seven and who were not consulted or transferred to palliative care. We reduced the percentage of patients with scores of more than five without palliative consultation from a mean of 68% to 16% and with scores of more than seven without care in palliative setting from a mean of thirty two percent to three percent after four months of project implementation. By standardising the palliative care referral process, we achieved our aim by reducing non- referral/consultation. This had the following impact on our healthcare system: Timely patient care leads to: -Assuring continuity and access to palliative care and consultation on a timely basis. -Increased patient satisfaction -Improved the quality of life -Better survival -Standarded care processes -Minimising patient and caregiver distress -Increased awareness and decreased resistance -Improved communication among teams. -Helped us with the job planning inside our facility and guided us to better use resources. Patient Safety: -Reduce exposure to chemotherapy -Reduce exposure to radiation Efficiency and Reduce waste: -Reduced unit cost -Reduced length of stay

-Minimising patient and caregiver distress -Increased awareness and decreased resistance -Improved communication among teams. -Helped us with the job planning inside our facility and guided us to better use resources. Patient Safety: -Reduce exposure to chemotherapy -Reduce exposure to radiation Efficiency and Reduce waste: -Reduced unit cost -Reduced length of stay -Reduced admission and readmission rates See supplementary file: ds1622.ppt - “Old and new process map, Fish bone diagram, survey results (Pie and Pareto chart) and Run chart with improvement results” Lessons and Limitations Involvement of all the key stakeholders reduced resistance to change. Continuous reminders, presentations and open access to data was required to sustain this project. Increase in palliative care consultation and transfer resulted in the increase in the demands of staff and other resources. Capacity and demand analysis was essential to smoothly implement and sustain this project.

change. Continuous reminders, presentations and open access to data was required to sustain this project. Increase in palliative care consultation and transfer resulted in the increase in the demands of staff and other resources. Capacity and demand analysis was essential to smoothly implement and sustain this project. Conclusion The data shows a clear increase in the number of consultations and transfers to palliative care earlier using the scoring tool and the newly implemented process. This was not usual practice before our project, where acute Oncology - Haematology teams missed such consultations, depriving their patients from the privilege of specialised palliative services and the benefits mentioned above. Standardising the referral process and creating objective referral tools are needed to facilitate the transfer of care from one level to another, in a patient centered and collaborative way. The process improves management of psychological, social, and spiritual issues associated with living with cancer. Timely referral to palliative care minimises patient and caregiver distress and ensures better quality of life, patient safety and appropriate measures at the end of life. Supplementary Material Web supplement Web supplement Team members: Dr. Mufid M El Mistri, Dr. Kamal Aboudi, Ms. Amra Alkhalil, Dr. Reham H. Negmeldin, Dr. Hanadi Al Ayoubi, Dr .Azza Hassan, Dr. Saad Eziada. Declaration of interests: Nothing to declare.

Problem Until recently it has been common practice in our orthopaedic department that a letter summarizing an outpatient consultation is sent solely to the patients' GP. This was recently changed and patients are now included in correspondence. We undertook a patient satisfaction questionnaire to determine if patients found this change in practice to be beneficial. Anecdotal evidence showed that some secretaries have been contacted by patients either having not understood the letter or having concerns regarding the content. It is particularly important to assess the patient perceived value of this practice given the annual cost. Background There are a number of published studies across a variety of disciplines showing a positive patient response to receiving a copy of the GP letter. Otolaryngology patients understood the GP letter in 94% of cases. [1] Vascular, gastroenterology, dermatology and ophthalmology oncology patients also found the letter beneficial. [2–5] Not all published studies demonstrate such a positive response. A UK study invited ENT patients to complete a survey following their outpatient consultation. [6] Only 43% wished to receive a copy of their GP letter and on receipt of this, 60% found the letter helpful. For orthopaedic patients, a previous study found that interest in receiving a letter was also low, with 0.3% requesting a copy of their GP letter. [7] However, a limitation of this study was the potential introduction of responder bias since patients had to first register their interest by returning a completed form in a provided stamped addressed envelope.

udy found that interest in receiving a letter was also low, with 0.3% requesting a copy of their GP letter. [7] However, a limitation of this study was the potential introduction of responder bias since patients had to first register their interest by returning a completed form in a provided stamped addressed envelope. Generating an additional copy of the GP letter is not without cost. Not only does the practice double the paper, envelope and stamp cost, but it also requires additional secretarial time to fold and place them into envelopes. From the surgeons perspective, increased time may be spent signing letters. It is therefore important to determine whether the practice is beneficial to patients. Following the introduction of a new policy at our hospital to routinely send patients a copy of the GP letter, we were interested in obtaining robust information on patient satisfaction with this process. Baseline Measurement Prior to the introduction of our policy to copy the patient into their GP letter, it was unknown objectively whether patients were satisfied with not having receiving this letter previously. Secretaries did not report that patients had telephoned or written to request a copy, although patients may not have necessarily realised that this option had been available.

py the patient into their GP letter, it was unknown objectively whether patients were satisfied with not having receiving this letter previously. Secretaries did not report that patients had telephoned or written to request a copy, although patients may not have necessarily realised that this option had been available. Design A policy was introduced into our department whereby a copy of the GP letter is routinely sent to the patient, if over 18 years old, in order to optimize communication. It is important that the individual understands their diagnosis and treatment. During the consultation the patient has an opportunity to ask questions, but the information given may be misunderstood or forgotten. It may therefore be useful for patients to receive written information to provide an opportunity to consolidate or generate understanding or raise questions/concerns if the information is not as the patient recollects. Strategy In order to assess the success of this new policy, a six question survey was created by the authors. After establishing whether the individual had received a copy of the letter, it was important to ascertain whether it had also been read. It was decided that important areas to assess were patient comprehension of the letter, anxiety generated, whether the process had been helpful, and finally whether they would like to receive letters in the future.

ndividual had received a copy of the letter, it was important to ascertain whether it had also been read. It was decided that important areas to assess were patient comprehension of the letter, anxiety generated, whether the process had been helpful, and finally whether they would like to receive letters in the future. The wording of the questions was assessed by the authors to ensure no ambiguity. The paper questionnaire was distributed to patients by the clinic receptionist and collected by clinic nurses when the patient entered the consultation room. The following six questions were generated by the authors: Did you receive a copy of the letter sent to your GP after your last appointment? Did you read the letter? Did you understand the letter? Did anything in the letter worry you or cause you any anxiety? Did you find it helpful to be sent a copy of the letter? If you were given the choice, would you like a copy of the GP letter after this appointment? Results 124 patients responded, of which 83 (67%) had received a letter following their appointment. Of the 83 who did receive a letter, 60% had attended fracture clinic, 39% elective and 1% unknown. Of those that responded there was a near equal gender distribution; 56% male and an age range from 18 to 83 years; a fair representation of our outpatient demographics. The graph shows the outcome of the questions surveyed. Of the 40 patients who did not receive a copy of the letter, 32 (80%) would wish to in the future. See supplementary file: ds2031.jpg - “patient satisfaction”

Results 124 patients responded, of which 83 (67%) had received a letter following their appointment. Of the 83 who did receive a letter, 60% had attended fracture clinic, 39% elective and 1% unknown. Of those that responded there was a near equal gender distribution; 56% male and an age range from 18 to 83 years; a fair representation of our outpatient demographics. The graph shows the outcome of the questions surveyed. Of the 40 patients who did not receive a copy of the letter, 32 (80%) would wish to in the future. See supplementary file: ds2031.jpg - “patient satisfaction” Lessons and Limitations The protocol for our study involved the clinic receptionist distributing questionnaires to patients when they were presented to be booked in. This method was chosen to provide patients ample time to complete the questionnaire prior to their appointment. Our experience was that receptionists sometimes became overwhelmed with work at busy clinic times and therefore not all patients were given an opportunity to complete the form. This was therefore a limitation of our study. An alternative would have been for them to receive the paperwork during or at the end of the consultation, but this was not considered practical because of time restraints and the assumption that patients would be keen to leave the clinic as soon as the appointment was over. The surgeons need to be aware that the letters are being sent direct to patients and some may have to modify their tone and language.

Lessons and Limitations The protocol for our study involved the clinic receptionist distributing questionnaires to patients when they were presented to be booked in. This method was chosen to provide patients ample time to complete the questionnaire prior to their appointment. Our experience was that receptionists sometimes became overwhelmed with work at busy clinic times and therefore not all patients were given an opportunity to complete the form. This was therefore a limitation of our study. An alternative would have been for them to receive the paperwork during or at the end of the consultation, but this was not considered practical because of time restraints and the assumption that patients would be keen to leave the clinic as soon as the appointment was over. The surgeons need to be aware that the letters are being sent direct to patients and some may have to modify their tone and language. It is reassuring that the majority of patients surveyed were pleased with the practice. It was also clear however, that a small proportion of patients did not understand the content of the letter or find it helpful, and some felt that they would prefer not to receive such correspondence. Given the cost of sending these letters, excluding these patients might be considered beneficial. In practical terms however, this may be more of a challenge. The clinician or clinic nurse would need to make a note of each patient's preference for a letter and then relay this information to the secretary, who would individually remove the letter from the printing run.

these patients might be considered beneficial. In practical terms however, this may be more of a challenge. The clinician or clinic nurse would need to make a note of each patient's preference for a letter and then relay this information to the secretary, who would individually remove the letter from the printing run. A concern is that nearly a third of patients did not recall receiving a letter. We suspect that this may not be truly representative of our practice. Firstly, some questionnaires were inadvertently handed to parents/guardians of patients under the age of 18 years. This patient group do not routinely receive a copy of the GP letter. We excluded patients where age was available, but unfortunately age was unknown for nearly a half of respondents. If some of these respondents were children, then the percentage of patients who should have but did not receive the letter would be lower. Secondly, we would expect some patients attending follow up to have previously been seen prior to the introduction of this new practice and therefore will distort this particular result. Thirdly, patient recall bias may well also mean that the number of patients not receiving a letter is actually lower that we report.

Secondly, we would expect some patients attending follow up to have previously been seen prior to the introduction of this new practice and therefore will distort this particular result. Thirdly, patient recall bias may well also mean that the number of patients not receiving a letter is actually lower that we report. Comments were invited at the end of the survey. The majority were positive but for patients who found the content of the letter troubling, only one volunteered their reason for this. The source of concern was an inaccuracy which was then corrected following contact with the department. This example reinforces the advantage of receiving correspondence. A further project may be useful to identify all sources of anxiety in order to see if preventing them from arising in future might be possible. One patient volunteered that they found the letter useful as they found it reassuring that their GP had the details on file. It would be interesting to identify why other patients found the letter useful and to see if there is an impact on reducing the number of GP appointments. These points were out of the scope of this project. Conclusion Our results demonstrate that most patients are satisfied with our current correspondence practice. Other studies have found similar results for some other specialties. [1–5]

Comments were invited at the end of the survey. The majority were positive but for patients who found the content of the letter troubling, only one volunteered their reason for this. The source of concern was an inaccuracy which was then corrected following contact with the department. This example reinforces the advantage of receiving correspondence. A further project may be useful to identify all sources of anxiety in order to see if preventing them from arising in future might be possible. One patient volunteered that they found the letter useful as they found it reassuring that their GP had the details on file. It would be interesting to identify why other patients found the letter useful and to see if there is an impact on reducing the number of GP appointments. These points were out of the scope of this project. Conclusion Our results demonstrate that most patients are satisfied with our current correspondence practice. Other studies have found similar results for some other specialties. [1–5] Unfortunately although patient satisfaction is high, the process does not necessarily improve recall. [8] Demand for a copy of the GP letter is also influenced by the number of outpatient visits. Lepping et al found decreasing demand with increasing numbers of appointments. [9] Although most of these studies have shown that receiving the GP letter is welcomed greatly by patients, results should be interpreted with caution. Non-responders may be less likely to read the GP letter or find it useful, which would introduce responder bias. This may also be a limitation of our study.

Unfortunately although patient satisfaction is high, the process does not necessarily improve recall. [8] Demand for a copy of the GP letter is also influenced by the number of outpatient visits. Lepping et al found decreasing demand with increasing numbers of appointments. [9] Although most of these studies have shown that receiving the GP letter is welcomed greatly by patients, results should be interpreted with caution. Non-responders may be less likely to read the GP letter or find it useful, which would introduce responder bias. This may also be a limitation of our study. Patient specific letters have been considered by some authors. Improved patient comprehension of this letter was found [10] as might be expected, but there are conflicting results on whether there is any advantage over receiving a copy of the GP letter. [3,11] Dictating a separate patient letter increases the time spent per consultation and it may be argued that this is unnecessary given patient satisfaction with the current process. A small number of patients in our study did not wish to receive correspondence in future. Excluding these patients from the process may be beneficial to the patient as well as financially (cost of stationery and postage), but is potentially at the expense of secretarial and clinical staff's time. Supplementary Material Web supplement We would like to acknowledge the orthopaedic/fracture clinic receptionists for distributing the questionnaire and the clinic staff for collecting the responses. Declaration of interests: Nothing to declare.

Problem Recent outbreaks of vaccine-preventable diseases in England and Wales highlight the importance of ensuring that paediatric inpatients are up to date with their immunisations. Standard vaccination history taking at the Royal Cornwall Hospital generally constitutes a cursory verbal enquiry invariably resulting in a three letter entry in the notes - “utd”. Along with Walton et al. [1] I felt this to be a generic problem. Up to 40% of patients presenting to urban centres lack one or more immunisations [1–5] and I was concerned that we may be missing patients who were vulnerable to vaccine-preventable diseases. Verbal immunisation history-taking is very much the status-quo, despite evidence that the use of computer records can help. [1,6–7] Ubiquitous constraints on time, the ever-evolving immunisation schedule, and imperfect parental-recall also hinder the identification of missed doses and full documentation of immunisation histories. Background Immunisation is one of the most effective health interventions in existence yet outbreaks of vaccine-preventable diseases continue to occur even in developed countries. [8] High rates of cover are needed to provide adequate herd immunity and there is evidence that a significant proportion of paediatric inpatients are not up to date even in areas with relatively high levels of community cover. [1,4]

utbreaks of vaccine-preventable diseases continue to occur even in developed countries. [8] High rates of cover are needed to provide adequate herd immunity and there is evidence that a significant proportion of paediatric inpatients are not up to date even in areas with relatively high levels of community cover. [1,4] In every country a proportion of parents may decline immunisation for their children, however, studies consistently demonstrate the existence of a cohort of children who are amenable to immunisation when offered in the clinical setting, but for one reason or another do not actively seek immunisation and are not identified by routine immunisation history-taking. [1–5, 9] The use of regional Child Health Information Systems (CHISs) which hold individual immunisation records has been advocated as a means of improving the quality of immunisation histories for decades. [1,5] Several studies in urban paediatric centres have successfully used CHIS-based systems to improve identification of under-immunised patients, [1, 3,-4] however there is no published evidence from more rural areas with higher rates of cover.

as a means of improving the quality of immunisation histories for decades. [1,5] Several studies in urban paediatric centres have successfully used CHIS-based systems to improve identification of under-immunised patients, [1, 3,-4] however there is no published evidence from more rural areas with higher rates of cover. Baseline Measurement To establish the extent of the problem, the CHIS records of 200 consecutive admissions to the paediatric assessment unit were compared with these patient's documented immunisation histories. Thirty patients (15%) were documented as missing one or more immunisation on their CHIS record, however only 5 (17%) of these were correctly identified in the clerking notes. 4 (13%) of the under-immunised patents had the wrong immunisations documented as missing. None of these patients had a full immunisation history recorded in the clerking documentation and 8 (38%) had no immunisation information documented at all. 9 (33%) were documented as being “up to date”.

ied in the clerking notes. 4 (13%) of the under-immunised patents had the wrong immunisations documented as missing. None of these patients had a full immunisation history recorded in the clerking documentation and 8 (38%) had no immunisation information documented at all. 9 (33%) were documented as being “up to date”. Design After discussion with the child health records department I obtained access to the regional CHIS, which contains full immunisation histories for every child in the county. I trained ward-clerks to use the system, and with consultant and ward-manager approval they were asked to print each admission's full vaccination history and file it with the clerking documents for reference. Paediatricians were advised to use the printouts when clerking new patients and I also trained them to access the CHIS when ward-clerks were not available. The current UK immunisation schedule was made available in paper and electronic formats. I discussed the system before implementation at a team business meeting to address any queries. Similar systems have been used to good effect in the studies referenced above and tallied with colleagues' experiences in New Zealand and centres in other countries around the globe. As it takes approximately 2 weeks for an immunisation to be registered on the system and occasional errors still occur, the CHIS printout should augment rather than replace parental history. Accepting these two limitations, printed CHIS records are otherwise quickly obtained and provide a complete and accurate immunisation record.

approximately 2 weeks for an immunisation to be registered on the system and occasional errors still occur, the CHIS printout should augment rather than replace parental history. Accepting these two limitations, printed CHIS records are otherwise quickly obtained and provide a complete and accurate immunisation record. Strategy The intervention was first mooted at a journal-club meeting with senior paediatric staff in the context of a review of a similar project at Great Ormond Street Hospital. Initial feedback highlighted several barriers experienced by other authors. Some staff felt immunisation to lie beyond the remit of secondary care, others felt CHIS records would be inaccessible, and concerns were raised that the system would deliver little benefit due to high levels of community cover. Results from the baseline audit galvanised support for the intervention which was refined through discussion with consultants, the ward manager, and ward-clerks. Responsibility for accessing and printing the CHIS immunisation histories was given to the ward clerks who were familiar with the software and already had responsibility for assembling the clerking documentation. It was agreed to trial the system for 3 weeks and then re-audit to examine efficacy before permanently adopting the new system.

ccessing and printing the CHIS immunisation histories was given to the ward clerks who were familiar with the software and already had responsibility for assembling the clerking documentation. It was agreed to trial the system for 3 weeks and then re-audit to examine efficacy before permanently adopting the new system. The system was presented to junior staff at a teaching session a week before implementation and again to the whole team at a business meeting on the morning of the first day. Following feedback from these meetings the current UK immunisation schedule was made available on posters in the doctors' office and electronically on a shared drive. Results One week after the new system was introduced the CHIS records of a further 200 consecutive admissions to the paediatric assessment unit were compared with the clerking documentation. A comparable number of admissions were documented as lacking one or more immunisations on the CHIS (29/200, 15%). 15 of these 29 had their missing immunisations correctly documented in the notes. This represents a 35% increase in positive identification of under-immunised patients (95% CI; 12–58%). Eight (28%) of the 29 patients had a copy of the full vaccination history in the clerking documents compared with 0 at baseline. This represents a 28% increase (95% CI;12–44%).

ions correctly documented in the notes. This represents a 35% increase in positive identification of under-immunised patients (95% CI; 12–58%). Eight (28%) of the 29 patients had a copy of the full vaccination history in the clerking documents compared with 0 at baseline. This represents a 28% increase (95% CI;12–44%). Lessons and Limitations Exploring and engaging with staff concerns was an important element of this project, as was identifying key members the medical, nursing, pharmaceutical, and administrative teams. Having local evidence from the baseline audit to augment national evidence was invaluable in motivating these individuals to drive the changes amongst their peers. The project served to highlight the vast amounts of data that is routinely collected but seldom used and emphasised how usefully this information can be employed. The project was limited by the short time interval between implementation and re-audit which may over-estimate the effect in the medium to long term. Doctors seldom printed CHIS immunisation histories themselves and subsequently ‘out of hours’ immunisation histories were of a poorer quality. Extending ward-clerk hours has been suggested by the ward manager which would have a positive impact but the bedding in of cultural change would be far more constructive.

term. Doctors seldom printed CHIS immunisation histories themselves and subsequently ‘out of hours’ immunisation histories were of a poorer quality. Extending ward-clerk hours has been suggested by the ward manager which would have a positive impact but the bedding in of cultural change would be far more constructive. Conclusion The pervasive, if not ubiquitous problem of incomplete and inaccurate immunisation histories, systematically discriminates against a small but significant group of under-immunised patents. Utilising readily-available CHIS data can significantly improve the quality of immunisation histories in clinical settings, contributing towards a reduction in vaccine-preventable disease susceptibility for individuals and increased herd-immunity for populations. Helen Vickerstaff, Carol Matthews Declaration of interests: Nothing to declare.

Problem After performing procedures involving one or multiple sharp pieces of equipment or ‘sharps’ there is often no quick and accessible sharps bin for their safe disposal. Instead one must transport this equipment, potentially infected with hazardous blood products, away from the bedside to bins situated elsewhere (e.g. end of bays), risking injury and exposure to others en route. With regards to patient safety, this can be looked at in both the acute and long term settings. Acutely, there is the simple risk of a sharps-related injury plus the potential exposure to hazardous blood products. The long term problem includes the risk of an exposed and seroconverted individual transferring infected blood products to others in the community or workplace as well as the effect it has on the workforce. There are dozens of scenarios in which the risk of a sharps injury is increased based on the current layout of sharps bin on the ward but some commonly occurring examples are as follows: The further from the bed the sharps bin is, the greater the distance one must walk and the more people and equipment/furniture one may pass to properly dispose of the sharp(s). The more cramped and cluttered the bay is, the more the problem and the subsequent risk are exacerbated.

There are dozens of scenarios in which the risk of a sharps injury is increased based on the current layout of sharps bin on the ward but some commonly occurring examples are as follows: The further from the bed the sharps bin is, the greater the distance one must walk and the more people and equipment/furniture one may pass to properly dispose of the sharp(s). The more cramped and cluttered the bay is, the more the problem and the subsequent risk are exacerbated. If curtains are pulled around the bed space, one loses focus on the evolving dynamics of the bay with regards to the number of persons in the bay as well as not being able to see who may be walking towards you. When the curtain is pulled open, often with the sharps in the opposite hand, one runs the risk of a potentially harmful collision. Certain times of the day e.g. ward round, visiting hours, drug rounds, nursing handovers, cleaning times etc. all increase the numbers of people and equipment in the already crowded bays thus greatly increasing the risk of an incident. With sharps bins at the end of the bay people take less responsibility for informing the necessary staff as to when they need to be replaced. If you reach a bin post-procedure and it is full then one must travel even further with the sharp(s) to find another. Unfolding emergency situations involve multiple personnel in a cramped area with a lot of sharp equipment. "Crash Trolleys" should have sharps bins attached to them but they are usually not removable so physically getting sharps to the bins is hazardous.

With sharps bins at the end of the bay people take less responsibility for informing the necessary staff as to when they need to be replaced. If you reach a bin post-procedure and it is full then one must travel even further with the sharp(s) to find another. Unfolding emergency situations involve multiple personnel in a cramped area with a lot of sharp equipment. "Crash Trolleys" should have sharps bins attached to them but they are usually not removable so physically getting sharps to the bins is hazardous. It was therefore evident that a solution was needed to a well-established problem to help reduce risk and improve quality of sharps disposal in the hospital setting. Background Through passing conversation it became apparent that some colleagues expressed concerns regarding the risk imposed by poorly placed sharps bins. This is non-conducive to effective and safe working practices especially when the use of sharp instruments is undoubtedly a practice performed regularly and throughout all hospitals nationwide. In addition, although some of the current equipment has specially designed sheaths to protect the user these are not available for all equipment and for those that do have them, they are not universally used. Likewise, if a procedure fails, more often than not the sheath protection system fails to activate or is not utilised thus negating its purpose.

current equipment has specially designed sheaths to protect the user these are not available for all equipment and for those that do have them, they are not universally used. Likewise, if a procedure fails, more often than not the sheath protection system fails to activate or is not utilised thus negating its purpose. In 2012 the NHS employed 146,075 doctors and 369,868 qualified nursing staff. It also dealt with over one million patients every 36 hours.[1] With such large numbers of staff dealing with sharp equipment and so many patients potentially requiring their use it is unsurprising there are accidental needlestick injuries (NSI's). In fact, a recent statement from the NHS noted that “injuries caused by needles and other sharp instruments are one of the most common and serious risks to healthcare workers. With 40,000 incidents reported each year (and at least as many unreported), this is a major cause for concern for the NHS.”[2] Furthermore, in a National Audit Office report published in 2003, ‘A safer place to work - improving the management of health and safety risks in NHS trusts’, it was stated that under reporting rates of sharps related injuries may be as high as 85%.[3] The same publication also stated that sharps related injuries accounted for 17% of accidents to NHS staff nationwide, second only to manual handling accidents (18%).[3]

the management of health and safety risks in NHS trusts’, it was stated that under reporting rates of sharps related injuries may be as high as 85%.[3] The same publication also stated that sharps related injuries accounted for 17% of accidents to NHS staff nationwide, second only to manual handling accidents (18%).[3] When considering the high numbers of people being affected by NSI‘s it seems illogical to have a disposal system that risks exposure to so many staff, patients, and others which in essence could be made much safer by bringing the sharps bin to the procedure rather than transferring the sharps elsewhere afterwards. To put the problem in to perspective, and bearing in mind the issue of major under reporting, an audit of sharps, splash, and bite injuries between July to December 2010 established that there were 120 injuries to St George's Hospital (SGH) staff reported, of which 85 were NSI's.[4] The provisional cost of those 120 injuries was £53,000, which covered necessary staff, lab work, and medication but excluded lost man hours related to stress and side effects of any ensuing medication.[4] Further to this, another audit between January and June 2012 found even more, with 148 NSI's reported in SGH across a similar time frame.[5]

hose 120 injuries was £53,000, which covered necessary staff, lab work, and medication but excluded lost man hours related to stress and side effects of any ensuing medication.[4] Further to this, another audit between January and June 2012 found even more, with 148 NSI's reported in SGH across a similar time frame.[5] Most of the injuries occur on the wards, in A&E, and Theatres. Of these, source testing revealed seven positive results; five were infected with Hepatitis C Virus (HCV) and two with Human Immunodeficiency Virus (HIV). Although only a fraction were known to be infected with high risk blood borne viruses (BBV), the numbers are still significant. The pathogens that contribute the greatest concern are most certainly Hepatitis B Virus (HBV), HCV and HIV but there are many others that can be transmitted including other strains of Hepatitis, Epstein Barr Virus (EBV), parvovirus B19 and possibly prions (thought to be linked to transmissible spongiform encephalopathies).[6] HBV, HCV and HIV remain difficult to contract via NSI's but people do seroconvert and people do die from them.[3] It has been shown that when exposed to a percutaneous injury with a sharp instrument infected with HBV, HCV or HIV the transmission rate is approximately 30%, 3% and 0.3% respectively.[7] In addition, the psychological effect of an NSI, even if no pathogen is identified can be significant and reticence of an affected individual to use sharp equipment can be prolonged.

ous injury with a sharp instrument infected with HBV, HCV or HIV the transmission rate is approximately 30%, 3% and 0.3% respectively.[7] In addition, the psychological effect of an NSI, even if no pathogen is identified can be significant and reticence of an affected individual to use sharp equipment can be prolonged. From 11th May 2013 the NHS became bound by a new EU Directive for the Prevention from Sharp Injuries in the Hospital and Healthcare sector. The aim of this directive, amongst other things, is to further reduce risk and increase safety and protection of its workers.[8] This project helps identify problems in the workplace which this directive aims to improve upon and will hopefully supplement the work already done by SGH to ultimately improve health and safety in the workplace. In addition to this new directive it is worth mentioning that there are additional pieces of health and safety legislation related to sharps injuries that hospitals already have to abide by. This includes The Health and Safety at Work etc. Act (1974) [9] and The Health Act (2006) [10] plus four others [11–14] and three EU directives. [15,16,17]. The legal obligations can also be extended to include those surrounding the provision of sharps disposal systems whereby The Care Quality Commission (CQC) provides necessary licenses to NHS healthcare services if they meet the standards dictated by the aforementioned acts.

s [11–14] and three EU directives. [15,16,17]. The legal obligations can also be extended to include those surrounding the provision of sharps disposal systems whereby The Care Quality Commission (CQC) provides necessary licenses to NHS healthcare services if they meet the standards dictated by the aforementioned acts. With a significant amount of legislation surrounding this topic, implementing change undoubtedly imparts additional financial duties to NHS healthcare organisations. However, it is worth noting that in 2004 a legal ruling against the Scottish Ambulance Service stated that cost cannot be a reason not to provide safety equipment for sharps, as it breached the aforementioned European health and safety laws.[18] The NHS therefore has its own extensive policies surrounding the health and safety issues for NSI's and SGH being an NHS facility should follow them. The NHS Employers document, ‘Needlestick Injury’ produced in 2011 explicitly states a number of key guidance points which are adapted from the World Health Organisations (WHO) guidance “hierarchy of control”.[6] There is a large amount of guidance but some of the points, specifically related to sharps disposal suggest the following: Where possible, there should be access to “adequate numbers of easily accessible sharps disposal containers”[6] Reducing exposure to occupational hazards can be achieved by “placing sharps containers at eye level and within arm's reach”[6] and “disposing of sharps immediately after use in designated sharps containers”[6]

With a significant amount of legislation surrounding this topic, implementing change undoubtedly imparts additional financial duties to NHS healthcare organisations. However, it is worth noting that in 2004 a legal ruling against the Scottish Ambulance Service stated that cost cannot be a reason not to provide safety equipment for sharps, as it breached the aforementioned European health and safety laws.[18] The NHS therefore has its own extensive policies surrounding the health and safety issues for NSI's and SGH being an NHS facility should follow them. The NHS Employers document, ‘Needlestick Injury’ produced in 2011 explicitly states a number of key guidance points which are adapted from the World Health Organisations (WHO) guidance “hierarchy of control”.[6] There is a large amount of guidance but some of the points, specifically related to sharps disposal suggest the following: Where possible, there should be access to “adequate numbers of easily accessible sharps disposal containers”[6] Reducing exposure to occupational hazards can be achieved by “placing sharps containers at eye level and within arm's reach”[6] and “disposing of sharps immediately after use in designated sharps containers”[6] All sharps should be disposed of carefully at the point of use. This means that suitable sharps containers (conforming to British Standard BS EN ISO 23907:2012) [19] should be portable enough to take to the site of a procedure, and designed specifically to allow needles and sharp instruments to be disposed of easily and safely at the point of use.

of carefully at the point of use. This means that suitable sharps containers (conforming to British Standard BS EN ISO 23907:2012) [19] should be portable enough to take to the site of a procedure, and designed specifically to allow needles and sharp instruments to be disposed of easily and safely at the point of use. From all of the above legislation, policy and guidance is would appear that a portable sharps system was a likely candidate to help meet these health and safety expectations and so was chosen to go forward to trial to see if it had a place in SGH. Baseline Measurement Initially it had been a number of staff, mainly doctors who advocated for their wards, who verified there was an issue with the layout of sharps bins in their workplace. A questionnaire was therefore circulated amongst many staff members of differing roles and disciplines across the hospital to formally assess if this was not just a select group of worried individuals. The questionnaire firstly divulged the whereabouts of the person's workplace and their role. It then contained several questions that allowed the partaker to personally identify any concerns over safety or risk and if our solution could potentially benefit them and those around them in their workplace. A total of 37 questionnaires were returned and data implied:

abouts of the person's workplace and their role. It then contained several questions that allowed the partaker to personally identify any concerns over safety or risk and if our solution could potentially benefit them and those around them in their workplace. A total of 37 questionnaires were returned and data implied: 73% felt sharps bins are poorly placed. Of this population, 63% felt that they themselves were at risk with the current sharps bin system and 70% felt others were at risk too. 100% of this population felt portable sharps bins were a good idea and 96% said they would feel safer with them. Of the 27% that did not feel sharps bins were poorly placed, 50% still felt that they themselves were at risk with their current sharps bin set-up; likewise 50% felt others were at risk too. Furthermore, of this 27% population, 80% felt portable sharps bins were a good idea, and 80% said they would feel safer with them. It is important to note, that the remaining 20% consisted purely of General Intensive Care Unit staff where every patient has their own sharps bin by the bedside. Of the overall sample population, 95% felt portable sharps bins were a good idea and 95% said they would feel safer with their introduction.

Of the 27% that did not feel sharps bins were poorly placed, 50% still felt that they themselves were at risk with their current sharps bin set-up; likewise 50% felt others were at risk too. Furthermore, of this 27% population, 80% felt portable sharps bins were a good idea, and 80% said they would feel safer with them. It is important to note, that the remaining 20% consisted purely of General Intensive Care Unit staff where every patient has their own sharps bin by the bedside. Of the overall sample population, 95% felt portable sharps bins were a good idea and 95% said they would feel safer with their introduction. The result of these questionnaires identified the vast majority felt unnecessarily exposed and that the simple implementation of portable sharps bins could ease the risk to them, their colleagues, and other persons on the ward. A copy of the questionnaire is attached. In addition, it is worth noting that although most wards in the hospital do not have portable sharps bins, some such as Heberden, McEntee, and Dalby ward do. The difference in practice regarding handling of sharps and safety of personnel within the same hospital seems illogical and further suggests the need for a standardised policy regarding the use of sharps bins. See supplementary file: ds1246.doc - “Staff Questionnaire regarding reducing the risk of sharps”

The result of these questionnaires identified the vast majority felt unnecessarily exposed and that the simple implementation of portable sharps bins could ease the risk to them, their colleagues, and other persons on the ward. A copy of the questionnaire is attached. In addition, it is worth noting that although most wards in the hospital do not have portable sharps bins, some such as Heberden, McEntee, and Dalby ward do. The difference in practice regarding handling of sharps and safety of personnel within the same hospital seems illogical and further suggests the need for a standardised policy regarding the use of sharps bins. See supplementary file: ds1246.doc - “Staff Questionnaire regarding reducing the risk of sharps” Design We proposed the trial of portable sharps bins allowing for the immediate disposal of sharps at the point of care thus reducing the risk of unnecessary exposure. Since portable sharps bins systems are already in use on certain wards then it is apparent they are sustainable there. In fact portable sharps bins systems are already used within many hospitals nationwide so in affect their sustainability is already proven. The exact reason portable bins are not used on all wards is not known to current ward staff but it is not secondary to cost nor should it be when considering the legal opinion around finance and sharps disposal. We chose to base the trial on the Acute Medical Unit (AMU). We chose AMU because we wanted a ward with: High turnover Large numbers of staff High numbers of procedures where NSI's are a regular risk Multi-disciplinary teams

Design We proposed the trial of portable sharps bins allowing for the immediate disposal of sharps at the point of care thus reducing the risk of unnecessary exposure. Since portable sharps bins systems are already in use on certain wards then it is apparent they are sustainable there. In fact portable sharps bins systems are already used within many hospitals nationwide so in affect their sustainability is already proven. The exact reason portable bins are not used on all wards is not known to current ward staff but it is not secondary to cost nor should it be when considering the legal opinion around finance and sharps disposal. We chose to base the trial on the Acute Medical Unit (AMU). We chose AMU because we wanted a ward with: High turnover Large numbers of staff High numbers of procedures where NSI's are a regular risk Multi-disciplinary teams The device we chose to trial was a 2.5 litre round sharps bin with attachable (and reusable) tray. This bin was selected from the suppliers catalogue as it was deemed neither too big to be heavy and cumbersome, nor too small so as to limit the range of equipment that could be disposed of in them. It is important to note that that the use of portable sharps bins is not a universal solution. They are part of a holistic approach to safer disposal of sharps and should be used in conjunction with already established measures.[20] These include continuous education and training, not re-sheathing needles, and the use of gloves (which has been shown to remove 86% of blood from the outside of a needle when punctured).[21]

part of a holistic approach to safer disposal of sharps and should be used in conjunction with already established measures.[20] These include continuous education and training, not re-sheathing needles, and the use of gloves (which has been shown to remove 86% of blood from the outside of a needle when punctured).[21] Strategy The primary PDSA Cycle provided highly positive results in favour of portable sharps bins and did not necessitate the need for further cycles. See supplementary file: ds1606.doc - “PDSA Cycle 1” Post-Measurement After the trial a questionnaire was circulated to assess the response from staff members that used them. The questionnaires were completed by a variety of doctors, nurses, and health care assistants, all of varying grades. 31 questionnaires were returned and data implied: 97% felt that the portable sharps bin system reduced risk to themselves and others 81% felt safer using the portable sharps bin system 90% felt safer knowing their colleagues were using the portable sharps bin system 87% felt the portable sharps bin system were user friendly 90% would be happy for the portable sharps bin system to be continuously implemented on AMU The 13% that felt they were not user friendly said: - They took up too much room on the trolleys in the bays (two persons) - If you fall over carrying the portable sharps bin you risk spilling its contents (one person) - One person did not see the point of them (one person) 45% felt that the portable sharps bin system could be improved and these were their suggestions: - They could be smaller (four persons)

- They took up too much room on the trolleys in the bays (two persons) - If you fall over carrying the portable sharps bin you risk spilling its contents (one person) - One person did not see the point of them (one person) 45% felt that the portable sharps bin system could be improved and these were their suggestions: - They could be smaller (four persons) - Staff need education on their use so as not to accidentally dispose of the reusable tray (two persons) - They allowed for a situation where staff were not cleaning the trays properly (two persons) - AMU needed more of them (four persons) - They should be rolled out hospital wide (one person) *n.b. one person left two comments. We see the four remarks for AMU needing more portable sharps bin systems and the one for rolling them out hospital wide as positive remarks since this was only a trial on a single ward. If we exclude these five positive remarks then the new percentage for those who felt that the portable sharps bin system needing improving is only 31%. Of those that felt they did not need improving, the following positive feedback was obtained: - They were a good size (two persons) - They were easy to use (three persons) - They were safe for staff and patients (five persons) - They were useful (one person) There was some mild resistance to a possible change in the use of equipment however the majority of questionnaires showed that people welcomed the idea of portable sharps bins. The overall data therefore implied that portable sharps bins would be accepted if they were introduced into the clinical environment.

- They were useful (one person) There was some mild resistance to a possible change in the use of equipment however the majority of questionnaires showed that people welcomed the idea of portable sharps bins. The overall data therefore implied that portable sharps bins would be accepted if they were introduced into the clinical environment. See supplementary file: ds1607.docx - “Trial Run of Sharps Bin Data” Lessons and Limitations Problems encountered & what was learned: Getting people to complete and return questionnaires within working hours was extremely difficult. Only a small percentage of those handed out were returned and we thank the staff who went out of their way to get more forms filled in only because they supported the cause. Getting the initial trial under way took a long time as we had to hand the ordering of equipment over to other staff who firstly did not understand the time frame we were working to plus decided to order what they felt was best rather than what we had asked. I learned that it was key to limit the number of people involved in the transferal of information and requests. People do not like change. We were met with hostility from some staff who did not like that we were trying to change their work practice. Fortunately, we were met with much more support than hostility but it was still difficult to deal with, especially when ultimately we were trying to improve safety. We have to constantly remember the bigger picture and not let individual negativity prevent progress.

ke that we were trying to change their work practice. Fortunately, we were met with much more support than hostility but it was still difficult to deal with, especially when ultimately we were trying to improve safety. We have to constantly remember the bigger picture and not let individual negativity prevent progress. Conclusion The aim of this project was to identify if informal feelings about the risk imposed to staff, patients, and other members of the public regarding the sharps bin system in St George's Hospital was real and if a portable sharps bin system could help. Initial data showed an overwhelming agreement that people did feel that a portable sharps bin system would be safer than the current system and that it would be beneficial to all. It also revealed a disparity across the hospital since some wards already used them. With this information and knowledge of current and encroaching legislation regarding safer sharps disposal practices we gained the support of the team involved in such matters for St George's Hospital. The project then progressed to a trial run of a portable sharps bin system in the Acute Medical Unit which showed that the vast majority of staff felt that their introduction on the ward was a positive and necessary safety measure. The results of this project suggest the need for hospital-wide usage of a portable sharps bin system to maintain better, safer, and more advanced safety practices when disposing of sharp equipment. Additionally, it will hopefully suggest the same to other healthcare institutes in the UK.

e and necessary safety measure. The results of this project suggest the need for hospital-wide usage of a portable sharps bin system to maintain better, safer, and more advanced safety practices when disposing of sharp equipment. Additionally, it will hopefully suggest the same to other healthcare institutes in the UK. Supplementary Material Web supplement Web supplement Web supplement Declaration of interests: Nothing to declare

Problem Surgical morbidity and mortality are significant public health concerns. Preventable post-operative complications result in needless patient suffering, prolonged hospital stay and wasted hospital resources. Complications following hepatobiliary and pancreatic (HPB) surgery are among the highest of any surgical speciality, due to a combination of patient and procedure-related factors (1). Morbidity and mortality rates in our department have been well documented, as part of regular audit cycles. In 2010, we published an analysis of 99 consecutive patients undergoing pancreatic resection between January 2006 and September 2008 (2). In total, there were 86 post-operative complications occurring in 55 patients (55.6%). Our in-hospital or 30-day mortality rate was 3%. For liver surgery, contemporaneous audit results for the two-year period 2009-2010 showed that there were 114 complications following 233 consecutive liver resections and a mortality rate of 1.3% We have developed a specific HPB Quality Improvement Program (QIP) and introduced this in September 2012, with the purpose of reducing post-operative morbidity and mortality rates. Background Despite the effects of centralisation for complex surgery, advances in pre-operative patient optimisation, operative techniques and post-operative care, liver and pancreatic surgery remain associated with a high morbidity and a significant mortality.

We have developed a specific HPB Quality Improvement Program (QIP) and introduced this in September 2012, with the purpose of reducing post-operative morbidity and mortality rates. Background Despite the effects of centralisation for complex surgery, advances in pre-operative patient optimisation, operative techniques and post-operative care, liver and pancreatic surgery remain associated with a high morbidity and a significant mortality. A major systematic review of liver resection for colorectal metastases has assessed the published evidence for its efficacy and safety (1). 30 independent studies met all the eligibility criteria for the review and data on 30-day mortality and morbidity only were included from a further nine studies. Death within 30 days of hepatic resection was reported by 24 studies, ranging from 0% to 6.6% of patients (median 2.8%). The commonest causes of postoperative morbidity were: wound infection (5.4%), generalised sepsis (4.6%), pleural effusion (4.3%), bile leak (4.0%), perihepatic abscess (3.0%), hepatic failure (2.8%), arrhythmia (2.8%), postoperative haemorrhage (2.7%), cardiac failure (2.4%) and pneumonia (1.9%). Similarly, a major review of contemporary standards in pancreatic surgery found a mortality rate in high-volume centres of 1 to 4% (3). Intra-abdominal abscess following pancreatic resection occurred in 1 to12 % of patients, postoperative haemorrhage in 2 to 15%, pancreatic fistula ranged from 2 to 24% (depending on definition), and the incidence of delayed gastric emptying ranged from 14 to 70 %.

a mortality rate in high-volume centres of 1 to 4% (3). Intra-abdominal abscess following pancreatic resection occurred in 1 to12 % of patients, postoperative haemorrhage in 2 to 15%, pancreatic fistula ranged from 2 to 24% (depending on definition), and the incidence of delayed gastric emptying ranged from 14 to 70 %. In general, the most significant efforts to decrease surgical morbidity and mortality have included the World Health Organisation (WHO) Surgical Safety Checklist and the National Surgical Quality Improvement Programme (NSQIP) of the American College of Surgeons (ACS). The WHO Surgical Safety Checklist is designed to improve team communication and consistency of care and hence decrease complications and deaths as a result of surgery. A study of the implementation of the WHO checklist in eight hospitals across the world showed a reduction in the complication rate of 36% and inpatient death by 47% (4). As a consequence, a Patient Safety Alert was issued in the UK in January 2009 by the National Patient Safety Agency, requiring NHS organisations to ensure the WHO checklist is completed in every patient undergoing a surgical procedure. The NSQIP provides a prospective, peer-controlled, validated database of pre-operative to 30 days post-operative surgical outcomes based on clinical data. In 2009, a study evaluating 118 hospitals using the ACS NSQIP from 2005-2007 found that every year these hospitals were able to prevent 250-500 complications, save 12-36 lives and reduced costs by millions of dollars (5). In the UK, the implementation of a systematic trauma quality improvement system was associated with a fall in the mortality rate among patients presenting in shock (6).

5-2007 found that every year these hospitals were able to prevent 250-500 complications, save 12-36 lives and reduced costs by millions of dollars (5). In the UK, the implementation of a systematic trauma quality improvement system was associated with a fall in the mortality rate among patients presenting in shock (6). Baseline Measurement In 2010, we published an analysis of 99 consecutive patients undergoing pancreatic resection between January 2006 and September 2008 (2). In total, there were 86 post-operative complications occurring in 55 patients (55.6%). The International Study Group for Pancreatic Surgery (ISGPS) have provided definitions for the common pancreas-specific complications following pancreatic surgery, namely: pancreatic fistula (PF) (7), post-pancreatectomy haemorrhage (PPH) (8) and delayed gastric emptying (DGE) (9). Our rates for PF, PPH and DGE were 19%, 5% and 21% respectively. Each complication is graded for severity of impact, with grade A representing the mildest and grade C the most severe complication. See supplementary file Methods: Table 1- Pancreas post-operative morbidity 2010 series (2) See supplementary file Methods: Figure 1- Pancreas post-operative complications according to the ISGPS definitions (2) The 30-day or in-hospital mortality was 3% (n = 3). One patient developed severe endocarditis, a second patient developed a pancreatic anastomotic leak and died of respiratory failure, and the third patient aspirated in the immediate post-operative period, despite a nasogastric tube and died of respiratory failure.

See supplementary file Methods: Figure 1- Pancreas post-operative complications according to the ISGPS definitions (2) The 30-day or in-hospital mortality was 3% (n = 3). One patient developed severe endocarditis, a second patient developed a pancreatic anastomotic leak and died of respiratory failure, and the third patient aspirated in the immediate post-operative period, despite a nasogastric tube and died of respiratory failure. Contemporaneous audit results for the two-year period 2009-2010 showed that there were 114 complications following 233 consecutive liver resections and a mortality rate of 1.3%. The International Study Group for Liver Surgery (ISGLS) have provided definitions for the liver-specific complications following liver surgery, namely: bile leak (BL) (10), post-hepatectomy haemorrhage (PHH) (11) and post-hepatectomy liver failure (PHLF) (12). However, these definitions were only published in 2011 and therefore not utilised at the time of the baseline audit. Our rates for BL, PHH and PHLF were 6.4%, 11.2% and 13.7%. There was 3 post-operative deaths following liver surgery (1.3%): 2 from liver failure and 1 from a cerebrovascular accident on day 9. See supplementary file: ds2497.docx - “Methods”

Contemporaneous audit results for the two-year period 2009-2010 showed that there were 114 complications following 233 consecutive liver resections and a mortality rate of 1.3%. The International Study Group for Liver Surgery (ISGLS) have provided definitions for the liver-specific complications following liver surgery, namely: bile leak (BL) (10), post-hepatectomy haemorrhage (PHH) (11) and post-hepatectomy liver failure (PHLF) (12). However, these definitions were only published in 2011 and therefore not utilised at the time of the baseline audit. Our rates for BL, PHH and PHLF were 6.4%, 11.2% and 13.7%. There was 3 post-operative deaths following liver surgery (1.3%): 2 from liver failure and 1 from a cerebrovascular accident on day 9. See supplementary file: ds2497.docx - “Methods” Design The HPB QIP is a system for recording, analysing and reducing post operative morbidity and mortality. The inspiration for this system was the approach outlined in the Trauma Performance Improvement Reference Manual produced by the Performance Improvement Subcommittee of the American College of Surgeons Committee on Trauma in 2002 (13). Modifications were made to incorporate the many differences and specificities of HPB surgery. See supplementary file Methods: the HPB QIP Proforma. The process: The Weekly QIP Meeting:

Design The HPB QIP is a system for recording, analysing and reducing post operative morbidity and mortality. The inspiration for this system was the approach outlined in the Trauma Performance Improvement Reference Manual produced by the Performance Improvement Subcommittee of the American College of Surgeons Committee on Trauma in 2002 (13). Modifications were made to incorporate the many differences and specificities of HPB surgery. See supplementary file Methods: the HPB QIP Proforma. The process: The Weekly QIP Meeting: A weekly QIP meeting is undertaken. This is consultant led but attended by the whole team, who participate via the presentation and analysis of each complication. For each complication, a proforma has been completed, containing patient demographics, the date of surgery and the type of complication that has developed. This forms the starting point of the QIP discussion. Categorisation & Grading: The type or nature of each complication is categorised. Internationally agreed definitions, such as those produced by the ISGPS (7)(8)(9) and the ISGLS (10)(11)(12) are used where applicable. For general complications, the Clavian-Dindo system is used (14). This also grades according to increasingly significant clinical impact Justification and Error Analysis:

The type or nature of each complication is categorised. Internationally agreed definitions, such as those produced by the ISGPS (7)(8)(9) and the ISGLS (10)(11)(12) are used where applicable. For general complications, the Clavian-Dindo system is used (14). This also grades according to increasingly significant clinical impact Justification and Error Analysis: An assessment is made as to whether each complication was justifiable, unavoidable, or consistent with reasonable and prudent practice given the situation or clinical data available or not justifiable, avoidable and not consistent with the standards of the practice or service. For complications considered not justifiable, a root cause analysis is undertaken to identify the errors that gave rise to the complication. Errors can occur at any time in the patient pathway, from pre-operative patient selection, intra-operative errors to errors made in post-operative management. Action Plans: An action plan is created in each case where a complication has been considered not justifiable. Action plans include: on-going monitoring, audit, new policy formation, further departmental training or education as well as individual discussion and counselling. This allowed us to make changes as soon as problems were identified to help achieve a reduction in operative complication rates. Mortality Analysis: Each death is analysed in a similar way and a judgement made as to whether the death was preventable or not, using the categories: Not preventable, Possibly Preventable, Probably Preventable and Preventable. Return to theatre and readmission rates:

An action plan is created in each case where a complication has been considered not justifiable. Action plans include: on-going monitoring, audit, new policy formation, further departmental training or education as well as individual discussion and counselling. This allowed us to make changes as soon as problems were identified to help achieve a reduction in operative complication rates. Mortality Analysis: Each death is analysed in a similar way and a judgement made as to whether the death was preventable or not, using the categories: Not preventable, Possibly Preventable, Probably Preventable and Preventable. Return to theatre and readmission rates: Each of these adverse events is also analysed, errors identified and an action plan formulated. Sharing Information: Consolidated data and discussion of each avoidable complication and death is then presented to the wider surgical department at the regular audit meetings. These meetings are multidisciplinary and provide a platform for shared learning. Statistical analysis: Categorical data such as complication rates were summarised for all patients using proportions and bar graphs. Numerical data such as length of stay were summarised for both groups (those with complications and those without) using medians and interquartile ranges. Complication rates were compared with previously audited and published results, using the chi-square test. Statistical analyses was performed using StatsDirect statistical software version 2.7.7 and Stata/IC version 10.0.

r both groups (those with complications and those without) using medians and interquartile ranges. Complication rates were compared with previously audited and published results, using the chi-square test. Statistical analyses was performed using StatsDirect statistical software version 2.7.7 and Stata/IC version 10.0. Strategy The impact of this proposal will be measured in terms of Quality Improvement. The Institute of Medicine report “Crossing the Quality Chasm” (15), defined quality based upon six aims for improvement, which have become accepted definitions of the dimensions of quality: effectiveness, efficiency, patient centeredness, safety, timeliness and equity. Effectiveness; “avoiding both the overuse of ineffective care and the underuse of effective care”. Measured by: Complication rates (according to definitions of the ISGPS, ISGLS and Clavien system) and Mortality rate Efficiency; “The reduction of waste…and the total cost of care”. Measured by: Total length of stay and total hospital costs Patient Centeredness; “respecting the individual patient's choices and needs”. Measured by: Patient satisfaction questionnaire Safety; “avoiding injuries to patients from the care that is intended to help them”. Measured by: Complication rates and Mortality rate Timeliness; “continually reducing waiting times and delays”. Equity; “closing racial and ethnic gaps”. Measured by: Patient satisfaction questionnaire and demographic data from patient registration.

Safety; “avoiding injuries to patients from the care that is intended to help them”. Measured by: Complication rates and Mortality rate Timeliness; “continually reducing waiting times and delays”. Equity; “closing racial and ethnic gaps”. Measured by: Patient satisfaction questionnaire and demographic data from patient registration. By introducing this project to the department we aim to reduce complication rates and in turn improve patient satisfaction, reduce hospital stay, prevent avoidable readmissions and in doing so improve the quality of care delivered. See supplementary file Methods: an example of a potential cost saving. Results Current Complication rates: A total of 326 HPB operations were performed over a six month period. 30 pancreatic resections were performed with 15 patients developing 20 complications (50% complication rate). 45 Liver resections were performed with 14 patients developing 17 complications (31% complication rate) . 202 cholecystectomies were performed with 6 patients developing a total of 6 complications (3% complication rate). In the remaining 34 miscellaneous procedures, there were 4 further complications in 4 patients. There were 2 deaths; one following pancreatectomy and one after liver resection.

ns (31% complication rate) . 202 cholecystectomies were performed with 6 patients developing a total of 6 complications (3% complication rate). In the remaining 34 miscellaneous procedures, there were 4 further complications in 4 patients. There were 2 deaths; one following pancreatectomy and one after liver resection. Pancreatic fistula was the most common complication with a rate for all ISGPS grades of 23%. The group “other complications” included two intra abdominal collections and one each of the following: pressure sore, gastric fistula, iatrogenic splenic injury, incisional hernia, Chyle leak, CVA, GI bleed, acute kidney injury, central line infection, enteric fistula and haematoma. See supplementary file Results for Figure 2: Complications by type and frequency Grading of complications: Post pancreatic resection: In total 7 pancreatic fistulae were identified (23.3%): 2 grade A, 3 grade B and 2 grade C. There was 1 grade B delayed gastric emptying (3.3%). There were no cases of post pancreatectomy haemorrhage. There were 12 other post-pancreatectomy complications graded according to the Clavien-Dindo system: 3 grade 1, 1 grade 2, 0 grade 3a, 1 grade 3b, 3 grade 4a, 3 grade 4b and 1 grade 5. Post hepatectomy: In total 3 bile leaks were identified (6.6%): 2 grade A and 1 grade B. One patient developed grade A liver failure. There were no post-hepatectomy haemorrhages. There were 12 other post-hepatectomy complications graded according to the Clavien-Dindo system: 5 grade 1, 3 grade 2, 3 grade 3a, 0 grade 3b, 1 grade 4a, 0 grade 4b, 1 grade 5. Justification:

In total 3 bile leaks were identified (6.6%): 2 grade A and 1 grade B. One patient developed grade A liver failure. There were no post-hepatectomy haemorrhages. There were 12 other post-hepatectomy complications graded according to the Clavien-Dindo system: 5 grade 1, 3 grade 2, 3 grade 3a, 0 grade 3b, 1 grade 4a, 0 grade 4b, 1 grade 5. Justification: Thirty complications were justified as unavoidable and sixteen as avoidable (33.3%). See supplementary file Results: Figure 3 Justification by procedure Errors: Following a root cause analysis in each case where the complication was considered unjustified or avoidable, 20 different errors were identified in 16 sixteen complications. See supplementary file Results: Figure 4 Breakdown of errors identified following each procedure for unjustified complications Action plans: The majority of action plans included tabulation and tracking (n = 41). Other actions included: formulation of new policy (n=2), individual counselling (n=4) and educational offering (n=4). Comparison with baseline audit data from 2009 and 2010: 114 complications occurred in 233 liver operations during the baseline period, compared with 17 complications in 45 liver operations during the QIP period, OR=0.63 (95% CI: 0.33 to 1.22), p=0.17 86 complications occurred in 99 pancreatic resections during the baseline period, compared with 20 complications in 30 pancreatic resections during the QIP period, OR=0.30 (95% CI: 0.12 to 0.79), p=0.01 Return to theatre and Readmission rates :

114 complications occurred in 233 liver operations during the baseline period, compared with 17 complications in 45 liver operations during the QIP period, OR=0.63 (95% CI: 0.33 to 1.22), p=0.17 86 complications occurred in 99 pancreatic resections during the baseline period, compared with 20 complications in 30 pancreatic resections during the QIP period, OR=0.30 (95% CI: 0.12 to 0.79), p=0.01 Return to theatre and Readmission rates : 5 patients were readmitted during the six month period. 3 following pancreatic resections, 1 following an open cholecystectomy and one following biliary reconstruction. Two of these patients (including the open cholecystectomy and following one pancreatic resection) required a re operation. A further 4 patients required a return to theatre. Of the 6 re operations, 2 were secondary to pancreatic fistula, 2 were secondary to bile leaks and 1 each following the development of post-operative bleeding and a gastrojejunostomy leak. Deaths: 2 of the 47 complications were deaths, giving a 90 day or in-hospital mortality rate of 0.61% for all operations. Mortality rates following liver resection and pancreatectomy were 2.2% and 3.3% respectively.

5 patients were readmitted during the six month period. 3 following pancreatic resections, 1 following an open cholecystectomy and one following biliary reconstruction. Two of these patients (including the open cholecystectomy and following one pancreatic resection) required a re operation. A further 4 patients required a return to theatre. Of the 6 re operations, 2 were secondary to pancreatic fistula, 2 were secondary to bile leaks and 1 each following the development of post-operative bleeding and a gastrojejunostomy leak. Deaths: 2 of the 47 complications were deaths, giving a 90 day or in-hospital mortality rate of 0.61% for all operations. Mortality rates following liver resection and pancreatectomy were 2.2% and 3.3% respectively. On mortality analysis, that following liver resection occurred after a right hemihepatectomy with synchronous right hemicolectomy. Post-operatively the patient developed severe ARDS and died of respiratory failure. In this case, errors identified included patient selection and intravenous fluid prescribing. This death was graded as probably preventable. The action plan implemented in this case involved formulation of new policy, individual counselling and educational offering. The death following pancreatectomy was due to a post-operative myocardial infarction. Despite cardiological assessment and stress testing pre-operatively, the error identified was of patient selection and the death deemed possibly preventable. The action plan was formation of a new policy or procedure. See supplementary file: ds2496.docx - “Results” Lessons and Limitations Lessons learnt:

On mortality analysis, that following liver resection occurred after a right hemihepatectomy with synchronous right hemicolectomy. Post-operatively the patient developed severe ARDS and died of respiratory failure. In this case, errors identified included patient selection and intravenous fluid prescribing. This death was graded as probably preventable. The action plan implemented in this case involved formulation of new policy, individual counselling and educational offering. The death following pancreatectomy was due to a post-operative myocardial infarction. Despite cardiological assessment and stress testing pre-operatively, the error identified was of patient selection and the death deemed possibly preventable. The action plan was formation of a new policy or procedure. See supplementary file: ds2496.docx - “Results” Lessons and Limitations Lessons learnt: This project has demonstrated that a HPB QIP is an effective way to address the significant clinical problem of high morbidity rates following liver and pancreatic surgery. Success requires a commitment to quality improvement from the clinical team, the organisation the team works in and the wider National Health Service (NHS). Only once a culture of safety and harm reduction is considered a paramount objective can real progress be made.

idity rates following liver and pancreatic surgery. Success requires a commitment to quality improvement from the clinical team, the organisation the team works in and the wider National Health Service (NHS). Only once a culture of safety and harm reduction is considered a paramount objective can real progress be made. It is therefore essential that a program such as this has the whole-hearted supported of hospital management. The clinicians leading the program must have the ability to recommend and introduce change, otherwise the process becomes merely an exercise in data collection. Consequently, an understanding of change management and how to overcome vested interests opposed to change, in a diplomatic but effective manner, is desirable. Sustainability requires that the current upsurge in interest in Quality Improvement in the NHS is maintained and that lessons are learnt from, for example, the disastrous outcomes and standards of care outlined in the Francis report (16). Corporate self-interest and target-driven management should never again be allowed to over-ride the pursuit of safe clinical care. Whether this particular HPB QIP can continue to make improvements in the reduction of surgical complications in a sustained, year-on-year fashion remains to be seen but is the focus of our on-going efforts and future work. Limitations: Potential limitations of this study include ascertainment bias, underpowering and observer bias.

Sustainability requires that the current upsurge in interest in Quality Improvement in the NHS is maintained and that lessons are learnt from, for example, the disastrous outcomes and standards of care outlined in the Francis report (16). Corporate self-interest and target-driven management should never again be allowed to over-ride the pursuit of safe clinical care. Whether this particular HPB QIP can continue to make improvements in the reduction of surgical complications in a sustained, year-on-year fashion remains to be seen but is the focus of our on-going efforts and future work. Limitations: Potential limitations of this study include ascertainment bias, underpowering and observer bias. Complication rates depend not just on the quality of surgical skill and perioperative care, but also on definition and on the rigour with which complications are sought. The highly sensitive definitions provided by the ISGPS and ISGLS are therefore valuable as they allow, for the first time, comparison between institutions in a valid manner. Some (mainly those produced by the ISGLS) were not published until 2011, so complications identified during the baseline period were either retrospectively applied or identified according to contemporary standards. The rigour with which complications were sought was high during both periods (as we published an analysis of our complications during the baseline period) but the precise purpose of a weekly QIP meeting is the completeness of case ascertainment. The effects of this limitation, however, is to tend to make improvements more difficult to identify.

lications were sought was high during both periods (as we published an analysis of our complications during the baseline period) but the precise purpose of a weekly QIP meeting is the completeness of case ascertainment. The effects of this limitation, however, is to tend to make improvements more difficult to identify. The current complication rates were based on an analysis of the first six months after implementation of the HPB QIP. This compares with at least a two-year period of baseline measurement. Differences in complications may not have emerged for liver surgery because of the relatively small numbers during the current period and the study is certainly underpowered to detect a difference in mortality rates between the two periods. It may be argued that the reductions in the complication rates already achieved were a result of the intense scrutiny a department comes under when a QIP is introduced (a surgical Hawthorne effect (17)) rather than as a result of changes introduced as part of an action plan. Ultimately it matters less whether Quality Improvement is achieved as a result of observation than by changed practice, than that its objectives are achieved and complication rates reduced. Quality Improvement is most likely a complex interaction of both factors. Conclusion In summary, a HPB QIP has been designed and introduced to our unit. Early results show that complications can be significantly reduced with this approach.

It may be argued that the reductions in the complication rates already achieved were a result of the intense scrutiny a department comes under when a QIP is introduced (a surgical Hawthorne effect (17)) rather than as a result of changes introduced as part of an action plan. Ultimately it matters less whether Quality Improvement is achieved as a result of observation than by changed practice, than that its objectives are achieved and complication rates reduced. Quality Improvement is most likely a complex interaction of both factors. Conclusion In summary, a HPB QIP has been designed and introduced to our unit. Early results show that complications can be significantly reduced with this approach. The scale of the problem of post operative morbidity and mortality after this type of surgery remains high. These high complication rates reflect not just the relatively elderly patient population with comorbidities, the technically challenging nature of the surgery but also sensitive definitions and thorough case ascertainment. The HPB QIP is a rigorous approach to grade every complication and death. Errors are identified and an action plan made in each case. A statistically significant reduction in pancreas related complications has already been obtained. Further work is required to achieve and maintain ongoing reductions in complication rates and postoperative deaths. Supplementary Material Web supplement Web supplement None Declaration of interests: Nothing to declare

Problem For patients in an acute hospital setting, deterioration in clinical condition frequently occurs outside of normal working hours. In some patients, cardio-pulmonary resuscitation (CPR) is unlikely to improve survival but this does not preclude the use of other resuscitative treatment modalities, such as intravenous fluids and antibiotics, or more invasive measures like ventilator support and inotrope/vasopressor therapy. Patient factors, including pre-morbid function, influence the clinical benefit conferred by individual treatment modalities, but any pre-existing wishes and values will also help determine which of these measures may be inappropriate. Within working hours there is greater opportunity to explore these factors, and often it is possible for in-hours teams to identify patients at foreseeable risk of deterioration. In these patients, documentation of any inappropriate treatments allows the in-hours team to tailor care to the individual's clinical circumstances and guide out-of-hours (OOH) management, thus promoting beneficence. Our preliminary research suggested that the resuscitative treatment modalities used OOH in patients categorised ‘not for CPR', was sometimes considered by in-hours teams to conflict with best interests.

care to the individual's clinical circumstances and guide out-of-hours (OOH) management, thus promoting beneficence. Our preliminary research suggested that the resuscitative treatment modalities used OOH in patients categorised ‘not for CPR', was sometimes considered by in-hours teams to conflict with best interests. Background The principle of beneficence dictates that the health professional's duty is to act in the best interests of the patient at all times. Prolonging life at all costs without due regard to the burden of treatment conflicts with this principle, and it is thus the duty of the doctor to carefully consider the likelihood of benefit from each treatment modality, on an individual patient basis, giving thought to pre-morbid level of function, beliefs and wishes. Blanket policies of ‘for all treatment’ or ‘for no treatment’ are ethically indefensible.

his principle, and it is thus the duty of the doctor to carefully consider the likelihood of benefit from each treatment modality, on an individual patient basis, giving thought to pre-morbid level of function, beliefs and wishes. Blanket policies of ‘for all treatment’ or ‘for no treatment’ are ethically indefensible. The resuscitation council outlined that ;advance care planning, including making decisions about CPR, is an important part of good clinical care for those at risk of cardio-pulmonary arrest.' However, other trusts have already identified that in patients unlikely to benefit from CPR, quality of care can be improved by documenting a treatment escalation plan (TEP) to guide management in the event of an OOH clinical deterioration. By tailoring management to the individual patient's clinical circumstances and subsequently minimising the risk of on-call teams issuing treatments with limited conferred benefit, TEPs can promote beneficence. On a TEP, all available treatment modalities are laid out individually, with clear indication beside those which may be inappropriate; these decisions are dynamic and can change with variation in clinical condition. They should ideally be discussed with the patient early in their illness while capacity to make specific decisions about future life sustaining treatments is still preserved. If the patient lacks capacity to participate in decision making, a Lasting Power of Attorney (where one exists) and the family and next of kin should be engaged.

lly be discussed with the patient early in their illness while capacity to make specific decisions about future life sustaining treatments is still preserved. If the patient lacks capacity to participate in decision making, a Lasting Power of Attorney (where one exists) and the family and next of kin should be engaged. The aim of the study was to identify whether creating a TEP within normal working hours in patients categorised ‘not for CPR’ could reduce the number of patients receiving inappropriate treatments during OOH deterioration. This was in comparison to similarly categorised patients who had no written documentation of inappropriate treatment modalities.

ntify whether creating a TEP within normal working hours in patients categorised ‘not for CPR’ could reduce the number of patients receiving inappropriate treatments during OOH deterioration. This was in comparison to similarly categorised patients who had no written documentation of inappropriate treatment modalities. Baseline Measurement On a single day, the clinical notes of 178 patients were audited. In those who had a completed CPR form (58%; n= 103), 46% (n=81) were ‘not for CPR’ but in more than three quarters of these patients (78%; n= 61), there was no documentation of which treatment modalities were considered to be inappropriate in the event of clinical deterioration. On the same day, the number of patients who experienced an OOH clinical deterioration (5pm-9am) requiring review by on-call doctors was recorded (n=30). In 40% (n=12) and no CPR decision was documented. In the remainder (n=18) with a CPR decision, ‘not for CPR’ was documented in 50% (n=9) but 77% of these patients (n=7) had no written documentation of treatment measures considered inappropriate. In the two patients who did have a documented ceiling of escalation, the phrase ‘in the event of deterioration, this patient is for ward based care only’ was used, with no mention of specific resuscitative treatment options. Subsequent feedback from the in-hours team regarding appropriateness of the OOH treatment in these 9 patients was assessed via questionnaire the following morning. In 44% (n=4), one or more treatment modalities were felt to have been inappropriate for the patient in question and not in their best interests.

nt options. Subsequent feedback from the in-hours team regarding appropriateness of the OOH treatment in these 9 patients was assessed via questionnaire the following morning. In 44% (n=4), one or more treatment modalities were felt to have been inappropriate for the patient in question and not in their best interests. In a survey of junior doctors in the hospital, 86% recalled at least one occasion where they had required a senior colleague to complete a CPR form after deterioration in a patient's clinical condition. All of the doctors surveyed felt that a treatment escalation plan documented by the in-hours team would have been useful to guide management OOH. Design Failure to document any inappropriate treatment modalities for individual patients stems partly from reluctance to consider clinical deterioration before it has happened. The situations in which patients deteriorate can be complex and the appropriateness of treatments may differ based on the circumstances surrounding the deterioration. By adapting a TEP document already established in another NHS trust and incorporating it into our trust's existing CPR form, the new TEP-CPR form aimed to force clinicians to consider both the possibility of deterioration and the appropriateness of individual treatment modalities when making decisions about CPR. The basic structure of the original CPR form was maintained because improved participation in a trial of a form-based intervention has been previously documented when the intervention is introduced into a familiar design

oration and the appropriateness of individual treatment modalities when making decisions about CPR. The basic structure of the original CPR form was maintained because improved participation in a trial of a form-based intervention has been previously documented when the intervention is introduced into a familiar design A quasi-experiment design was used to test the aim in two groups - intervention and control. All patients in the intervention group had a fully completed TEP-CPR form; the TEP component was only completed if the CPR decision was ‘not for CPR’ thus everyone in the intervention group was ‘not for CPR’. The control group included all the patients on the remaining adult medical and surgical wards who were ‘not for CPR’ but had no documentation of what treatments were considered inappropriate in the event of clinical deterioration. Thus the independent variable was whether or not a patient had a new CPR-TEP document. The dependent variable was appropriateness of OOH treatment in those patients who experienced clinical deterioration OOH, as judged by questionnaire-based feedback from the in-hours team the following morning. Levels of inappropriate treatment between the two groups were compared to test the aim. Strategy In total, four PDSA cycles were used to develop the final TEP-CPR form.

A quasi-experiment design was used to test the aim in two groups - intervention and control. All patients in the intervention group had a fully completed TEP-CPR form; the TEP component was only completed if the CPR decision was ‘not for CPR’ thus everyone in the intervention group was ‘not for CPR’. The control group included all the patients on the remaining adult medical and surgical wards who were ‘not for CPR’ but had no documentation of what treatments were considered inappropriate in the event of clinical deterioration. Thus the independent variable was whether or not a patient had a new CPR-TEP document. The dependent variable was appropriateness of OOH treatment in those patients who experienced clinical deterioration OOH, as judged by questionnaire-based feedback from the in-hours team the following morning. Levels of inappropriate treatment between the two groups were compared to test the aim. Strategy In total, four PDSA cycles were used to develop the final TEP-CPR form. PDSA 1 - the new TEP-CPR form was shown to several elderly care and oncology consultants. In elderly patients and in those with cancer, there is often a foreseeable risk of clinical deterioration. The advice of consultants in these fields was thus sought because they frequently engage in decision making about what treatments would be in an individual's best interests in the event of clinical deterioration. Initially six resuscitative treatment modalities were laid out in a pyramid design with simple measures (IV fluids, antibiotics and blood transfusions) placed lower in the pyramid and more invasive measures (inotrope/vasopressor therapy, renal replacement therapy and invasive ventilation) placed higher. The aesthetics of the design were well received however there was concern that decision making regarding the more invasive treatments would be difficult for clinicians as the appropriateness of each may depend on the specific clinical condition. Since all three invasive measures are facilitated in the HDU/ITU setting, they were merged under one unifying option ‘for escalation to HDU/ITU’. The resuscitative treatment options on the modified TEP-CPR from, in order of least invasive (bottom of the pyramid) to most invasive (top of the pyramid) was thus IV fluids, antibiotics and escalation to HDU/ITU.

acilitated in the HDU/ITU setting, they were merged under one unifying option ‘for escalation to HDU/ITU’. The resuscitative treatment options on the modified TEP-CPR from, in order of least invasive (bottom of the pyramid) to most invasive (top of the pyramid) was thus IV fluids, antibiotics and escalation to HDU/ITU. PDSA 2 - the modified TEP-CPR was piloted for 2 weeks on an oncology ward and an elderly care ward. These wards were specifically chosen because they had the highest rates of OOH clinical deterioration. In this initial stage, usability of the form, factors influencing completion and safety of the form were assessed. Although there was unanimous agreement that the form was user-friendly, concerns over the safety of the form were raised. There is huge variability in the circumstances under which a patient's clinical condition may deteriorate. In the same patient, treatments which are judged inappropriate may in other instances be considered appropriate. Thus in the event of a patient surviving a deterioration, there was a theoretical risk of the TEP-CPR form displaying advice that may not be valid for a further deterioration under different circumstances. Many consultants were uncomfortable with this idea from a legal and professional point of view. Mandatory documentation of a date for review of the decisions was suggested by some. A series of additional boxes were also included to indicate to the OOH team that the designated review had taken place and advise them of when the in-hours team felt the next review was necessary. The absence of evidence that the form had been reviewed would invalidate the advice suggested by the in-hours team; in this situation the patient was viewed as if they had no TEP-CPR form. If there was no evidence in one of the provided boxes that this review had occurred, the decisions on the form would be invalidated. Other situations rendering the form invalid were discharge from hospital and transfer to another healthcare setting. The responsibility for completion and review of the TEP-CPR form rested with the most senior clinician in charge of the patient's care, but it was possible for the task to be delegated to another member of the team provided level of training was greater than ST3 (specialty trainee year 3). It was advised that wherever possible, the patient should be involved in decision making and that ideally the decisions should be agreed with the whole healthcare team.

it was possible for the task to be delegated to another member of the team provided level of training was greater than ST3 (specialty trainee year 3). It was advised that wherever possible, the patient should be involved in decision making and that ideally the decisions should be agreed with the whole healthcare team. PDSA 3 - following the initial pilot and above modifications to the TEP-CPR form, a further one week pilot was performed on the same wards using the most up to date version of the form. The addition of the special circumstances box was well received and allowed clinicians to be less rigid in their decision making, which had previously been cited as a criticism from several consultants. Feedback from the second pilot indicated that the mandatory review date and provision of additional boxes to indicate time of next review, eased the anxiety surrounding use of the previous form. No further suggestions were made and the final version of the form was thus created.

as a criticism from several consultants. Feedback from the second pilot indicated that the mandatory review date and provision of additional boxes to indicate time of next review, eased the anxiety surrounding use of the previous form. No further suggestions were made and the final version of the form was thus created. PDSA 4 - The form was used for a further 2 months on the oncology ward and the elderly care ward. The TEP component was completed by the clinical team within working hours in all patients who were deemed to be ‘not for CPR’. The intervention group was all of the patients on these 2 wards with TEP component of the form completed, who experienced clinical deterioration OOH. Questionnaire-based feedback from the in-hours team about the appropriateness of the OOH treatment given, was collected the following morning for these patients. Over the study period, the difference in appropriateness of OOH treatment with use of the TEP-CPR form was compared to treatment of patients in the control group who deteriorated OOH. The control group included patients on other hospital wards with a completed CPR form documenting ‘not for CPR’ but without any documentation of TEP in the notes.

difference in appropriateness of OOH treatment with use of the TEP-CPR form was compared to treatment of patients in the control group who deteriorated OOH. The control group included patients on other hospital wards with a completed CPR form documenting ‘not for CPR’ but without any documentation of TEP in the notes. Results The number of admissions to the two intervention wards over the study period was 90; the TEP component of the new document was completed in 75.5% (n=68), for all patients whose CPR decision was ‘not for CPR’. In this group, 66% (n=45) had an OOH clinical deterioration during the study period. There were 36 patients in the comparison group. At the end of the study period, questionnaire feedback indicated that 11.1% of patients in the group with the new CPR-TEP document had received inappropriate OOH care compared to 44.4% of patients in the group without the document). Analysis of the medical notes in the 5 patients in the intervention group whose OOH care was deemed inappropriate despite a completed CPR-TEP form identified that the documented ceiling of appropriate treatment modalities had not been followed due to disagreement by the medical registrar on call.

without the document). Analysis of the medical notes in the 5 patients in the intervention group whose OOH care was deemed inappropriate despite a completed CPR-TEP form identified that the documented ceiling of appropriate treatment modalities had not been followed due to disagreement by the medical registrar on call. Lessons and Limitations The limitations of the study are related to the study design. Patients were not assigned randomly to the intervention group. The CPR-TEP document was completed for patients on the two wards in the hospital with the highest rates of OOH clinical deterioration. These wards were an acute elderly care ward and an oncology ward. In these patients there was foreseeable risk of clinical deterioration and due to the high proportion of time that is spent communicating with patients and relatives/carers on these wards, a great deal is known about the patient's wishes thus it may have been easier to decide which treatment modalities would be in the patient's best interests. For patients on the other wards in whom CPR was deemed futile but without obvious potential for clinical deterioration, deciding which treatment modalities are in the patient's best interests may not be so easy; what is or is not appropriate may depend on the nature of deterioration. Our sample size was very small and although our data is promising, it is limited in its power. To improve this we need to monitor greater numbers of patients who have deteriorated and then follow up with feedback from in-hours teams.

t be so easy; what is or is not appropriate may depend on the nature of deterioration. Our sample size was very small and although our data is promising, it is limited in its power. To improve this we need to monitor greater numbers of patients who have deteriorated and then follow up with feedback from in-hours teams. Conclusion In-hours clinical teams have greater opportunity to explore patients’ pre-morbid function, wishes and values by talking directly to the patient as well as relatives/carers. They are therefore better placed to make decisions about which treatment modalities are in the best interests of the patient, in the event of clinical deterioration. Despite this, documentation of these decisions is poor. Most clinical deterioration occurs OOH and when these important decisions are left solely to on-call teams, the management can be subsequently viewed by the in-hours team to be conflicting with the best interests of the patient. This study has shown that this disparity can be reduced by completing a TEP in patients who, despite perceived futility of CPR, may require other resuscitative treatment modalities OOH. TEPs can therefore promote beneficence.

equently viewed by the in-hours team to be conflicting with the best interests of the patient. This study has shown that this disparity can be reduced by completing a TEP in patients who, despite perceived futility of CPR, may require other resuscitative treatment modalities OOH. TEPs can therefore promote beneficence. The proportion of patients dying in the setting of an acute hospital ward (about 60%) does not correlate with data from public surveys about preferred place of dying. As many as two thirds of patients reaching the end of life would prefer to die at home or in a hospice environment and the Second Annual Report of the End of Life Care Strategy suggests that many people are needlessly sent to hospital to die simply because care home staff are unsure of what else to do (1). Every effort should be made to address this inconsistency particularly in view of the fact that 54% of complaints in acute hospitals are related to care of the dying, according to national survey undertaken by the Health Care Commission in 2007. Indeed the NHS End of Life Care Strategy stipulates that all people approaching the end of life should have their needs assessed, their wishes and preferences discussed and an agreed set of actions reflecting the choices they make about their care recorded in a care plan (2). Historically, this aim has not been well achieved. Success has largely been limited by the attitude - endemic within our society - that death and dying is a taboo area. It is imperative to raise the profile of end of life care in order to change this negative attitude both within the medical community and among the public. Considering any treatment modalities which may be inappropriate for the individual patient with subsequent written documentation in the form of a TEP is just one small step towards achieving this cultural change. Ideally, advance care planning (ACP) should be at the forefront of the clinicians mind, whether this is in an outpatient clinic or GP practice. However, identifying groups of patients who might benefit from ACP and ensuring that the clinician has enough time for these discussions can be difficult. One way to prompt clinicians to consider ACP is to use the Gold Standards Framework Surprise Question, “would you be surprised if this patient died in the next 12 months”. If the answer to the question is ‘no’ a conversation about the patient's beliefs and wishes on potential life sustaining treatment should be initiated and documented in the medical notes.

r ACP is to use the Gold Standards Framework Surprise Question, “would you be surprised if this patient died in the next 12 months”. If the answer to the question is ‘no’ a conversation about the patient's beliefs and wishes on potential life sustaining treatment should be initiated and documented in the medical notes. It is important to do this while the patient has capacity to make these decisions, which may be lost in the event of future deterioration. Research suggests that the outpatient clinic setting is an ideal place to discuss these important issues as there is greater privacy than on the open hospital ward and patients are often seen over a long period of time by the same consultant (or his/her team). All doctors will at some point be involved in end of life care and should therefore take an interest in ensuring that quality of life during this period. Dr Peter Cavanagh, Dr Peter Campbell, Dr Lucy Pollock, Dr Julie Walthers, Dr Joanne Watson National End of Life Care Programme. The route to success. Department of Health. London, 2010. Declaration of interests: None

Problem Falls are the most common patient safety incident reported to the National Patient Safety Agency (NPSA) and can lead to injury or death (1) and incur considerable cost for the NHS. (2) In 2010 the NPSA recommended NHS organisations minimise the risk of inpatient falls, though use of falls prevention teams, production of local targets for reducing harm due to falls, focused efforts on time or places falls are most likely to occur, provision of falls prevention training for staff, and detailed prevention plans for vulnerable patients. (3) We found that inpatient falls were the commonest reported incident in the Elderly Care wards; as such they are an area of significant risk regarding patient safety. Background Annually, approximately 282,000 inpatient falls are reported to the National Patient Safety Agency, making them the most common patient safety incident reported. Significant numbers of falls result in death or moderate to severe injury, (1) including over 1065 serious injuries and at least 83 directly attributable deaths, with costs of approximately £15 million per annum. Most inpatient falls involve patients aged over 75 years with significant co-morbidities, (2) patients typically found in Elderly Care wards. Research shows inpatient falls may be reduced by 18 to 31% through multi-factorial assessments and interventions. (4) However, national audits have found low levels and/or poor implementation of relevant evidence-based assessments and interventions throughout the UK. (2)

Background Annually, approximately 282,000 inpatient falls are reported to the National Patient Safety Agency, making them the most common patient safety incident reported. Significant numbers of falls result in death or moderate to severe injury, (1) including over 1065 serious injuries and at least 83 directly attributable deaths, with costs of approximately £15 million per annum. Most inpatient falls involve patients aged over 75 years with significant co-morbidities, (2) patients typically found in Elderly Care wards. Research shows inpatient falls may be reduced by 18 to 31% through multi-factorial assessments and interventions. (4) However, national audits have found low levels and/or poor implementation of relevant evidence-based assessments and interventions throughout the UK. (2) The FallSafe project, (http://www.rcplondon.ac.uk/projects/fallsafe) a quality improvement initiative focusing on prevention and management of falls, identified that successful studies used ward based leaders rather than visiting specialists, engaged a multidisciplinary team, and addressed five to fifteen risk factors for falls in their interventions. In addition it was noted that combinations of evidence-based interventions were required to improve patient outcomes. (2) It is acknowledged that not all falls can be prevented without unacceptable restrictions to patients' independence or dignity, (2) and if a fall cannot be prevented, a prompt and effective response should ensue, to achieve the best possible recovery, and avoidance of further falls.

The FallSafe project, (http://www.rcplondon.ac.uk/projects/fallsafe) a quality improvement initiative focusing on prevention and management of falls, identified that successful studies used ward based leaders rather than visiting specialists, engaged a multidisciplinary team, and addressed five to fifteen risk factors for falls in their interventions. In addition it was noted that combinations of evidence-based interventions were required to improve patient outcomes. (2) It is acknowledged that not all falls can be prevented without unacceptable restrictions to patients' independence or dignity, (2) and if a fall cannot be prevented, a prompt and effective response should ensue, to achieve the best possible recovery, and avoidance of further falls. Baseline Measurement This project was carried out in a 19 bed unit, one of four Elderly Care wards. A baseline audit was undertaken to establish the total number of falls on the ward for one calendar year, by review of incident report forms. The number of patient bed days for the same year was obtained and the inpatient falls rate was calculated as the number of falls / 1000 patient bed days. The baseline falls rate was 14.70 falls / 1000 bed days for November 2010 - October 2011. All unobserved falls, including those reported as ‘found on floor’ were included. Observed falls were included, except those reported as ‘assisted to floor’.

Baseline Measurement This project was carried out in a 19 bed unit, one of four Elderly Care wards. A baseline audit was undertaken to establish the total number of falls on the ward for one calendar year, by review of incident report forms. The number of patient bed days for the same year was obtained and the inpatient falls rate was calculated as the number of falls / 1000 patient bed days. The baseline falls rate was 14.70 falls / 1000 bed days for November 2010 - October 2011. All unobserved falls, including those reported as ‘found on floor’ were included. Observed falls were included, except those reported as ‘assisted to floor’. Design The aims of the project were to reduce inpatient falls by 20% and to improve quality of care provided post-fall. A ward-based medical doctor was identified as clinical lead. Using ‘plan do study act’ learning cycles, the clinical lead led a multi-disciplinary team to introduce care plans, incentive posters and post-fall management guidelines. Feedback sessions were organised with ward staff to review interventions and post-intervention re-audits were conducted to assess impact.

nical lead. Using ‘plan do study act’ learning cycles, the clinical lead led a multi-disciplinary team to introduce care plans, incentive posters and post-fall management guidelines. Feedback sessions were organised with ward staff to review interventions and post-intervention re-audits were conducted to assess impact. Results were disseminated via ward feedback sessions, departmental educational meetings, and wider to medical specialties through the hospital audit programme and trust-wide Safety, Quality and Effectiveness programme. The initial intervention was a multi-factorial falls assessment and care plan that has been used successfully in other falls reduction studies. (5) This form was completed by nursing staff; the first part uses NPSA's ‘four screening questions’ to elicit a history of falls prior to admission, after admission, anxiety about falling, and attempts to walk alone despite unsteadiness. The patient is considered at high risk of falls if a ‘yes’ response is obtained to any of the screening questions and a more thorough assessment and intervention is then performed, using the second part of the form. (2) The second part of the care plan examined areas of potential increased risk for falls, such as orthostatic hypotension, bladder frequency, and medications, (2) thus enabling adaption of care to prevent falls.

Results were disseminated via ward feedback sessions, departmental educational meetings, and wider to medical specialties through the hospital audit programme and trust-wide Safety, Quality and Effectiveness programme. The initial intervention was a multi-factorial falls assessment and care plan that has been used successfully in other falls reduction studies. (5) This form was completed by nursing staff; the first part uses NPSA's ‘four screening questions’ to elicit a history of falls prior to admission, after admission, anxiety about falling, and attempts to walk alone despite unsteadiness. The patient is considered at high risk of falls if a ‘yes’ response is obtained to any of the screening questions and a more thorough assessment and intervention is then performed, using the second part of the form. (2) The second part of the care plan examined areas of potential increased risk for falls, such as orthostatic hypotension, bladder frequency, and medications, (2) thus enabling adaption of care to prevent falls. The care plans were introduced initially for use with one consultant's patients who were admitted with a fall. A feedback session with ward staff was organised; problems including where to place care plans in notes to ensure completion and regular review, and how long nursing staff should have to complete them, were identified and addressed promptly to suit the working of the ward. Feedback sessions with ward staff were positive as nursing staff subjectively felt the care plans identified high-risk patients and enabled adaption of care to suit individuals' needs.

eview, and how long nursing staff should have to complete them, were identified and addressed promptly to suit the working of the ward. Feedback sessions with ward staff were positive as nursing staff subjectively felt the care plans identified high-risk patients and enabled adaption of care to suit individuals' needs. Strategy As a result of the positive feedback, it was decided that the care plans should be completed for all patients admitted to the ward, regardless of reason for admission or consultant. Monthly monitoring of care plan completion achieved a compliance rate of 89%, and highlighted that up to 81% of patients were considered high-risk. A re-audit, three months after the initial introduction of the care plans, showed a 13.4% reduction in the inpatient falls rate compared with baseline (12.73 falls / 1000 patient bed days, November 2011- January 2012). A ‘walking-stick’ poster was introduced as a visual incentive to aid and encourage nursing staff. This was completed on a daily basis and highlighted if a fall occurred, allowing annotation regarding number, location, or reason for the fall. Feedback was positive regarding use of the ‘walking-stick’ poster as staff stated it was a good visual reminder of progress and provided an incentive to continue. A six month re-audit of the inpatient falls rate was conducted following the introduction of both interventions. This showed a 10.6% reduction in the inpatient falls rate (13.14 falls/1000 patient bed days, November 2011 to April 2012).

Feedback was positive regarding use of the ‘walking-stick’ poster as staff stated it was a good visual reminder of progress and provided an incentive to continue. A six month re-audit of the inpatient falls rate was conducted following the introduction of both interventions. This showed a 10.6% reduction in the inpatient falls rate (13.14 falls/1000 patient bed days, November 2011 to April 2012). Trust guidelines regarding falls were published during the project. These included a post-fall assessment poster to aid medical and nursing staff in post-fall management, focusing on head, neck and pelvic/hip injuries. A feedback session with ward staff was again organised and this was positive, with subjective improvement in quality of post-fall care. Post-Measurement A one year re-audit was conducted to assess the on-going effects of the interventions. The inpatient falls rate had reduced by 15.4% (12.44 falls / 1000 patient bed days for November 2011 to October 2012). Yet to obtain our initial goal of a 20% reduction in the inpatient falls rate, we intend to continue implementing and monitoring the changes described, with further re-auditing as required: we need to ensure the reduction we have achieved is sustained. We have shared the learning in this project throughout our department and intend to extend the work to the other three Elderly Care wards. We have fed back the learning to other medical specialties through local audit meetings. We also intend to hand ownership of the project to a clinical nurse lead, to maintain and improve inpatient falls rates.

in this project throughout our department and intend to extend the work to the other three Elderly Care wards. We have fed back the learning to other medical specialties through local audit meetings. We also intend to hand ownership of the project to a clinical nurse lead, to maintain and improve inpatient falls rates. Lessons and Limitations The number of falls in an Elderly Care ward can be reduced by the use of a multi-factorial assessment and interventional care plan. A multidisciplinary team approach is necessary for success and we would suggest a dedicated time for the clinical lead to educate staff. In hindsight, as most interventions are nurse-orientated, a ward-based nurse would be best placed to fulfil the role of clinical lead. Conclusion Falls are the most common patient safety incident reported, frequently resulting in moderate to severe injury or death; thus reduction of falls and adequate post-fall management is of utmost importance. This study has demonstrated good compliance with a multi-factorial falls assessment and care plan and an incentive poster, as well as positive feedback from staff regarding usage. The inpatient falls rate decreased by 15.4% over one year: still to obtain our initial goal of a 20% reduction in the inpatient falls rate, we intend to continue implementing and monitoring the changes described, with further re-auditing as required.

Problem Obtaining microbiology specimens from infants and children can be a challenging task. Not only is it distressing for the patient and parents, but the process involves a lot of time, and preparation, from the clinical team. In young infants, sedation is sometimes used to perform lumbar puncture in difficult cases. A delay in receiving microbiology results can impact clinical management, leading to empirical antibiotic treatment of infection and unnecessary, distressing repeat investigation. All microbiology specimens are sent to an off-site laboratory for analysis. With multiple steps in the transport process involving clinicians, porters, and laboratory staff, the pathway is complex with multiple potential causes for the delay in obtaining results. All stakeholders involved were keen to investigate and improve this vital service. Background The project was carried out in the Paediatric Department at a Central London teaching hospital. The Paediatric Department comprises four children's wards with over forty beds, the Paediatric Intensive Care Unit and the Paediatric Accident and Emergency. A departmental audit highlighted a delay in this transport process with some samples taking in excess of eight hours to reach the laboratory and others reported as ‘missing’. The audit did not highlight where delays were taking place or possible contributing factors.

Care Unit and the Paediatric Accident and Emergency. A departmental audit highlighted a delay in this transport process with some samples taking in excess of eight hours to reach the laboratory and others reported as ‘missing’. The audit did not highlight where delays were taking place or possible contributing factors. The protocol for sending microbiology specimens detailed the steps involved in sending specimens both in and out-of-hours with emphasis on the use of the Pneumatic Tube System (PTS) for sending specimen in-hours. With limited knowledge of the protocol among staff in the department, and other limitations which were later realised, transport of urgent specimens was not as efficient as it should be. The issue had also been highlighted through clinical incident reporting. Although an important problem, with possible implications to patient safety, there was limited information on where delays were occurring and areas in which improvements could be made. Consequently there had been little in the way of progress to improve the service.

been highlighted through clinical incident reporting. Although an important problem, with possible implications to patient safety, there was limited information on where delays were occurring and areas in which improvements could be made. Consequently there had been little in the way of progress to improve the service. Baseline Measurement Details of total transit time obtained from a previous departmental audit, opinion gauged from staff on the ward and clinical incident forms were the main drivers for this project. A sticker was designed to affix to microbiology specimen bags. This served several purposes: To assign accountability to those involved, to track each step in the transport process and to raise awareness. The multi-purpose sticker allowed us to assess the scale of the problem and provided an objective way of monitoring improvement. By asking staff to sign, time and date at each step we were able to record the exact time taken at each stage in order observe potential areas which could be causing delay in transport. Our baseline measurement was obtained one month after introducing the sticker tracker which revealed an average transport time of 160 minutes. See supplementary file: Figure 1- The Sticker Tracker.doc

Baseline Measurement Details of total transit time obtained from a previous departmental audit, opinion gauged from staff on the ward and clinical incident forms were the main drivers for this project. A sticker was designed to affix to microbiology specimen bags. This served several purposes: To assign accountability to those involved, to track each step in the transport process and to raise awareness. The multi-purpose sticker allowed us to assess the scale of the problem and provided an objective way of monitoring improvement. By asking staff to sign, time and date at each step we were able to record the exact time taken at each stage in order observe potential areas which could be causing delay in transport. Our baseline measurement was obtained one month after introducing the sticker tracker which revealed an average transport time of 160 minutes. See supplementary file: Figure 1- The Sticker Tracker.doc Design It was imperative that our intervention allowed us to identify exactly where delays in the transport process were occurring so that these could be used as a platform to explore potential contributing factors. The Quality Improvement Project team comprised of a Consultant Paediatrician, the Quality and Safety Manager of Pathology Business Services, the Head of the Paediatric Risk and Audit Team, and a Foundation Year 1 Doctor. Together we considered various methods of tracking the transport process considering financial limitations and sustainability, finally deciding on the use of a sticker tracking system.

lity and Safety Manager of Pathology Business Services, the Head of the Paediatric Risk and Audit Team, and a Foundation Year 1 Doctor. Together we considered various methods of tracking the transport process considering financial limitations and sustainability, finally deciding on the use of a sticker tracking system. Using the protocol for sending urgent microbiology specimens a sticker was designed which required the member of staff responsible at each stage of the process to time, date and sign, at each stage of the process (Figure 1). On reviewing the design we further agreed we would number the stickers making note of which number stickers were allocated to the various clinical areas, enabling us to also monitor use of the stickers in the different Paediatric departments. The production of the stickers was funded by the off-site Microbiology Laboratory . In the initial planning stages we decided that the stickers would be employed for a six month period allowing us enough time to assess the problem, make necessary changes and monitor any improvement to the service, after which time the sticker would no longer need to be in place. We anticipated that asking staff to complete more paperwork would be a challenge and that, in the context of a busy working environment, staff may forget to use the stickers so we ensured that we dedicated time to appropriately promote the use of the stickers using emails, induction meetings, posters and meeting staff in person. Following the launch, all completed stickers were analysed weekly using an Excel spreadsheet.

t of a busy working environment, staff may forget to use the stickers so we ensured that we dedicated time to appropriately promote the use of the stickers using emails, induction meetings, posters and meeting staff in person. Following the launch, all completed stickers were analysed weekly using an Excel spreadsheet. Strategy In the initial phase of auditing stickers and liaising with staff, key problem areas were highlighted. These included lack of knowledge of the protocol for sending urgent specimens, lack of trust in the Pneumatic Tube System (PTS) which should be used for sending specimens in-hours, insufficient pods to send samples via the PTS and poor completion of stickers. These led to a delay in samples reaching the chemical pathology lab. Porters were called to deliver specimens via foot which took longer and was an inappropriate use of the portering service, taking porters away from other duties in the hospital. We subsequently improved the design of the protocol, so that is was more user-friendly, and were displayed in appropriate ward locations.

lab. Porters were called to deliver specimens via foot which took longer and was an inappropriate use of the portering service, taking porters away from other duties in the hospital. We subsequently improved the design of the protocol, so that is was more user-friendly, and were displayed in appropriate ward locations. We provided education of the protocol at a local level to nurses and doctors. An audit was conducted on the pneumatic tube system, which tracked transit time of pods from the ward, to the Chemical Pathology Lab, with a view to increasing staff trust the pod system. Proposals were made for obtaining funding for the provision of more pods which has been granted. The stickers were further promoted at new doctors’ induction, meetings with the portering department and laboratory staff, to encourage correct completion of the sticker.

ith a view to increasing staff trust the pod system. Proposals were made for obtaining funding for the provision of more pods which has been granted. The stickers were further promoted at new doctors’ induction, meetings with the portering department and laboratory staff, to encourage correct completion of the sticker. In the second phase we observed more promising results with an improved rate of sticker completion and an improved specimen transport time ranging from 50 minutes to 4.5 hours. The reporting of three incidents via Datix (online incident reporting software) caused us to re-evaluate and make further changes. The three incidents were investigated at senior departmental level using root-cause analysis. Following this further strategies were implemented which included pathology staff from the laboratory taking on the additional responsibility of chasing samples which have not reached their laboratory within two hours of receiving a call from the ward stating that a sample has been sent, the use of one portering system to be used in and out-of-hours, a ‘Pod Awareness Campaign’ reviving the use of the Pneumatic Tube System, and most significantly the development of a new Central Specimen Reception. Previously samples were sent to different locations depending on whether they were sent in-hours or out-of-hours. The centralisation of a specimen collection point which would be managed by laboratory staff will hopefully prevent samples not reaching the correct location and enable more efficient transfer to the off-site laboratory.

ples were sent to different locations depending on whether they were sent in-hours or out-of-hours. The centralisation of a specimen collection point which would be managed by laboratory staff will hopefully prevent samples not reaching the correct location and enable more efficient transfer to the off-site laboratory. Post-Measurement Measurement of improvement was through continual audit of completed stickers on a weekly basis. Between March and September we collected a total of 51 stickers, 41 of which were completed with enough information to include in the analysis. From March 2012 to September 2012 we saw a dramatic reduction in total transit time from an average of 160 minutes in March 2012 to an average of 69 minutes by September (Figure 2). This demonstrated objective improvement in transport of urgent specimens with the faster identification of causative organisms leading to more appropriate use of antibiotic therapy and prevention of the need for repeat investigation. There has also been a reduction in the total number of Datix incidents reported regarding delayed results or missing samples. Clinical staff have also reported greater reliance in the service, with better understanding of the protocol. The sticker tracker has been employed by the Neonatal Department and other adult medical departments have expressed desire to use the sticker. Our intervention successfully identified problem areas allowing implementation of changes. We hope that the intervention has resulted in a change in culture in those using the service.

cker tracker has been employed by the Neonatal Department and other adult medical departments have expressed desire to use the sticker. Our intervention successfully identified problem areas allowing implementation of changes. We hope that the intervention has resulted in a change in culture in those using the service. See supplementary file: Figure 2- Average Specimen Transit Time.ppt Lessons and Limitations Despite attempts at promoting the new tracking system, we found that initial use of the stickers were limited. This demonstrated the importance of thorough planning and promotion before the introduction of any intervention and the need to employ various methods of communication to do this. We found meeting with groups of professionals in person was most helpful in explaining the importance of involvement in the project. We also recognised the importance of involving multiple stakeholders in any quality improvement project in order to gain a better perspective of the problem. Another limitation was funding which affected our ability to provide more pods for use in the Pneumatic Tube System at an early stage. The project highlighted the complexity of one single service in the large hospital setting and how one service and its failure can impact on patient care. It is to engage multiple stakeholders, and a large team, to achieve a successful outcome.

Lessons and Limitations Despite attempts at promoting the new tracking system, we found that initial use of the stickers were limited. This demonstrated the importance of thorough planning and promotion before the introduction of any intervention and the need to employ various methods of communication to do this. We found meeting with groups of professionals in person was most helpful in explaining the importance of involvement in the project. We also recognised the importance of involving multiple stakeholders in any quality improvement project in order to gain a better perspective of the problem. Another limitation was funding which affected our ability to provide more pods for use in the Pneumatic Tube System at an early stage. The project highlighted the complexity of one single service in the large hospital setting and how one service and its failure can impact on patient care. It is to engage multiple stakeholders, and a large team, to achieve a successful outcome. Staff need to be informed of protocols in their local department, whether they are clinical, procedural or for the use of a service as ultimately better knowledge of service leads to better use of it. Most importantly we were reminded of the responsibility we all have in maintaining patient safety and the importance of regular involvement in quality improvement at any level in training.

ther they are clinical, procedural or for the use of a service as ultimately better knowledge of service leads to better use of it. Most importantly we were reminded of the responsibility we all have in maintaining patient safety and the importance of regular involvement in quality improvement at any level in training. Conclusion The transport of urgent specimens to an off-site laboratory is a complex service involving multiple members of staff and a number of steps. Multiple factors were the cause of the delay in the transport of urgent specimen, compromising patient safety. A simple sticker tracker was employed highlighting specific problems which could be addressed. The measures implemented dramatically reduced specimen transport time and have led to positive changes in the service leading to improved patient care. The intervention acted as a reminder of the protocol and raised awareness of an important issue in the department. The methodology employed here can be applied to other situations where the cause of the problem is not immediately identifiable. Involving multiple stakeholders will provide greater perspective of any problem and opitimise the chances of a successful outcome. The development of a new central specimen reception will hopefully contribute in improving the problem throughout the hospital. For the outcome to be sustainable it is important that staff involved are regularly informed and reminded of the protocol in place for sending urgent microbiology specimens and that regular audit is implemented to ensure a high quality service is maintained.

contribute in improving the problem throughout the hospital. For the outcome to be sustainable it is important that staff involved are regularly informed and reminded of the protocol in place for sending urgent microbiology specimens and that regular audit is implemented to ensure a high quality service is maintained. Supplementary Material Web supplement Web supplement

Problem The British Association of Urological Surgeons released guidelines in January 2011 with regard to the safe insertion of SPCs. These included good documentation of the procedure with attention paid specifically to the indication for insertion, safe insertion and subsequent catheter care. In our hospital we wanted to investigate whether or not we were compliant with these guidelines and if not, whether we could improve our system to improve patient safety. Background We accessed the online guidelines published by BAUS in January 2011. The BAUS guidelines state the following: ‘The suprapubic catheter (SPC) is a useful and widely used tool in urological practice. However, complications can arise from its insertion or ongoing care. Currently there are no guidelines relating to SPC usage. Guidelines are suggested to help maximise safety and ensure best practice in relation to SPC usage.’ The BAUS guidelines looked into all available evidence at the time relating to SPC insertion and if evidence was not available then expert opinions were sought to clarify details. Baseline Measurement We were able to access figures collected in 2009 within the same department at Kingston Hospital which showed that 19 patients had suprapubic catheters inserted. Of these 19, no cases used ultrasound scan (USS) to aid insertion. Since then use of USS has become part of the guidelines and this was one of the parameters that we looked at.

cess figures collected in 2009 within the same department at Kingston Hospital which showed that 19 patients had suprapubic catheters inserted. Of these 19, no cases used ultrasound scan (USS) to aid insertion. Since then use of USS has become part of the guidelines and this was one of the parameters that we looked at. Design Deciding to insert a suprapubic catheter is a relatively straightforward clinical decision. However accurate documentation of the procedure, including method of insertion, assistance to insertion, and indication for insertion is important but not always completed. By comparing our patient records with the BAUS guidelines we could look at the areas where we fall short of the recommended standards. Also, by producing a proforma with headings for each of the various areas of required documentation, we could bring ourselves up to the required standard, and also have information readily available for future audits. Strategy By designing the proforma we realised that their were a number of different areas to improve on. This would involve educating the doctors and nurses on the wards, and, discussion with the ward, theatre and A&E managers. Our proposed proforma would have to be well advertised among the doctors and would have to be readily available in all the necessary locations. This would involve liaising with the respective managers to ensure that their was a ready stock of the proformas available. By making it routine to fill in the proformas, there would be a greater chance for the change to become ‘the norm.’

e doctors and would have to be readily available in all the necessary locations. This would involve liaising with the respective managers to ensure that their was a ready stock of the proformas available. By making it routine to fill in the proformas, there would be a greater chance for the change to become ‘the norm.’ We discussed the proposed proforma with the clinical governance lead in the department and the prososal was carried forward into the senior management meetings where it was approved. We also presented the proposal at a regional urology meeting where it received a positive response. See supplementary file: PDSA Cycles2.doc Post-Measurement We looked at all the criteria set out in the national guidelines. Our audit department helped us to identify all of the new suprapubic catheter insertions performed. We identified 36 supra-pubic catheter insertions during a time period from April 2010 to December 2011 after the guidelines were published. By looking through the notes, we analysed various parameters including the use of ultrasound to aid insertion. There were 12 emergency insertions and 24 elective insertions during the time period. In 17/36 (47.2%) insertions, ultrasound was used which was a significant improvement. Since then we have created our proforma which is mandatory for clinicians to complete when inserting SPC. We will be auditing documentation and use of USS in future to see if there has been an improvement, however as the proforma is mandatory we expect 100% concordance with guidelines. See supplementary file: userfiles-suprapubic catheters.doc

Post-Measurement We looked at all the criteria set out in the national guidelines. Our audit department helped us to identify all of the new suprapubic catheter insertions performed. We identified 36 supra-pubic catheter insertions during a time period from April 2010 to December 2011 after the guidelines were published. By looking through the notes, we analysed various parameters including the use of ultrasound to aid insertion. There were 12 emergency insertions and 24 elective insertions during the time period. In 17/36 (47.2%) insertions, ultrasound was used which was a significant improvement. Since then we have created our proforma which is mandatory for clinicians to complete when inserting SPC. We will be auditing documentation and use of USS in future to see if there has been an improvement, however as the proforma is mandatory we expect 100% concordance with guidelines. See supplementary file: userfiles-suprapubic catheters.doc Lessons and Limitations There were several limiting factors identified when carrying out this project. To access the data we relied on the coding department to have correctly identified every patient who underwent a suprapubic catheter insertion. Some patients may have been missed as a result of inaccurate coding. Although we thoroughly went through each set of notes on more than one occasion, sometimes we could not find the relevant piece of documentation. This is not to say it was never documented at all, but it does highlight the need for careful and clear documentation for procedures. This project would be easy one to undertake at other hospitals.

Lessons and Limitations There were several limiting factors identified when carrying out this project. To access the data we relied on the coding department to have correctly identified every patient who underwent a suprapubic catheter insertion. Some patients may have been missed as a result of inaccurate coding. Although we thoroughly went through each set of notes on more than one occasion, sometimes we could not find the relevant piece of documentation. This is not to say it was never documented at all, but it does highlight the need for careful and clear documentation for procedures. This project would be easy one to undertake at other hospitals. Conclusion We started with an issue regarding procedural documentation within a hospital. This is important for both safety and for medico-legal purposes. Our initial enquiries showed that our hospital was documenting the SPC insertion procedure but that improvements could be made. Once the national guidelines were introduced our documentation improved considerably to allow for a more careful analysis of whether or not we were complying with the guidelines. Even though the standards had improved, there were still a number of shortcomings in documentation, particularly with regard to reasons for not using ultrasound scan assistance when inserting the catheter. By designing a proforma, all of the necessary information could be neatly collated in one place allowing for both accurate description of the procedure as well as allowing us to keep a careful record of the circumstances surrounding that insertion.

s for not using ultrasound scan assistance when inserting the catheter. By designing a proforma, all of the necessary information could be neatly collated in one place allowing for both accurate description of the procedure as well as allowing us to keep a careful record of the circumstances surrounding that insertion. We believe this project will improve our clinical practice and also provide a useful tool for early identification of problems in the future. We have discussed the use of the proforma with the relevant areas of the hospital. These included the wards, theatres and A&E department. Ensuring a steady supply of the proformas to the relevant areas is not always easy, particularly as this procedure is not performed all that frequently in our hospital. The proforma was discussed at the clinical governance meeting for the urology department and agreed upon. We would hope that in future, we will see a further improvement in our documentation to a 100% compliance record with the national guidelines. Supplementary Material Web supplement Web supplement J Schneeweiss, T Nitkunan, RO Morley for their assistance with data collection.

Problem In the first few months of working in a South London hospital, there were three reported episodes of anaphylaxis where adrenaline was not available on the ward. This included an event where senior nurses had been informed of the lack of stock of adrenaline (during audit) and advised of the importance of having these emergency drugs to hand, and yet no action had been taken. A patient subsequently had an anaphylactic reaction to penicillin where no adrenaline was available. He was transferred to ITU. The main problems were lack of ward stock, the fact that this had not been picked up already, and when it had been highlighted, no action had been taken. The large number of people working in any given area in a hospital and differing shift patterns between team members means information may not always be correctly handed over. The high number of bank staff working means many staff members are practicing in an unfamiliar environment. An intervention therefore had to take these latter two issues into account for it to be sustainable.

al and differing shift patterns between team members means information may not always be correctly handed over. The high number of bank staff working means many staff members are practicing in an unfamiliar environment. An intervention therefore had to take these latter two issues into account for it to be sustainable. Background Ward stock is reviewed weekly by the ‘top-up technician’ who uses a ‘top-up’ stock list. When common drugs run out in between, nursing staff request further stock from the pharmacy. It is obviously unacceptable to wait for this point in the case of emergency drugs. 1:1000 adrenaline is not kept in the crash trolley with the other emergency drugs partly for fear of confusing it with adrenaline 1:10 000. The crash trolley contents are recorded on a laminated check list which is reviewed by a senior nurse. There are two systems in place. Crash trollies that are locked with easily broken toggles, are checked monthly, and after use, by the ward sister. Crash trollies in areas that are left open at all times are checked daily by a senior nurse. The lack of reported incidences regarding availability of these crash trolley drugs suggests this system works. It means it becomes a designated person's responsibility to check stock and it is therefore not affected by poor handover, or shift patterns. Keeping drugs in the crash trolley also provides a consistent location throughout all wards so drugs are at hand when required.

se crash trolley drugs suggests this system works. It means it becomes a designated person's responsibility to check stock and it is therefore not affected by poor handover, or shift patterns. Keeping drugs in the crash trolley also provides a consistent location throughout all wards so drugs are at hand when required. Baseline Measurement To measure the scale of this problem, stock of 1:1000 adrenaline was checked on all thirty adult wards. This revealed availability on only 50% of wards. Furthermore, the location of the drugs was very inconsistent (fig 1), often hard to find, and at the back of a ‘miscellaneous’ cupboard which is very unhelpful in an emergency situation. In order to establish if there were any other underlying problems, a questionnaire study was conducted to assess knowledge amongst nurses and junior doctors. This revealed a lack of knowledge on the basic management of anaphylaxis and, unsurprisingly, location of emergency drugs (figs 2 & 3). See supplementary file: Figures 1 to 6.doc Design We needed to design an intervention that would ensure 100% ward stock, a consistent drug location and improve staff knowledge. A meeting was held with senior pharmacists, resuscitation managers and a consultant anaesthetist, so that we could suggest a few ideas and see which one would be most suitable. Part of our questionnaire included questions regarding opinions on possible interventions to try and establish which would be most acceptable to ward staff.

held with senior pharmacists, resuscitation managers and a consultant anaesthetist, so that we could suggest a few ideas and see which one would be most suitable. Part of our questionnaire included questions regarding opinions on possible interventions to try and establish which would be most acceptable to ward staff. One of the issues revealed was that nursing staff were concerned that if 1:1000 adrenaline was kept in the crash trolley it may get confused with the 1:10 000 concentration which would, in itself, be a critical incident. However, the crash trolley seemed the most appropriate place for 1:1000 adrenaline given that it is an emergency drug, and the re-stocking process was already in place. It would therefore need to be stored in a separate pack to solve these issues, and the pack added to the check list. Whilst auditing stock it was also picked up that other drugs were missing. For example, some nurses had asked if we could also re-stock their hydrocortisone. Although this perhaps indicates a wider problem, for this current project it was felt that the pack should contain adrenaline, chlorphenamine and hydrocortisone. To address the lack of knowledge of staff, the packs were also to include the anaphylaxis algorithm. Any uncertainty during an event could therefore be clarified, mistakes prevented, and knowledge improved. The plan was to implement this initially on four pilot wards and do a ‘mini’ re-audit, rolling the plan out trust wide if proved effective. A senior pharmacist kindly worked out the cost effectiveness of this implementation.

ainty during an event could therefore be clarified, mistakes prevented, and knowledge improved. The plan was to implement this initially on four pilot wards and do a ‘mini’ re-audit, rolling the plan out trust wide if proved effective. A senior pharmacist kindly worked out the cost effectiveness of this implementation. Strategy The packs were initially introduced to four wards and we began our re-audit then. The intervention was very well received, and so, was rapidly implemented trust wide by pharmacy and resuscitation services. This occurred before we had fully assessed any further improvements we might be able to make. Post-Measurement Four months later we re-audited drug stock, location, and staff knowledge. This showed that stock had improved from 50% to 100%. 87% of this was found in the crash trolley, 13% in the controlled drugs cupboard and occasionally in both (fig 4). There was a slight improvement in staff knowledge, which we hope will improve exponentially as the packs are utilised (figs 5 and 6). The presence of the algorithm will help to prevent errors and to improve knowledge. Lessons and Limitations Whilst implementing the project we realised the importance of having senior members of staff on board to help cut through red tape and promote the intervention. Also, the value of asking members of staff involved for their opinions prior to intervention, as you need them on board if it is to be effective.

d Limitations Whilst implementing the project we realised the importance of having senior members of staff on board to help cut through red tape and promote the intervention. Also, the value of asking members of staff involved for their opinions prior to intervention, as you need them on board if it is to be effective. If we were to repeat the project again we would have more control at the point of implementation, as the packs were rolled out too rapidly for us to make minor improvements. For example, it would be better to have the adrenaline in a pre-packed syringe, if cost allows, rather than a needle, syringe and vial. Of the critical incidents that occurred prior to the audit, fortunately none had resulted in fatality. We hope that this intervention has removed this risk and enhanced patient safety on the wards. A further limitation of this study was the small number of foundation doctors and nurses questioned (23 in each group). However, this was purely to assess general knowledge and any lack would prompt the insertion of the algorithm into the pack. The pack itself cost £50 which is only marginally extra than the drugs themselves, making it a wholly sustainable intervention.

ber of foundation doctors and nurses questioned (23 in each group). However, this was purely to assess general knowledge and any lack would prompt the insertion of the algorithm into the pack. The pack itself cost £50 which is only marginally extra than the drugs themselves, making it a wholly sustainable intervention. Conclusion A death on a hospital ward due to lack of stock of emergency drugs is unacceptable. This study, triggered by some ‘near misses’, was aimed at ensuring this will not be the case. The key parts of this intervention were not only to ensure the stock of adrenaline on wards audited, but also to have a consistent location for these emergency drugs. The latter is to avoid delays in stressful situations, and when on-call staff members are unfamiliar with their surroundings. This is a very simple model that could be easily replicated elsewhere, but could perhaps also be extended to encompass other ward equipment if found lacking. Supplementary Material Web supplement

Problem We observed a high (5 out of 7 lines, 70%) rate of PICC blockages on the Trauma and Orthopaedics Ward over a two month period. This led to compromised patient care by delaying drug administration and blood sampling whilst alternative intravenous access was obtained. Blockages were also associated with reduced patient satisfaction, as patients suffered with complications associated with delayed treatment. The cost of treatment increased with the need to replace the PICC. PICC blockages were considered to be time consuming for staff and distracting from other daily duties. Some of the PICCs were blocking repeatedly which was very frustrating for both the staff and patients. To identify the contributing factors we compared current practice against the local and manufacturer's guidelines and found considerable deviation from guidelines. The following problems were identified: 1. Long and contradictory PICC care guidelines which were difficult to find 2. Lack of information sheets provided in the notes of patients who had a PICC inserted 3. Lack of documentation and accountability regarding flushing PICCs 4. Lack of training and awareness of ward staff regarding care of PICCs Background PICCs are Peripherally Inserted Central Catheters used in patients requiring long term venous access. They may be safer than conventional central lines and can stay in-situ for longer. Indications for use include administration of long term antibiotics, chemotherapy, or total parenteral nutrition (TPN). As with other types of lines, PICCs are subject to complications.

used in patients requiring long term venous access. They may be safer than conventional central lines and can stay in-situ for longer. Indications for use include administration of long term antibiotics, chemotherapy, or total parenteral nutrition (TPN). As with other types of lines, PICCs are subject to complications. The literature surrounding PICC blockage in the adult population is scarce. The majority of research concentrates on neonatal and paediatric practice, where complications associated with PICCs are well recognised. Barrier et al (1) reported that in their study of an immunocompetent paediatric population, more than 30% of PICCs developed at least one complication. A neonatal intensive care study undertaken by McCoy et al (2) looked at 1148 PICCs. 164 (14%) of these lines were replaced, either because of blockage, or migration of the line. Baseline Measurement We sampled all inpatients with indwelling PICCs over a period of two months on the Trauma & Orthopaedics (T&O) ward where we were working as Foundation Year 1 Doctors. Five out of the seven (70%) patients with PICCs in situ were affected by line blockage; some on multiple occasions. There was no formal documentation of blockages that had been resolved. Out of the five PICCs affected by blockage, two were unsuccessfully unblocked on the ward and required PICC exchange. This suggests that PICC exchange data would underestimate the scale of the problem.

d by line blockage; some on multiple occasions. There was no formal documentation of blockages that had been resolved. Out of the five PICCs affected by blockage, two were unsuccessfully unblocked on the ward and required PICC exchange. This suggests that PICC exchange data would underestimate the scale of the problem. Subsequently, hospital wide PICC activity was audited. There were 192 inpatient PICCs inserted in the hospital between October 2011 and 2012. 48 of those (25%) were inserted for T&O ward patients. During this period, 21 PICCs required exchange (11%). 8 out of 48 (17%) PICCs on the T&O ward required replacement compared with 13 out of 144 PICCs (9%) on other wards. This further alerted us to suboptimal PICC care on our ward. PICC blockage rates (14%) were comparable with data from a randomised controlled study by Kamala et al (3) which highlights that this problem is not confined to our hospital. Through problem analysis, we identified poor staff training as one of the potential contributors to PICC blockages. We assessed staff competency and confidence levels regarding PICC care using a questionnaire based on PICC care guidelines. Competency was assessed with an informal extended matching questions test; all stems needed to be answered correctly to be awarded a point. Nurses (n=8) all scored 0% whilst junior doctors (n=30) answered 6% of questions correctly. This lack of knowledge did not translate into low confidence levels. Staff were asked to rate their confidence level in dealing with PICCs on a scale of 1 (0%) to 5 (100%). Average confidence levels were 65% amongst nurses and 38% amongst junior doctors (Table 1).

nior doctors (n=30) answered 6% of questions correctly. This lack of knowledge did not translate into low confidence levels. Staff were asked to rate their confidence level in dealing with PICCs on a scale of 1 (0%) to 5 (100%). Average confidence levels were 65% amongst nurses and 38% amongst junior doctors (Table 1). See supplementary file: Table 1.docx Design We asked staff about their potential ideas for change and discuss our planned interventions to gauge feedback. Staff questionnaires highlighted that both nurses and junior doctors were not familiar with flushing regimens. Furthermore, as the flushes were neither prescribed nor signed for, there was no monitoring or accountability for the flushing of PICCs. Feedback from nursing staff identified that due to shift patterns of work, it was difficult to keep track of when the PICCs were flushed and by whom. Nursing staff reported that this information was rarely handed over. In conjunction with nursing staff, decided to prescribe flushes on the drug chart. Strategy We decided to carry out small-group hands-on teaching tailored to specific staff groups. This was, however, time consuming. We covered accessing PICCs, appropriate care to minimise risk of blockage, infection, and splitting of the line. Another intervention we designed was a sticker with simple and clear instructions reminding users to flush the PICC after use. Aide-memoires already in practice, for example stickers reminding the need to replace a cannula, are in widespread use, and are considered effective.

Strategy We decided to carry out small-group hands-on teaching tailored to specific staff groups. This was, however, time consuming. We covered accessing PICCs, appropriate care to minimise risk of blockage, infection, and splitting of the line. Another intervention we designed was a sticker with simple and clear instructions reminding users to flush the PICC after use. Aide-memoires already in practice, for example stickers reminding the need to replace a cannula, are in widespread use, and are considered effective. We collaborated with the radiology and infection control departments to design new guidelines. We advocated prescription of weekly heparin saline and as required (PRN) saline flushes for all patients with PICCs through our guidelines. The guidelines outline appropriate prescription of flushes and indications for PRN flushes. By mandatory prescribing of the flushes on the drug chart, there is uniformity in practice and we believe the flushing will be executed in a more consistent way. Non-adherence to the flushing regimen will be obvious from documentation in the drug chart. We produced two guidelines that, according to staff feedback, was clear, succinct, and easily available. Flow charts illustrated the steps of accessing the PICC line for: blood sampling, drug and fluid administration as well as how to manage a blocked line. One guideline was a short reference guideline available on the wards and in the patient notes. Second was a comprehensive guideline with detailed instructions on care of PICCs. Both guidelines are now available on the Trust Intranet.

blood sampling, drug and fluid administration as well as how to manage a blocked line. One guideline was a short reference guideline available on the wards and in the patient notes. Second was a comprehensive guideline with detailed instructions on care of PICCs. Both guidelines are now available on the Trust Intranet. Post-Measurement We measured the improvement of staff competency and confidence levels in caring for PICCs following a training session (Table 2). Our results were very encouraging. Competence levels increased from 6% to 70%, (absolute improvement of 64%) for junior doctors, and from 0% to 38%, (absolute improvement of 38%) for nurses. Staff confidence levels followed a similar trend. We observed an increase in confidence levels from 38% to 66% (absolute improvement of 28%) for junior doctors and from 65% to 80% (absolute improvement of 15%) for nurses. We are in the process of implementing all the changes described, and we aim to re-audit PICC blockages and exchanges three months post-intervention. We anticipate our interventions will translate into reduced blockage rates, improving patient outcomes, and reducing cost.

to 80% (absolute improvement of 15%) for nurses. We are in the process of implementing all the changes described, and we aim to re-audit PICC blockages and exchanges three months post-intervention. We anticipate our interventions will translate into reduced blockage rates, improving patient outcomes, and reducing cost. Estimating the cost of a single PICC insertion is difficult within the NHS setting. Considering the approximate cost of the PICC, time spent in the interventional radiology suite and staff involved, the cost was estimated to be approximately £1,000. The cost of the PICC replacement (either exchange or new insertion) was also estimated at approximately £1,000. There were 21 PICC exchanges undertaken in our hospital within one year (2011-2012). If PICC exchange rate was halved, there is a potential for over £10,000 of savings per annum. Moreover, there is also a hidden cost; which might be even greater, in time and effort needed to unblock PICCs on the ward. The entire cost of printing the new guidelines and stickers will amount to a fraction of the cost of one PICC exchange. See supplementary file: Table 2.docx Lessons and Limitations The biggest barrier to change came from staff reluctant to change embedded practice. This was overcome by communicating the need for change and emphasising the benefits of change in decreasing workload long-term.

Estimating the cost of a single PICC insertion is difficult within the NHS setting. Considering the approximate cost of the PICC, time spent in the interventional radiology suite and staff involved, the cost was estimated to be approximately £1,000. The cost of the PICC replacement (either exchange or new insertion) was also estimated at approximately £1,000. There were 21 PICC exchanges undertaken in our hospital within one year (2011-2012). If PICC exchange rate was halved, there is a potential for over £10,000 of savings per annum. Moreover, there is also a hidden cost; which might be even greater, in time and effort needed to unblock PICCs on the ward. The entire cost of printing the new guidelines and stickers will amount to a fraction of the cost of one PICC exchange. See supplementary file: Table 2.docx Lessons and Limitations The biggest barrier to change came from staff reluctant to change embedded practice. This was overcome by communicating the need for change and emphasising the benefits of change in decreasing workload long-term. We have learnt that simple measures can have a significant impact on patient care. In future we would consult individuals involved in the change process earlier on in the project. We also found that our project sometimes was slowed down by other work commitments. We hope to solve this problem by recruiting colleagues to assist us.

nt that simple measures can have a significant impact on patient care. In future we would consult individuals involved in the change process earlier on in the project. We also found that our project sometimes was slowed down by other work commitments. We hope to solve this problem by recruiting colleagues to assist us. We have assumed that the size of the problem of PICC blockages is greater than the PICC exchange rate from our audit on the Trauma & Orthopaedics ward. It can be argued that a greater sample of wards would be needed to justify such an assertion. Conclusion There is a lack of PICC care training for staff. Existing information leaflets were unclear and staff were unaware of where to access them. There was little insight from nursing staff as to the degree of variation in current practice from local guidelines and there was no accountability for PICC care. Our interventions should reduce delays in patient care (e.g. delivery of IV antibiotics), improve patient satisfaction and lead to a reduction in cost and overall reduction in workload for staff. Supplementary Material Web supplement

Problem Junior doctors are routinely asked to prescribe intravenous fluids (IVF) out-of-hours. Given time constraints, it is sometimes difficult to properly check clinical parameters before prescribing. In addition, patients may not be known to the doctor covering on-call duties. Consequently, there is uncertainty about the accuracy and safety of out-of-hours IVF prescribing, particularly in patients who may have specific fluid balance requirements. We wanted to implement a safety intervention that would not only provide basic information relevant to the patient but also improve out-of-hours IVF prescribing accuracy and the confidence of the junior doctor. Background Maintaining an optimal fluid balance in acutely unwell patients, particularly those with co-morbidities, can be difficult within a busy hospital environment. Managing insensible and sensible losses in patients with chronic heart and/or renal failure is a distinct challenge, as is completing an accurate fluid balance chart for patients who are nil by mouth, diuresing, non-catheterised or cognitively impaired.

-morbidities, can be difficult within a busy hospital environment. Managing insensible and sensible losses in patients with chronic heart and/or renal failure is a distinct challenge, as is completing an accurate fluid balance chart for patients who are nil by mouth, diuresing, non-catheterised or cognitively impaired. For many junior doctors starting on the wards, teaching on fluid balance and the correct fluid, volume and flow rate to prescribe is a distant memory from medical school. A recent study evaluating the IVF prescribing practices of Foundation Year 1 (FY1) doctors out-of-hours found significant variability. Although 82% (n = 149) had received teaching on IVF prescribing at medical school, only 48% had received teaching at their FY1 induction. Given IVF prescribing is a common task for the FY1 doctor, this is unfortunate. Less than half of those surveyed were able to check the medical notes or perform a clinical examination before prescribing. More than half were able to check the patient's blood results and read their fluid balance and observation charts. The authors recommended this variability be addressed by medical and foundation schools and NHS trusts to improve patient care. Consequently, junior doctors experience a degree of anxiety and a loss of prescribing confidence on-call when asked to prescribe multiple bags of IVF for unfamiliar patients under significant time pressures. This can result in prescribing variability and potential inaccuracies.

For many junior doctors starting on the wards, teaching on fluid balance and the correct fluid, volume and flow rate to prescribe is a distant memory from medical school. A recent study evaluating the IVF prescribing practices of Foundation Year 1 (FY1) doctors out-of-hours found significant variability. Although 82% (n = 149) had received teaching on IVF prescribing at medical school, only 48% had received teaching at their FY1 induction. Given IVF prescribing is a common task for the FY1 doctor, this is unfortunate. Less than half of those surveyed were able to check the medical notes or perform a clinical examination before prescribing. More than half were able to check the patient's blood results and read their fluid balance and observation charts. The authors recommended this variability be addressed by medical and foundation schools and NHS trusts to improve patient care. Consequently, junior doctors experience a degree of anxiety and a loss of prescribing confidence on-call when asked to prescribe multiple bags of IVF for unfamiliar patients under significant time pressures. This can result in prescribing variability and potential inaccuracies. Baseline Measurement For this project, we utilised a qualitative questionnaire to establish a pre-intervention baseline. FY1 doctors filled in the questionnaire to evaluate their confidence in out-of-hours IVF prescribing and whether they felt an IVF prescription label would be useful. 85% (n=27) stated they had been asked to prescribe IVF for unfamiliar patients (the remaining 15% had been working in ITU) and 77% felt that the label would be a useful prescribing aid. Importantly, 100% of all FY1s surveyed said they would be willing to trial the label on their ward.

rescription label would be useful. 85% (n=27) stated they had been asked to prescribe IVF for unfamiliar patients (the remaining 15% had been working in ITU) and 77% felt that the label would be a useful prescribing aid. Importantly, 100% of all FY1s surveyed said they would be willing to trial the label on their ward. See supplementary file: Example of a DAPS sticker on drug chart_0.png

rescription label would be useful. 85% (n=27) stated they had been asked to prescribe IVF for unfamiliar patients (the remaining 15% had been working in ITU) and 77% felt that the label would be a useful prescribing aid. Importantly, 100% of all FY1s surveyed said they would be willing to trial the label on their ward. See supplementary file: Example of a DAPS sticker on drug chart_0.png Design Having received a positive response from the FY1 doctors regarding the concept of an IVF prescription label, we devised a simple label for the fluids section of the adult drug chart. The label progressed through several designs until we reached an informational and aesthetic conclusion. It was important the label remained simple and easy to complete. The final design was then reviewed and approved by the hospital pharmacy. Quick to use, it functioned as a prompt for the junior doctor. It detailed basic patient identifiers and detailed ‘yes/no’ questions relating to chronic heart/renal failure. Other important factors relating to fluid balance could be noted in a free text section entitled ‘other’. The label was to be filled in by the patient's primary medical team and signed and dated. The label's size and expiration date allowed a degree of flexibility as several labels could be applied across the drug chart to reflect changes in fluid balance (for example, a patient admitted with acute kidney injury whose blood parameters improved). It was not our intention to replace the need for careful clinical assessment of all patients when prescribing IVF but to highlight those who had specific fluid balance requirements to the busy on-call junior doctor.

Baseline measurement In 2002 there were no national guidelines on the recognition of physical abuse or neglect, nor was there any standardised evidence based training for all paediatricians, or other health professionals such as dental practitioners. Training was offered on an ad hoc basis around the country, and only 6% of trainee paediatricians felt inclined to take on a key role in Child Protection (2). The judiciary had identified a lack of agreement between medical experts providing opinions to the courts for child abuse (11). No systematic reviews into the recognition or investigation of suspected physical abuse or neglect had been conducted. See supplementary file: ds1719.pptx - “Flow Diagram” Design To address these deficiencies, with funding from the NSPCC the Welsh Child Protection Systematic Review Group (renamed Cardiff Child Protection Systematic Reviews in 2012) was established. The team consists of a Program Director, Principal Investigator, two researchers, a research administrator and an information specialist, with input from a statistician and a varying team of reviewers drawn from paediatrics, medical and dental subspecialties (eg forensic pathology, radiology, psychology), social care and education, as dictated by the review topic. To date, 21 Systematic Reviews have been completed. These reviews critically appraise the world literature relating to the recognition and investigation of child abuse.

luid balance (for example, a patient admitted with acute kidney injury whose blood parameters improved). It was not our intention to replace the need for careful clinical assessment of all patients when prescribing IVF but to highlight those who had specific fluid balance requirements to the busy on-call junior doctor. The audit ran for a 16 day period (covering three weekends) on an acute medical ward. Permission was gained from senior clinical personnel. A publicity campaign (“are you up for a fluid challenge?”) ran prior to the launch with posters placed in key places around the hospital and via word-of-mouth, particularly to those doctors who would be on-call during the audit period. Strategy The first label was initially trialled on a busy elderly care ward. Unfortunately, as the label utilised light grey text on a plain white background, the medical teams did not see it on the drug chart and did not fill it in. We therefore acknowledged that there were difficulties with the aesthetic and focussed on a re-design. This involved the use of colour (a red border) and the addition of the word ‘caution’ at the top, centred, highlighted with fluorescent yellow to draw attention. We also included the ‘Doctors Advancing Patient Safety’ (DAPS) logo. The label was then re-trialled on a second, acute medical, ward with a resumption of our advertising campaign featuring the new design. We received positive feedback on the design from all medical personnel (including nursing staff) and compliance was excellent, with all labels completed appropriately.

Strategy The first label was initially trialled on a busy elderly care ward. Unfortunately, as the label utilised light grey text on a plain white background, the medical teams did not see it on the drug chart and did not fill it in. We therefore acknowledged that there were difficulties with the aesthetic and focussed on a re-design. This involved the use of colour (a red border) and the addition of the word ‘caution’ at the top, centred, highlighted with fluorescent yellow to draw attention. We also included the ‘Doctors Advancing Patient Safety’ (DAPS) logo. The label was then re-trialled on a second, acute medical, ward with a resumption of our advertising campaign featuring the new design. We received positive feedback on the design from all medical personnel (including nursing staff) and compliance was excellent, with all labels completed appropriately. See supplementary file: Example of DAPS stickers.png

The label was then re-trialled on a second, acute medical, ward with a resumption of our advertising campaign featuring the new design. We received positive feedback on the design from all medical personnel (including nursing staff) and compliance was excellent, with all labels completed appropriately. See supplementary file: Example of DAPS stickers.png Post-Measurement All doctors based on the ward or on-call for medicine during that specific time period were targeted for the post-audit questionnaire. Simple analysis was carried out in Microsoft Excel. Post-audit, 58% (n=7) saw the label. Out of those seven, 86% stated the label had prompted them to do the following: a) examine the patient b) check their blood results and c) check urine output. All seven (100%) stated that the label improved their confidence in prescribing IVF. In addition, 71% felt the label made them more cautious in prescribing IVF and 43% felt they prescribed less IVF. Overall, all seven doctors (100%) stated that the IVF prescription label was a useful addition to the drug chart. Lessons and Limitations We learnt a few lessons during the completion of this project: 1. Clinical staff are already overburdened with paperwork therefore it was important that the label remained simple and easy to use with a perceived and actual benefit to enhance compliance. Involving the ward clerk and ward pharmacist was useful to assist with the distribution and application of labels on all the charts.

1. Clinical staff are already overburdened with paperwork therefore it was important that the label remained simple and easy to use with a perceived and actual benefit to enhance compliance. Involving the ward clerk and ward pharmacist was useful to assist with the distribution and application of labels on all the charts. 2. Aesthetics were important to ensure the label was noticed on the adult drug chart. A good advertising campaign was also vital to raise awareness and successfully launch the project. 3. Out-of-hours IVF prescribing is not simply a concern for junior doctors but for all staff, as demonstrated by positive, anecdotal feedback we received from nurses, senior house officers and specialist registrars. Therefore, the label will be useful for all healthcare professionals to improve patient care and safety. The main limitation of the project was the small sample size: We were reliant on a small number of doctors being called to the ward out-of-hours. In addition, due to an increased focus on appropriate IVF prescribing by the nursing and medical staff, the primary medical teams were also ensuring that appropriate fluids were prescribed before the end of their shift, therefore obviating the need for nurses to bleep the on-call doctor.

alled to the ward out-of-hours. In addition, due to an increased focus on appropriate IVF prescribing by the nursing and medical staff, the primary medical teams were also ensuring that appropriate fluids were prescribed before the end of their shift, therefore obviating the need for nurses to bleep the on-call doctor. Conclusion Pressurised junior doctors would feel more confident prescribing IVF for unfamiliar patients if crucial information was readily visible on the drug chart. We feel that our label improved the accuracy of fluid prescribing, prescribing confidence and overall patient safety. Further studies are required to evaluate whether this translates to improved outcomes. In order to facilitate this, we have submitted a business case to the trust to implement the intervention on a wider scale and complete a larger audit. Supplementary Material Web supplement Web supplement

Problem By 2002 Child Protection in the UK was in crisis and clinicians were losing confidence in offering opinions in either clinical or legal arenas. One survey of GP registrars showed 76% felt they lacked sufficient expertise for future Child Protection work (1), whilst a later study of paediatric trainees demonstrated that only 38% were willing to get involved with Child Protection cases (2). The 2003 Laming Report followed the death of Victoria Climbie where health professionals had missed sentinel signs of abuse. The report drew national attention to the issue and highlighted the need for the development of a national training programme to improve the understanding and skills of the child health workforce (3). At the same time, three high profile criminal cases involving the prosecution of mothers for causing the deaths of their babies created public consternation, and clinicians were being vilified in the media for misrepresenting scientific evidence in Court and were becoming regularly reported to the GMC for suspected malpractice (4). Although few of these cases were upheld, clinicians lost confidence in the field of child protection. The Kennedy Report in 2004 (5) insisted that expert medical opinion presented in Court must be supported scientifically. In 2006 the Chief Medical Officer's report ‘Bearing good witness: proposals for reforming the delivery of medical expert evidence in family law cases’ (6) recommended that there should be a National Knowledge Service to support expert witnesses.

xpert medical opinion presented in Court must be supported scientifically. In 2006 the Chief Medical Officer's report ‘Bearing good witness: proposals for reforming the delivery of medical expert evidence in family law cases’ (6) recommended that there should be a National Knowledge Service to support expert witnesses. At this time, there were no evidence-based standards or clinical guidelines to inform the clinical assessment of suspected child abuse or neglect. Expert medical opinions in Court were provided by a handful of clinicians, relying on their own clinical experience, and personal reviews of the literature. There were no Systematic Reviews relating to the recognition or investigation of suspected abuse or neglect, in contrast to medical practice in other fields. Background All medical practitioners encounter Child Protection within their practice, either directly by those with clinical care of children, or indirectly by those whose adult patients may have access to, or responsibility for, children.

At this time, there were no evidence-based standards or clinical guidelines to inform the clinical assessment of suspected child abuse or neglect. Expert medical opinions in Court were provided by a handful of clinicians, relying on their own clinical experience, and personal reviews of the literature. There were no Systematic Reviews relating to the recognition or investigation of suspected abuse or neglect, in contrast to medical practice in other fields. Background All medical practitioners encounter Child Protection within their practice, either directly by those with clinical care of children, or indirectly by those whose adult patients may have access to, or responsibility for, children. On average, one child a week is killed in England and Wales at the hands of another person (7) and those who survive childhood abuse or neglect experience long lasting complications, both physical and psychological. There is increasing evidence that such adverse early childhood experiences contribute to the burden of adult health problems and increased utilisation of adult health services (8). However, while there is clearly an imperative to recognise such children and act to protect them from further abuse or neglect, false accusations cause enormous distress to the family concerned, and the public has expressed their discontent when these suspicions are not substantiated (9).

of adult health services (8). However, while there is clearly an imperative to recognise such children and act to protect them from further abuse or neglect, false accusations cause enormous distress to the family concerned, and the public has expressed their discontent when these suspicions are not substantiated (9). As such, it is essential that all practitioners are up to date with the current scientific literature informing their recognition of child maltreatment, and have access to clear guidelines as to what action to take in the event that they suspect a child is being abused or neglected (10). In reality, however, many practitioners feel overwhelmed at the prospect of reading all of the emerging scientific articles on the subject, and determining which of these are of sufficient quality to inform their practice. A search across three bibliographic databases (MEDLINE, Embase and PsycINFO) for the terms ‘child abuse’, ‘child neglect’, ‘child maltreatment’ and ‘child sexual abuse’ generated 2107 articles published in 2012 alone (searched on 11th April 2013). A clear need for evidence-based training of health professionals, and national guidelines for practitioners across all disciplines has been identified.

r the terms ‘child abuse’, ‘child neglect’, ‘child maltreatment’ and ‘child sexual abuse’ generated 2107 articles published in 2012 alone (searched on 11th April 2013). A clear need for evidence-based training of health professionals, and national guidelines for practitioners across all disciplines has been identified. Our aim therefore was to identify, critically appraise and synthesise all of the quality published scientific literature relevant to the recognition and investigation of physical abuse and neglect, to disseminate this in an accessible way to all practitioners, and to provide the data which could underpin national guidance, clinical practice, expert evidence in the Courts and national training programs. Baseline measurement In 2002 there were no national guidelines on the recognition of physical abuse or neglect, nor was there any standardised evidence based training for all paediatricians, or other health professionals such as dental practitioners. Training was offered on an ad hoc basis around the country, and only 6% of trainee paediatricians felt inclined to take on a key role in Child Protection (2). The judiciary had identified a lack of agreement between medical experts providing opinions to the courts for child abuse (11). No systematic reviews into the recognition or investigation of suspected physical abuse or neglect had been conducted. See supplementary file: ds1719.pptx - “Flow Diagram”

diatrics, medical and dental subspecialties (eg forensic pathology, radiology, psychology), social care and education, as dictated by the review topic. To date, 21 Systematic Reviews have been completed. These reviews critically appraise the world literature relating to the recognition and investigation of child abuse. This work enables professionals to apply scientific evidence to assist in distinguishing unintentional from abusive injuries, across ten themes: bites and oral injuries, dental neglect, bruising, fractures, burns, neurological injuries, retinal injuries, visceral injuries, spinal injuries, emotional abuse, and neglect. A rolling programme of annual updates ensures that the systematic reviews remain contemporaneous.

onal from abusive injuries, across ten themes: bites and oral injuries, dental neglect, bruising, fractures, burns, neurological injuries, retinal injuries, visceral injuries, spinal injuries, emotional abuse, and neglect. A rolling programme of annual updates ensures that the systematic reviews remain contemporaneous. Each systematic review begins with the formulation of a research question, from which a search strategy is developed to identify relevant peer-reviewed world literature. The initial search strategy is developed across OVID Medline databases using keywords and Medical Subject Headings (MeSH headings) and assessed for accuracy and relevance. The definitive all-language search is conducted across approximately 15 databases, dependent upon review topic. The search sensitivity is supplemented by a range of ‘snowballing techniques’ including consultation with subject experts and relevant organisations, hand searching selected websites, non-indexed journals and the references of all full-text articles. Abstracts and selected full-text articles are scanned by the Principal Investigator and eligible studies identified for review. For relevant foreign studies, English language versions are sourced from the author where available or appraised by foreign language reviewers or translations outsourced.

l full-text articles. Abstracts and selected full-text articles are scanned by the Principal Investigator and eligible studies identified for review. For relevant foreign studies, English language versions are sourced from the author where available or appraised by foreign language reviewers or translations outsourced. Each systematic review involves a national panel of reviewers, comprising paediatricians, child protection specialists, pathologists and is supplemented by specific specialities according to the review. These include neurologists, radiologists, ophthalmologists, dentists, educationalists, social workers, psychologists, and psychiatrists. At the start of each review, reviewers attend customised critical appraisal training and receive ongoing support throughout the review, including online resources and monthly meetings, to discuss progress and results. Reviews are undertaken using standardized critical appraisal forms, based on criteria defined by the National Health Service's Centre for Reviews and Dissemination Centre for Reviews and Dissemination, (12) and supplemented by systematic review advisory articles (13, 14, 15, 16, 17). Each study undergoes two independent reviews, with disagreement resolved by a third review. If needed, authors are contacted for further detail. Reviews are administered through a purpose built Microsoft Access database, used to co-ordinate and collate critical appraisal data. To date, the database holds more than 40,000 citations.

dergoes two independent reviews, with disagreement resolved by a third review. If needed, authors are contacted for further detail. Reviews are administered through a purpose built Microsoft Access database, used to co-ordinate and collate critical appraisal data. To date, the database holds more than 40,000 citations. Central to the review process is the assessment of the security of diagnosis of abuse or neglect. In the absence of a gold standard diagnostic test for child abuse or neglect, it is essential to minimise the risk of circularity, namely that the authors ‘diagnose’ abuse or neglect simply by the presence of the injury or feature under review. A unique ranking system was established for reviews relating to physical abuse (18) to ensure that the security of diagnosis was not based entirely on the clinical features of interest. These ‘rank of abuse’ criteria have been adapted for reviews relating to neglect (19), and adopted by other systematic review groups (20). Example flow diagram of different phases of systematic review (from review relating to dental neglect and following PRISMA guidance (21). (See supplementary files for an example flowchart)

Central to the review process is the assessment of the security of diagnosis of abuse or neglect. In the absence of a gold standard diagnostic test for child abuse or neglect, it is essential to minimise the risk of circularity, namely that the authors ‘diagnose’ abuse or neglect simply by the presence of the injury or feature under review. A unique ranking system was established for reviews relating to physical abuse (18) to ensure that the security of diagnosis was not based entirely on the clinical features of interest. These ‘rank of abuse’ criteria have been adapted for reviews relating to neglect (19), and adopted by other systematic review groups (20). Example flow diagram of different phases of systematic review (from review relating to dental neglect and following PRISMA guidance (21). (See supplementary files for an example flowchart) Strategy The results of each systematic review are disseminated via peer-reviewed publications, summary Core Info leaflets (http://www.core-info.cardiff.ac.uk/category/leaflets), on the project website (www.core-info.cardiff.ac.uk), and national and international presentations (approximately 15 per year). All reviews are submitted to peer review journals of different subspecialties, depending on the review concerned or the primary target audience.

www.core-info.cardiff.ac.uk/category/leaflets), on the project website (www.core-info.cardiff.ac.uk), and national and international presentations (approximately 15 per year). All reviews are submitted to peer review journals of different subspecialties, depending on the review concerned or the primary target audience. In collaboration with the NSPCC staff, we aimed to produce a themed Core Info leaflet around each review topic, printed in both English and Welsh. These leaflets have been written in a question and answer format and are designed for non paediatric health professionals or non health professionals, including but not limited to: nursery nurses, social workers, refuge workers, and the police. They are available for purchase for a nominal sum, or free to download from the NSPCC website (http://www.nspcc.org.uk). The Core Info website (free to all users) features not only the results of our main reviews, but also those of the annual updates, the specific review methodology and critical appraisal forms used, our publications and Core Info leaflets, and news of any upcoming presentations on the topics reviewed. Citations and hyperlinks to the abstracts of all included studies provide a unique resource for practitioners who are advised to read the source studies when presenting scientific evidence in Family and Criminal Court Child Protection cases. This ensures that the research is promoted to a wide audience, can be accessed by international colleagues, and is easily accessible to improve the quality of clinical practice.

ctitioners who are advised to read the source studies when presenting scientific evidence in Family and Criminal Court Child Protection cases. This ensures that the research is promoted to a wide audience, can be accessed by international colleagues, and is easily accessible to improve the quality of clinical practice. A principal target is to complete each systematic review within 18 months of the initial start date. After completion, the results are uploaded onto the project website as soon as possible. Due to the lengthy peer-review process, each review question is updated immediately prior to publication with a recent literature search and relevant studies reviewed. Market penetration is determined by analysing website usage data using Google Analytics and international surveys, tracking citations of publications using Google Scholar Citations, and monitoring downloads and sales of the leaflets. Results The research programme has changed the recognition and investigation of suspected child abuse and neglect from clinical practice based largely on experience (pre-2002) to clinical practice built on scientific evidence. Professionals involved in child protection cases can now base their diagnoses, conclusions and Court evidence on scientifically informed and clinically validated models and practices.

child abuse and neglect from clinical practice based largely on experience (pre-2002) to clinical practice built on scientific evidence. Professionals involved in child protection cases can now base their diagnoses, conclusions and Court evidence on scientifically informed and clinically validated models and practices. The 21 systematic-reviews (updated annually), and related primary studies have produced 28 peer-reviewed publications, across subspecialty journals such as Eye and Burns, as well as more broad journals such as the BMJ and Pediatrics. In collaboration with the NSPCC, we have produced six Core Info leaflets (Bruises, Fractures, Neurological injuries, Thermal injuries, Oral injuries and Bites, Emotional Neglect and Emotional Abuse of the Pre-school child) of which more than 250,000 have been sold or downloaded by allied professionals nationally. Through the Core Info website, our systematic reviews are accessed each month with more than 10,000 hits. The program has also informed five national clinical guidelines including the first NICE guideline on child maltreatment and the National Child Protection training program (22,23,24,25,26). Gaps in the evidence base have been identified and stimulated a primary research program that is ongoing within the department. The systematic reviews have challenged some longstanding views in child protection, and reiterated others. Examples of some of the findings into clinical approaches and practices regarding suspected cases of child abuse and neglect are summarised below:

The 21 systematic-reviews (updated annually), and related primary studies have produced 28 peer-reviewed publications, across subspecialty journals such as Eye and Burns, as well as more broad journals such as the BMJ and Pediatrics. In collaboration with the NSPCC, we have produced six Core Info leaflets (Bruises, Fractures, Neurological injuries, Thermal injuries, Oral injuries and Bites, Emotional Neglect and Emotional Abuse of the Pre-school child) of which more than 250,000 have been sold or downloaded by allied professionals nationally. Through the Core Info website, our systematic reviews are accessed each month with more than 10,000 hits. The program has also informed five national clinical guidelines including the first NICE guideline on child maltreatment and the National Child Protection training program (22,23,24,25,26). Gaps in the evidence base have been identified and stimulated a primary research program that is ongoing within the department. The systematic reviews have challenged some longstanding views in child protection, and reiterated others. Examples of some of the findings into clinical approaches and practices regarding suspected cases of child abuse and neglect are summarised below: Ageing of injuries: In 2005 Maguire et al concluded that it is not possible to age bruises in children accurately with the naked eye (27). However in 2012, informed by the paucity of scientific evidence identified by the systematic review of fracture dating (28), a primary study by the group concluded that it is possible to age fractures within broad time frames (29).

d that it is not possible to age bruises in children accurately with the naked eye (27). However in 2012, informed by the paucity of scientific evidence identified by the systematic review of fracture dating (28), a primary study by the group concluded that it is possible to age fractures within broad time frames (29). Characteristics of abusive bruises: While bruising patterns in non-abused children (rare in non-mobile infants, predominantly on the front of the body, over bony prominences and in a ‘T’ pattern on the face) were reasonably described in the literature, those in abused children (most commonly on face/ head, multiple or patterned) were only recorded in case series, with few large scale comparative studies (18). This review underpinned the group's successful application for the first MRC-funded large comparative longitudinal study (£1.4 Million, 2007-2012) on bruising in children (abused, non-abused, those with pre-existing coagulation disorders). Abusive fractures: Rib fractures, in the absence of major trauma or underlying bone disease have a high probability of abuse (positive predictive value (PPV) for abuse 71% (95% CI 42% to 91%). It is clear that the fracture type is of significance for some fractures (eg non-supracondylar fractures of the humerus have strong correlation with abuse whereas for others the child's developmental stage is a key variable, eg femoral fractures where the probability of abuse for non-mobile children is significantly greater than in mobile children) (30).

s of significance for some fractures (eg non-supracondylar fractures of the humerus have strong correlation with abuse whereas for others the child's developmental stage is a key variable, eg femoral fractures where the probability of abuse for non-mobile children is significantly greater than in mobile children) (30). Abusive head trauma (AHT): This has been the subject of recent controversy in the press, however our systematic reviews into this topic confirmed clinical associations between Intracranial injuries in a child less than three years and associated clinical features such as Retinal Haemorrhages PPV for AHT of 71% (CI 48-86%), Apnoea (PPV 93% (CI 73-98%), Rib fractures (PPV 73% (CI 5-88%). Furthermore, our unique ‘individual patient data analysis’ of six international studies (31), proposed a model to assist in the estimation of the probability of AHT from combined clinical features.

ch as Retinal Haemorrhages PPV for AHT of 71% (CI 48-86%), Apnoea (PPV 93% (CI 73-98%), Rib fractures (PPV 73% (CI 5-88%). Furthermore, our unique ‘individual patient data analysis’ of six international studies (31), proposed a model to assist in the estimation of the probability of AHT from combined clinical features. Retinal haemorrhages (RH) have long been recognised as an important feature of AHT, however, more recently a number of other conditions have been proposed as causing RH (Cardiopulmonary Resuscitation [CPR], Seizure, immunisations etc). Our systematic review of this topic confirmed the association between bilateral, multilayered, numerous and extensive RH with AHT while noting their rarity in non-abusive head trauma, where, if present, they are more likely to be unilateral, few in number and predominantly in the posterior pole. We identified no valid evidence to support the presence of RH following immunisations or CPR. This review highlighted a lack of internationally recognised reporting standards for haemorrhagic retinopathy in cases of AHT. We have now developed and validated such a tool (32).

mber and predominantly in the posterior pole. We identified no valid evidence to support the presence of RH following immunisations or CPR. This review highlighted a lack of internationally recognised reporting standards for haemorrhagic retinopathy in cases of AHT. We have now developed and validated such a tool (32). The quality of the group's work on bruising has been discussed in a Lancet editorial (33): ‘The conclusions are clinically intuitive, but provide a more empiric literature-based review that provides an essential framework for any clinician attempting to determine the cause of bruising.’ Furthermore, since its’ publication in 2005, the Systematic Review on the patterns of bruising in childhood (18) has been cited 123 times (Google Scholar citations, accessed 12th April 2013), and while the original review only identified 23 studies over a 53 year period, there have been a further 14 quality studies published in the seven years since the original review was conducted (34). Six Core Info leaflets developed jointly by the Cardiff team and the NSPCC (2007-2013) translate key research findings into practice for allied professionals in child protection. The Core Info leaflets are regularly updated to reflect the latest evidence and are widely used for national training (Levels 1-2) and as a quick reference source for health visitors, social services, general practitioners and police.

ate key research findings into practice for allied professionals in child protection. The Core Info leaflets are regularly updated to reflect the latest evidence and are widely used for national training (Levels 1-2) and as a quick reference source for health visitors, social services, general practitioners and police. The work of the Cardiff group informs the work of Child Protection clinicians and academics internationally. For example, the novel ranking system for the security of diagnosis of child abuse has been adopted internationally by Child Protection research groups, and in 2008 the Core Info website was launched, which has proved to be an invaluable resource for professionals worldwide. The website is used by over 1,000 health professionals, social workers, law enforcement, the judiciary and researchers from 40 countries monthly (Google Analytics accessed 21st March 2013). A recent survey of Child Protection paediatricians in the UK and Australia confirms that Core-Info is used by 60% of paediatricians surveyed to inform clinical decisions, provide continuing professional development and education material, inform legal reports, and give scientific validation to expert opinion presented.

A recent survey of Child Protection paediatricians in the UK and Australia confirms that Core-Info is used by 60% of paediatricians surveyed to inform clinical decisions, provide continuing professional development and education material, inform legal reports, and give scientific validation to expert opinion presented. Finally, the Systematic Reviews have directly informed five National Child Protection Guidelines and a National compulsory training program. The first NICE evidence-based maltreatment guidance (2008) drew upon eight of the systematic reviews which directly informed the recognition of physical abuse due to bruising, fractures, oral injury and bites, abusive head trauma and haemorrhagic retinopathy (22). The first joint guidelines published by Royal College of Radiology and Royal College of Paediatrics and Child Health in 2008 utilised the evidence base from the fractures reviews; ‘Which radiological investigation should be performed to identify fractures in suspected child abuse?’. Skeletal surveys now routinely include oblique views of the ribs for all children in UK under the age of two years where physical abuse is suspected (23). The second edition of RCPCH Child Protection Companion (2013) has been updated to incorporate the evidence-base from all 21 systematic reviews (24). Following an evidence gap identified in the retinal haemorrhages review (25) the Core-info researchers in conjunction with the lead Paediatric Ophthalmologist in this review, have completed a primary-study which devised and validated standards for retinal examination of children with suspected AHT (32). This systematic review and standardised recording has fed directly into the newly revised national standards for ophthalmological examination in suspected child abuse, which are due to be published shortly. The systematic review of oral injuries in children informed the 2009 guide to safeguarding children in dental practice (26). This publication informs all dental practitioners about their role and responsibility and how to recognise and act upon cases of suspected child abuse or neglect.

are due to be published shortly. The systematic review of oral injuries in children informed the 2009 guide to safeguarding children in dental practice (26). This publication informs all dental practitioners about their role and responsibility and how to recognise and act upon cases of suspected child abuse or neglect. The ultimate beneficiaries of this work are the children who are being abused. Through the adoption of national guidelines and the implementation of standardised evidence based practice across the UK, we anticipate that it is now far more likely that abuse will be recognised and appropriately investigated. Improved evidence presented in Court means that abused children are more likely to be protected from future harm and with a sound evidence base for expert witnesses to draw upon there are likely to be fewer miscarriages of justice.

it is now far more likely that abuse will be recognised and appropriately investigated. Improved evidence presented in Court means that abused children are more likely to be protected from future harm and with a sound evidence base for expert witnesses to draw upon there are likely to be fewer miscarriages of justice. Lessons and limitations Systematic reviewing is a lengthy and involved process, and very costly. Aside from the co-ordination of reviews, collation of critical appraisal data and analysis of included studies, the initial identification, screening and sourcing of relevant studies is a logistical challenge in its own right, requiring substantial administrative and IT resources. Proprietary packages exist for co-ordinating and tracking the various stages of a Systematic Review; for example, RevMan (35) can be used for the reviewing and analysis phase, and reference management software, such as Reference Manager or Endnote can be adapted to record the selection and location of relevant studies and even tracking review data. (36) We opted to design a purpose built sophisticated relational database in Microsoft Access which tracks all phases from screening and sourcing to review and dissemination, along with the collation of critical appraisal data. This has enabled the design and ongoing modification of a system adapted precisely to need, but does require a level of in-house expertise and maintenance, which other proprietary packages do not. We initially assumed that we could train sufficient clinicians / practitioners to undertake the reviews for each topic, but over the past five years, with increasing demands on consultants’ time, we have found that it is necessary for our ‘in house’ research admimistrators to absorb a larger percentage of the primary reviews, to ensure that we can complete the reviews within the allotted time frames.

ndertake the reviews for each topic, but over the past five years, with increasing demands on consultants’ time, we have found that it is necessary for our ‘in house’ research admimistrators to absorb a larger percentage of the primary reviews, to ensure that we can complete the reviews within the allotted time frames. The biggest issue is that the program relies upon charitable funding, with only one review (Neurological Injuries) receiving any statutory funding, whilst the output from this programme is used by a broad base of statutory agencies.

ndertake the reviews for each topic, but over the past five years, with increasing demands on consultants’ time, we have found that it is necessary for our ‘in house’ research admimistrators to absorb a larger percentage of the primary reviews, to ensure that we can complete the reviews within the allotted time frames. The biggest issue is that the program relies upon charitable funding, with only one review (Neurological Injuries) receiving any statutory funding, whilst the output from this programme is used by a broad base of statutory agencies. A further challenge is keeping the results up-to-date. Annual updates of reviews have been integral to the program, ensuring that the results remain relevant and applicable to Child Protection policy and practice; one new study could potentially alter the over-arching recommendations and thus impact upon a child's welfare. However this task becomes progressively more difficult as the number of topics increases. Our original dissemination strategy included scientific presentations, peer reviewed publications and the production of a series of leaflets summarising key findings and aimed at professionals other than paediatricians. However, it became apparent early on that the time taken from submission of a manuscript until publication (average 9-15 months) creates a significant delay in transmitting the results. Thus we created our own website, www.core-info.cf.ac.uk, which hosts all key results and links to the primary studies that are included. It is also an invaluable tool for presenting the findings of updates, since it is unrealistic to disseminate all of these in peer review publications. It also became apparent following the widespread awareness of our work, that professionals were relying on us as a resource to identify studies relating to, although not directly included in, our primary Systematic Review questions. We have been able to address this by adding ‘other useful references’ to our website pages, expanding themes as people corresponded with us.

eness of our work, that professionals were relying on us as a resource to identify studies relating to, although not directly included in, our primary Systematic Review questions. We have been able to address this by adding ‘other useful references’ to our website pages, expanding themes as people corresponded with us. With the digital world advancing apace, it will be crucial to continually improve the website's functionality, and offer additional resources via a dedicated member's area and educational resources by podcasts. A mobile Application is also under consideration, along with the development of a social media account to disseminate news and results in a timely fashion.

conduct, rules and standards are discussed. The whole team have a good understanding of why risk management is important. The Clinical Governance Lead is based on the unit and operates an ‘open door’ policy (where there is often a queue). Support is provided for all staff that are involved in an incident or complaint. Results The project is ongoing and provisional figures indicate a further increase in incident reporting and decrease in serious incidents. The results will continue to be monitored. The Patient Safety Incident Review Team was reviewed by the Aston Team Performance Inventory in November 2011; this measures the elements, dimensions and components that deliver effective performance at a team and organisational level. This report was positive and gave the team a catalyst to disseminate their work further. The team members reported a good deal of attachment to the team and to their team colleagues, this suggested that they were motivated to remain and promote the team in to the future. See report summary below. See supplementary file: ds1681.docx

l be crucial to continually improve the website's functionality, and offer additional resources via a dedicated member's area and educational resources by podcasts. A mobile Application is also under consideration, along with the development of a social media account to disseminate news and results in a timely fashion. Conclusion Child Protection is every health care professional's responsibility, with enormous consequences for the child and family if a mistaken diagnosis is made either way. In the absence of mandatory reporting in the UK, and with prevailing media hostility toward practitioners in this field, there is a demand from all sides for an ‘evidence based’ practice in this field. Despite the considerable challenges the Cardiff Child Protection Systematic Review team have developed an internationally recognised format for conducting systematic reviews of this difficult area, and have highlighted the current scientific evidence to underpin the recognition and investigation of suspected physical abuse and neglect. Through a multimedia approach, this has been disseminated to professionals and practitioners who come into contact with children, to ensure they have immediate access to an up to date source of published scientific evidence in the field. This has underpinned the first national guidance on the topic across disciplines, raised the clinical standards of the recognition of abuse, and stimulated a higher quality of research in the field. Supplementary Material Web supplement The NSPCC for funding, our panel of reviewers and translators.

Conclusion Child Protection is every health care professional's responsibility, with enormous consequences for the child and family if a mistaken diagnosis is made either way. In the absence of mandatory reporting in the UK, and with prevailing media hostility toward practitioners in this field, there is a demand from all sides for an ‘evidence based’ practice in this field. Despite the considerable challenges the Cardiff Child Protection Systematic Review team have developed an internationally recognised format for conducting systematic reviews of this difficult area, and have highlighted the current scientific evidence to underpin the recognition and investigation of suspected physical abuse and neglect. Through a multimedia approach, this has been disseminated to professionals and practitioners who come into contact with children, to ensure they have immediate access to an up to date source of published scientific evidence in the field. This has underpinned the first national guidance on the topic across disciplines, raised the clinical standards of the recognition of abuse, and stimulated a higher quality of research in the field. Supplementary Material Web supplement The NSPCC for funding, our panel of reviewers and translators. Declaration of interests: Nothing to declare.

Problem There were inefficiencies in the traditional pathway of diabetes care, with long term follow ups for PWD being conducted in secondary care clinics. There was an unacceptable variation in the quality of care provided in primary and community care. This was believed to be contributing to higher than expected rates of diabetic emergency admissions and complication rates in the local population. There was a disconnect between care services which resulted in an absence of structured care plans or duplication of effort. Care quality issues centred on clinician and patient knowledge. Amongst clinicians there was inequitable knowledge of diabetes and insulin management. Further, there was no access to prompt specialist advice regarding diabetes management. Patients were also expressing a preference for care management within primary care. Background When the project began there was no known similar examples across the UK that had been published. The project was designed to tackle a specific local problem with diabetes care, which although reflecting care across the UK, had already been initiated in a small way when the author and others carried out a RCGP/Lilly funded project in 1991 to facilitate structured diabetes care in Portsmouth District - a project that had encouraged and supported practices in the Portsmouth area to formalise their in house diabetes care management. Baseline measurement Prior to the project commencing, diabetes management was firmly split between Primary and Secondary care providers.

The project was designed to tackle a specific local problem with diabetes care, which although reflecting care across the UK, had already been initiated in a small way when the author and others carried out a RCGP/Lilly funded project in 1991 to facilitate structured diabetes care in Portsmouth District - a project that had encouraged and supported practices in the Portsmouth area to formalise their in house diabetes care management. Baseline measurement Prior to the project commencing, diabetes management was firmly split between Primary and Secondary care providers. Patients were managed in either ‘silo’ with minimal reference to one another and difficulties in communication between one another due to the straight jacket of traditional letters in between both groups. Previous attempts to use shared care books similar to ante natal care had failed to address the problem. There was a variation between practices in South East Hampshire (population aproximately 500,000) of patients with diabetes attending long term follow up in secondary care from 6% to 25% of the pactice diabetes population. Hospital waiting lists for follow up care had gradually increased over a 10 year period from 6 to 18 months. There was a systematic failure to discharge patients from secondary care or to support primary care in managing patients, each specialist - either in primary or secondary care - merely providing the best care as an individual they felt able to do.

Hospital waiting lists for follow up care had gradually increased over a 10 year period from 6 to 18 months. There was a systematic failure to discharge patients from secondary care or to support primary care in managing patients, each specialist - either in primary or secondary care - merely providing the best care as an individual they felt able to do. Design The GP with a Special Interest in Diabetes who instigated the process was pivotal to success in achieving this engagement. He recognised it was vital to share this vision with key commissioning and clinical stakeholders in ways which would engage them and secure agreement to the development of a new team and care pathway. The vision was challenging for two reasons: - It directly challenged the secondary care focused status quo - It would mean a shift of resources within the health economy. Therefore a strategy, reinforced by persistence and determination, which would appeal to both clinicians and commissioners was needed. Drawing on evidence based on best practice and most efficient use of resources (e.g. NSF for Diabetes) consistent messages were tailored and delivered to both groups to persuade them of the need and benefits of change. This successfully facilitated commissioner and clinician agreement enabled the leap of faith required to instigate the change.

on best practice and most efficient use of resources (e.g. NSF for Diabetes) consistent messages were tailored and delivered to both groups to persuade them of the need and benefits of change. This successfully facilitated commissioner and clinician agreement enabled the leap of faith required to instigate the change. Strategy There were two phases to implementation. Firstly, in 2007, the Community Diabetes Team was established and a Local Enhanced Service implemented. This allowed appropriate specialist support and education programmes to be in place. The team began to build relationships and a critical mass of upskilled primary care clinicians and PWD through systematic education programmes. Having demonstrated the model could provide the assurance and service quality needed, in 2011, the team moved onto the second phase, changing the secondary care model. Joint baseline assessments by Consultants and GPs identified patients for discharge to primary care and those who were more appropriate to be retained by the secondary care team through the ‘Super Six’ clinics: Pregnancy, Renal Dialysis, Insulin Pumps, Acute Type 1 Diabetes, Type 1 Education and Adolescents. Subsequently, GP practice meetings were held with a Diabetologist and CDT Specialist Nurse to review patients identified for discharge. These meetings began the support and engagement of practices through identifying care management issues and education requirements of clinicians. Open access via telephone/email also promotes joint problem solving.

ings were held with a Diabetologist and CDT Specialist Nurse to review patients identified for discharge. These meetings began the support and engagement of practices through identifying care management issues and education requirements of clinicians. Open access via telephone/email also promotes joint problem solving. Results The improvements in care have been significant. The initiative has enabled discharge of 666 (85%) of patients from secondary care since November 2011. At a cost per follow-up appointment of around £90 this represents a recurrent saving of £59,940 p.a. Another 108 patients now receive more appropriate secondary based care in a ‘Super Six clinic.’ New secondary care referrals have fallen from around 15 to 2 per month and 86 GP practice education visits have been undertaken with follow up visits booked. Since beginning in 2007 it has enhanced the skills and knowledge of PWD and clinicians: - 2996 PWD have undertaken DESMOND training - 287 clinicians have undertaken MERIT training - 2802 individual practice referrals seen - 30 clinicians have undertaken ‘Conversation Map’ training Patient feedback is overwhelmingly positive. PWD report feeling empowered and in control of their diabetes. They report that the training is equally useful for their carers who accompany them. Relationships with clinicians and other staff are consistently positive. Feedback reflects the value placed on gaining a rapid response to queries and ongoing cross organisational meetings support engagement and relationship management. MERIT training and update sessions are continually oversubscribed.

Patient feedback is overwhelmingly positive. PWD report feeling empowered and in control of their diabetes. They report that the training is equally useful for their carers who accompany them. Relationships with clinicians and other staff are consistently positive. Feedback reflects the value placed on gaining a rapid response to queries and ongoing cross organisational meetings support engagement and relationship management. MERIT training and update sessions are continually oversubscribed. In cost terms, the service has led to decommissioning of a large proportion of secondary based care, with revenue shifted to support the primary care model. Ongoing running costs for the team cover staffing (including consultant diabetologist input) and training and education costs. These currently stand at £152,100 per annum. The team remains within budget. Through discharging 666 patients from secondary care it is estimated that at a cost of around £90 per follow up appointment, this is saving around £59,940 per annum in revenue costs. The fall in new outpatient referrals also represents a reduction of from around 180 referrals p.a. to 24. This represents a reduction in need for provision of around 156 new appointment slots. With a new appointment costing around £200, this represents a recurrent saving of at least £31,200 p.a. The total saved is £91,140 p.a. All savings of course represent released resources that can be used differently to benefit care across the health economy. Lessons and limitations Lessons: It is always worth persisting with a good idea All stakehaolders need to be engaged with

Through discharging 666 patients from secondary care it is estimated that at a cost of around £90 per follow up appointment, this is saving around £59,940 per annum in revenue costs. The fall in new outpatient referrals also represents a reduction of from around 180 referrals p.a. to 24. This represents a reduction in need for provision of around 156 new appointment slots. With a new appointment costing around £200, this represents a recurrent saving of at least £31,200 p.a. The total saved is £91,140 p.a. All savings of course represent released resources that can be used differently to benefit care across the health economy. Lessons and limitations Lessons: It is always worth persisting with a good idea All stakehaolders need to be engaged with Sometimes a stakeholder is counter productive, other stakeholders have to engage and be involved to shift the balance in favour of change Postive feed back fires the imagination and work productivity Limitations: Initial enthusiasm for closer working between 1o and 2o care needs fostering, the practice educational sessions between the diabetes community team and GP practices will need ongoing facilitation to encourage enthusiasm and engagement of both parties It is much more difficult to engage doctors, both GPs and consultants, in the process than practice or comunity nurses. Doctors appear more inherently individualistic and anti team players. Ongoing funding of the scheme will require clear measurable objectives, these are in place but will change with time - this needs managing

It is much more difficult to engage doctors, both GPs and consultants, in the process than practice or comunity nurses. Doctors appear more inherently individualistic and anti team players. Ongoing funding of the scheme will require clear measurable objectives, these are in place but will change with time - this needs managing Conclusion The formation of the community diabetes team in 2007 led the way to improving diabetes management skills and education in primary care by supporting GP practices directly in their work place, community nursing teams and patients within their own homes or local environment. The team provided hands on patient and health care professional advice as well as mobile phone advice available throughout the working day. Specifically the team does not carry a patient case load, patients remain with their GP practice and the team provide support to both. Initial skepticism, fear of job losses and status changes on the part of secondary care specialists were alleviated by observing the resource in practice and enabled the secondary care team to formulate a ‘super six’ policy in 2011. This led to a structured discharge of patients to their GP practices, setting up super specialist diabetes clinics for those with specific needs, a robust referral system from primary care and regular twice yearly educational sessions within GP practices by the secondary care consultants and Diabetes Specialist nurses.

This led to a structured discharge of patients to their GP practices, setting up super specialist diabetes clinics for those with specific needs, a robust referral system from primary care and regular twice yearly educational sessions within GP practices by the secondary care consultants and Diabetes Specialist nurses. Both consultants and GPs have appreciated and enjoyed the fostering of relationships and putting ‘faces to names’, a step that it is hoped will lead to better diabetes care integration and future improved patient outcomes. Dr Partha Kar, Consultant in Diabetes and Endocrinology Queen Alexandra Hospital, Portsmouth Hospitals Foundation Trust Jane Egerton, Diabetes Specialist Nurse, Southern Health Foundation Trust, Debbie Fishwick, Diabetes Specialist Nurse, Southern Health Foundation Trust, and all the other team members from South East Hampshire Community Diabetes Team who have helped develop this project. Declaration of interests: None to declare

Problem Staphylococcus aureus is a common cause of both community and hospital acquired bacteraemia, and is associated with significant morbidity and mortality. The management of Staphylococcus aureus bacteraemia is multi-faceted. It often requires prolonged courses of antimicrobial therapy as well as a thorough assessment and investigations to identify the source and seek any complications, such as metastatic foci. Given the meticulous approach required when treating patients with S. aureus bacteraemia, there is potential for some aspects of optimal management to be missed, especially in an environment where time and bed space are at a premium. Failure of any aspect of the optimal management, however, is associated with negative patient outcomes. Background S. aureus bacteraemia is associated with a mortality of 20-30%, and suboptimal management can significantly impact on the associated morbidity (1, 2, 3). Failure to remove an infected intravascular focus increases the risk of treatment failure, recurrence of S. aureus bacteraemia and metastatic complications (4, 5). Based on this data, our first measurement evaluated the adequacy and timely removal or debridement of the source of bacteraemia.

ciated morbidity (1, 2, 3). Failure to remove an infected intravascular focus increases the risk of treatment failure, recurrence of S. aureus bacteraemia and metastatic complications (4, 5). Based on this data, our first measurement evaluated the adequacy and timely removal or debridement of the source of bacteraemia. Endocarditis is a well documented complication in around 12% of cases, although rates vary between different population groups and rates from 5% up to 60% have been reported (2, 3). This highlights the need for echocardiography in all cases of S. aureus bacteraemia, even in the absence of peripheral stigmata of endocarditis. The British Society for Antimicrobial Chemotherapy (BSAC) and the Infectious Diseases Society of America (IDSA) both recommend echocardiography in all cases of S. aureus bacteraemia in their guidelines (6, 7). Based on these guidelines, our second measurement assessed whether echocardiography was performed in all adult patients with Staphylococcus aureus bacteraemia. Obtaining a repeat blood culture is recommended after initiation of appropriate treatment. This enables the early identification of complications and persistence of bacteraemia. Hence our third measurement assessed whether clearance blood cultures were obtained.

Endocarditis is a well documented complication in around 12% of cases, although rates vary between different population groups and rates from 5% up to 60% have been reported (2, 3). This highlights the need for echocardiography in all cases of S. aureus bacteraemia, even in the absence of peripheral stigmata of endocarditis. The British Society for Antimicrobial Chemotherapy (BSAC) and the Infectious Diseases Society of America (IDSA) both recommend echocardiography in all cases of S. aureus bacteraemia in their guidelines (6, 7). Based on these guidelines, our second measurement assessed whether echocardiography was performed in all adult patients with Staphylococcus aureus bacteraemia. Obtaining a repeat blood culture is recommended after initiation of appropriate treatment. This enables the early identification of complications and persistence of bacteraemia. Hence our third measurement assessed whether clearance blood cultures were obtained. Treatment of less than two weeks is associated with a higher risk of complications (8). The presence of an irremovable or undrainable primary focus, endocarditis, a metastatic focus of infection or persistence of bacteraemia are all indications for prolonged antimicrobial therapy of four to six weeks (6, 7, 9, 10). It is uncertain whether de-escalation to oral therapy impacts on the relapse rate.

ons (8). The presence of an irremovable or undrainable primary focus, endocarditis, a metastatic focus of infection or persistence of bacteraemia are all indications for prolonged antimicrobial therapy of four to six weeks (6, 7, 9, 10). It is uncertain whether de-escalation to oral therapy impacts on the relapse rate. Based on this evidence, the fourth measurement evaluated the adequacy of antimicrobial duration and choice. A minimum of two weeks of intravenous antibiotics for uncomplicated bacteraemia, and four to six weeks of antibiotics for complicated bacteraemia was considered adequate. Documentation of S. aureus bacteraemia in the discharge summary enables earlier identification of complications following a patient's discharge, such as recurrence of bacteraemia, metastatic foci of infection or endocarditis. The fifth measurement assessed whether S. aureus was documented in the discharge summary. A previous study revealed that patients under the care of medical teams who did not follow the treatment recommendations by infectious diseases consultants were more likely to experience a relapse of the bacteraemia (4). Many of the project's Plan-Do-Study-Act learning cycles were therefore centred around improving clinical liaison between the clinicians and the microbiology team.

al teams who did not follow the treatment recommendations by infectious diseases consultants were more likely to experience a relapse of the bacteraemia (4). Many of the project's Plan-Do-Study-Act learning cycles were therefore centred around improving clinical liaison between the clinicians and the microbiology team. Baseline measurement In order to determine the scale of the problem, the management of 56 patients with Staphylococcus aureus bacteraemia was reviewed at the Royal Hampshire County Hospital (January 2012 to October 2012) and the Basingstoke and North Hampshire Hospital (April 2010 to May 2011), both part of the Hampshire Hospitals Foundation Trust. The following five aspects were assessed: Adequate and timely removal or debridement of the source of bacteraemia Echocardiography in adults with S. aureus bacteraemia to exclude or confirm endocarditis Repeat blood culture to prove clearance of bacteraemia or allow early identification of complications Adequate duration (minimum of two weeks of intravenous antibiotics for uncomplicated bacteraemia, four to six weeks of antibiotics for complicated bacteraemia) and choice of antibiotics Documentation of bacteraemia in the discharge summary

Repeat blood culture to prove clearance of bacteraemia or allow early identification of complications Adequate duration (minimum of two weeks of intravenous antibiotics for uncomplicated bacteraemia, four to six weeks of antibiotics for complicated bacteraemia) and choice of antibiotics Documentation of bacteraemia in the discharge summary The above baseline measurements were obtained by reviewing patient notes as well as the microbiology bacteraemia notes and discharge summaries. Echocardiography findings were obtained by liaising with the echocardiography department. The adequacy of antibiotic treatment was assessed by reviewing the electronic drug prescribing records. All microbiology results were reviewed, including initial and repeat blood cultures as well as cultures from other sites indicating possible sources or metastatic foci of infection.

h the echocardiography department. The adequacy of antibiotic treatment was assessed by reviewing the electronic drug prescribing records. All microbiology results were reviewed, including initial and repeat blood cultures as well as cultures from other sites indicating possible sources or metastatic foci of infection. The most common sources identified in the baseline study were skin or soft tissue infection (26%) and bone or joint infection (21%). Adequate source control was obtained in almost all the patients (96%). However, just under half (49%) of the patients studied underwent echocardiography, and just over half (56%) had clearance blood cultures within the required time frame. Only 59% of patients with uncomplicated S. aureus bacteraemia received an appropriate treatment course, whilst all patients with a complicated S. aureus bacteraemia received an adequate duration of therapy (see figure 1 for definition of uncomplicated and complicated bacteraemia). The diagnosis of a S. aureus bacteraemia was included in the discharge summary of 65% of the patients. See supplementary file: ds1862.doc - “Figure 1 Uncomplicated versus complicated bacteraemia”

The most common sources identified in the baseline study were skin or soft tissue infection (26%) and bone or joint infection (21%). Adequate source control was obtained in almost all the patients (96%). However, just under half (49%) of the patients studied underwent echocardiography, and just over half (56%) had clearance blood cultures within the required time frame. Only 59% of patients with uncomplicated S. aureus bacteraemia received an appropriate treatment course, whilst all patients with a complicated S. aureus bacteraemia received an adequate duration of therapy (see figure 1 for definition of uncomplicated and complicated bacteraemia). The diagnosis of a S. aureus bacteraemia was included in the discharge summary of 65% of the patients. See supplementary file: ds1862.doc - “Figure 1 Uncomplicated versus complicated bacteraemia” Design It was felt that the key to improving the management of S. aureus bacteraemia was through education and encouraging clear communication between microbiologists and clinicians, as well as bedside review of patients by the microbiology team where applicable. In order to create a sustainable improvement in practice, awareness and teaching was targeted at different members and levels of the clinical team, including the microbiology team, junior doctors and more senior clinicians. Strategy PDSA cycle1 Teaching on ‘Optimising the management of S. aureus bacteraemia’ at the regional microbiology training day, Wessex deanery (November 2012). PDSA cycle 2

Design It was felt that the key to improving the management of S. aureus bacteraemia was through education and encouraging clear communication between microbiologists and clinicians, as well as bedside review of patients by the microbiology team where applicable. In order to create a sustainable improvement in practice, awareness and teaching was targeted at different members and levels of the clinical team, including the microbiology team, junior doctors and more senior clinicians. Strategy PDSA cycle1 Teaching on ‘Optimising the management of S. aureus bacteraemia’ at the regional microbiology training day, Wessex deanery (November 2012). PDSA cycle 2 Present findings of the baseline measurements as well as the proposed improvement plan at the Quality event Hampshire Hospitals Foundation Trust (February 2013). Disseminate initial results to the microbiology consultants across both hospital sites (December 2012). PDSA cycle 3 Improve clinical liaison and communication between microbiology team and clinicians by specifically recommending echocardiography in patients with significant S. aureus bacteraemia, as well as documentation in patient notes where applicable (November 2012 to May 2013). PDSA cycle 4 Clinical review of patients on the ward by the microbiology team as indicated, optimising the initial management and documenting the advice to enhance collaboration between the teams (November 2012 to May 2013). PDSA cycle 5

Improve clinical liaison and communication between microbiology team and clinicians by specifically recommending echocardiography in patients with significant S. aureus bacteraemia, as well as documentation in patient notes where applicable (November 2012 to May 2013). PDSA cycle 4 Clinical review of patients on the ward by the microbiology team as indicated, optimising the initial management and documenting the advice to enhance collaboration between the teams (November 2012 to May 2013). PDSA cycle 5 Discussion with junior doctors at their Foundation teaching with regards to documentation of bacteraemias in the discharge summary, allowing prompt identification of subsequent recurrence of bacteraemia or metastatic foci of infection (Royal Hampshire County Hospital, May 2013). Results Following the implementation of the quality improvement project, the management of patients with S. aureus bacteraemia was reviewed using the same methods and measurements as was used in the baseline study.

Discussion with junior doctors at their Foundation teaching with regards to documentation of bacteraemias in the discharge summary, allowing prompt identification of subsequent recurrence of bacteraemia or metastatic foci of infection (Royal Hampshire County Hospital, May 2013). Results Following the implementation of the quality improvement project, the management of patients with S. aureus bacteraemia was reviewed using the same methods and measurements as was used in the baseline study. 24 patients with S. aureus bacteraemia were identified between November 2012 and May 2013 (Figure 2). Bone or joint infection and line or medical device infection were the most common sources of bacteraemia (29% and 25% respectively). As noted in the pre-intervention study, adequate source control was obtained in almost all patients (96%). Encouragingly, the proportion of patients undergoing an echocardiogram after the intervention was markedly improved, with 88% of patients undergoing the investigation, compared to 49% pre-intervention. Another marked improvement was seen in the timely obtaining of clearance blood cultures, with 88% of patients having clearance blood cultures within the 2-4 day window, compared to 56% pre-intervention.

ervention was markedly improved, with 88% of patients undergoing the investigation, compared to 49% pre-intervention. Another marked improvement was seen in the timely obtaining of clearance blood cultures, with 88% of patients having clearance blood cultures within the 2-4 day window, compared to 56% pre-intervention. Similar to the baseline study, all patients with complicated bacteraemia received a minimum of four weeks of antibiotics. Importantly, 70% of patients with uncomplicated S. aureus bacteraemia in the post-intervention group received an appropriate duration of antibiotic treatment, compared to 59% in the pre-intervention group. S. aureus bacteraemia was also more frequently documented in the discharge summary (75% in the post-intervention group versus 65% in the pre-intervention group). See supplementary file: ds1864.doc - “Figure 2. Results of baseline and post-intervention study.” Lessons and limitations Whilst implementing the Plan-Do-Study-Act learning cycles, it became evident that the engagement and support of the entire microbiology team was pivotal in raising the standard of management of S. aureus bacteraemia. There was also a marked improvement in the management of patients when the microbiology team reviewed the patients on the ward and documented directly in the patient notes, rather than just consulting over the telephone. Daily bacteraemia ward rounds were already common practice at one of the two District General Hospitals.

was also a marked improvement in the management of patients when the microbiology team reviewed the patients on the ward and documented directly in the patient notes, rather than just consulting over the telephone. Daily bacteraemia ward rounds were already common practice at one of the two District General Hospitals. Although this project was not designed to evaluate patient outcome, it was noted that less than two weeks of intravenous anti-staphylococcal treatment appeared to be linked to recurrence of bacteraemia in the post-intervention group. Two of the three patients who received less than two weeks of intravenous anti-staphylococcal treatment developed a recurrence of S. aureus bacteraemia within two months. None of the other patients in the post-intervention group have developed a recurrence of S. aureus bacteraemia to date. Whilst a reduced duration of antibiotic therapy in the short-term may appear cost-effective, the long-term impact on both patient outcome and hospital resources outweighs these immediate gains. Furthermore, a hospital stay may not be required for the entire duration of intravenous therapy, since antibiotics can be safely administered via the ‘Rapid Access Clinic’ in the Medical Admissions Unit or via Outpatient Antimicrobial Therapy (OPAT).

tient outcome and hospital resources outweighs these immediate gains. Furthermore, a hospital stay may not be required for the entire duration of intravenous therapy, since antibiotics can be safely administered via the ‘Rapid Access Clinic’ in the Medical Admissions Unit or via Outpatient Antimicrobial Therapy (OPAT). The post-intervention study was performed over a shorter timescale than the baseline study, which is one of the limitations of the project. As a result, there were fewer patients in the post-intervention study. Nonetheless, it was felt that there were sufficient numbers of patients in the post-intervention study for the improvements found to represent a real change in management. Conclusion Staphylococcus aureus bacteraemia is a common, but serious infection associated with significant morbidity and mortality. The project aimed to improve the multi-faceted and sometimes complex management of these patients by implementing five ‘Plan-Do-Study-Act’ learning cycles at two District General Hospitals. The post-intervention review showed significant improvement in the number of patients receiving appropriate antimicrobial treatment for uncomplicated S. aureus bacteraemia, exclusion of endocarditis by echocardiography and demonstrating clearance of the bacteraemia by follow-up blood cultures. The support of the entire microbiology team was pivotal in the successful outcome of the quality improvement project. Supplementary Material Web supplement Web supplement Dr Fatima El-Bakri, Bruce Wake, the microbiology team at Hampshire Hospitals Foundation Trust.

Conclusion Staphylococcus aureus bacteraemia is a common, but serious infection associated with significant morbidity and mortality. The project aimed to improve the multi-faceted and sometimes complex management of these patients by implementing five ‘Plan-Do-Study-Act’ learning cycles at two District General Hospitals. The post-intervention review showed significant improvement in the number of patients receiving appropriate antimicrobial treatment for uncomplicated S. aureus bacteraemia, exclusion of endocarditis by echocardiography and demonstrating clearance of the bacteraemia by follow-up blood cultures. The support of the entire microbiology team was pivotal in the successful outcome of the quality improvement project. Supplementary Material Web supplement Web supplement Dr Fatima El-Bakri, Bruce Wake, the microbiology team at Hampshire Hospitals Foundation Trust. Declaration of interests: Nothing to declare.

Problem Foot infection in people with diabetes is a very common complication, with previous work showing that up to 58% of diabetes related foot ulcers were infected (1). Foot infections remain one of the commonest diabetes related cause of acute hospital admission (2). We wanted to try and reduce the number of admissions from our specialist multidisciplinary diabetic foot clinic by developing our own diabetic foot antibiotic protocol. Background To date, the choice of antibiotic regimen for use in diabetes related foot infections has largely remained at the discretion of the prescribing physician. Whilst deep tissue samples or swab cultures are key to guiding antibiotic choice and should always be sought when treatment is being considered, most often, only superficial specimens are taken. Empirical therapy using narrow spectrum antibiotics active against aerobic gram positive cocci are the most commonly prescribed agents because these are the predominant microorganisms that colonise and infect ulcers (3,4). Broad spectrum empirical therapy is only indicated for severe infections and for infections in ischaemic feet (4). It has also been recommended that the choice of this empirical antibiotic therapy and the route of its administration should be determined by the severity of the infection and the likely aetiological organisms (4). The UK National Institute for Health and Clinical Excellence (NICE) added the caveat that the antibiotic with the lowest acquisition costs be used (5).

The key measure for improvement was the increase in incident reporting (44% increase 2011 to 2012) and the decrease in serious incidents (see attached report). The figures support the theory that the increase in minor incidents being reported and managed has reduced the incidence of serious incidents. See supplementary file: ds1615.docx Design When reviewing the problem it became clear that the number of serious incidents would need to be reduced. In a complex health environment is important that staff feel comfortable to report incidents and are encouraged to learn from these. Systems may be changed and improved. These changes and lessons learned from the minor incidents help to reduce the number of serious incidents. The Team used the therory of the Heinrich ratio to base their principles on. This theorises for every 300 minor / near miss incidents there will be one serious incident. Therefore managing and reporting the minor incidents was extremely important. Strategy The strategic theme that provided direction was from the Senior Management Team who would demonstrate commitment to safety through strong visible and consistent leadership. The provision of high-quality, affordable, health care is an increasingly difficult challenge, and therefore a robust patient safety process is relevant to all health care professionals; the initiative would ensure that safety and quality were the primary concern for the multidisciplinary team.

f this empirical antibiotic therapy and the route of its administration should be determined by the severity of the infection and the likely aetiological organisms (4). The UK National Institute for Health and Clinical Excellence (NICE) added the caveat that the antibiotic with the lowest acquisition costs be used (5). In 2008 the reconfiguration of our specialist multidisciplinary diabetic foot service included the recognition that we needed a more cohesive approach to empirical antibiotic prescribing. We reviewed several guidelines and felt that the Infectious Disease Society of America's (IDSA) guideline, whilst excellent and widely used, was limiting because it relied mainly on the use of oral antibiotics in the outpatient setting for those who did not need hospitalisation, or intravenous antibiotics for those who did. We felt there was a category of patients for whom their infections were too severe for oral antibiotics alone, but for whom hospitalisation was potentially avoidable. We termed this degree of infection as ‘moderate infection - borderline admission’. We introduced our guideline and did a cost analysis of the rationalisation of agents, as well as an economic analysis of admissions avoided as a result of the use of intramuscular agents. Baseline measurement Of the 144 sets of note available for review, of the 288 who fulfilled the criteria, 64 were from patients given antibiotics prior to the introduction of our protocol and the remaining 80 were from after its introduction.

We introduced our guideline and did a cost analysis of the rationalisation of agents, as well as an economic analysis of admissions avoided as a result of the use of intramuscular agents. Baseline measurement Of the 144 sets of note available for review, of the 288 who fulfilled the criteria, 64 were from patients given antibiotics prior to the introduction of our protocol and the remaining 80 were from after its introduction. The most commonly prescribed regimen prior to the introduction of the protocol was the combination of amoxicillin 500mg three times daily and flucloxacillin 500mg four times daily. The second most commonly prescribed regimen was amoxicillin 500mg three times daily, flucloxacillin 500mg four times daily, and metronidazole 400mg three times daily. The cheapest regimen prescribed was erythromycin 500mg four times daily. The costs per patient for an average three week course of these regimens were £16.50, £20.85 and £12.24 respectively. The overall average cost per patient for an average three week cost on any of the pre-protocol regimes was £17.12 per patient. See supplementary file: ds1612.doc - “Table 1” Design The antibiotic foot policy that developed by the multidiscilplinary foot team is shown in Table 1. Our team comprises of diabetologists, podiatrists, specialist antimicrobial pharmacists, vascualr and orthopaedic surgeons and microbiologists

The overall average cost per patient for an average three week cost on any of the pre-protocol regimes was £17.12 per patient. See supplementary file: ds1612.doc - “Table 1” Design The antibiotic foot policy that developed by the multidiscilplinary foot team is shown in Table 1. Our team comprises of diabetologists, podiatrists, specialist antimicrobial pharmacists, vascualr and orthopaedic surgeons and microbiologists Strategy The number of prescribers in the foot clinic was limited to those who ran foot clinics, and the guideline was widely advertised within our Trust. The guideline was ratified by the Drugs, Therapeutics and Medicines Management Committee of our institution, as well as the Therapeutic Advisory Group of our Primary Care Trust. A copy of the guideline was hosted on the county wide General Practice electronic register. Results We analysed the notes of the 80 patients treated after the introduction of the protocol who fulfilled the inclusion criteria of new lesions with no previous antibiotic use. The most commonly prescribed regimen was co-amoxiclav 625 mg three times daily with an estimated cost of £16.29 per patient for a three week course.

e analysed the notes of the 80 patients treated after the introduction of the protocol who fulfilled the inclusion criteria of new lesions with no previous antibiotic use. The most commonly prescribed regimen was co-amoxiclav 625 mg three times daily with an estimated cost of £16.29 per patient for a three week course. Between January 2009 and October 2010 we also prescribed intramuscular ceftriaxone together with oral ciprofloxacin and metronidazole 26 times in 23 individual patients, all of whom were treated according to our guideline. The daily cost of the intramuscular and oral antibiotic regimen (ceftriaxone 1g in 3.5 mls of 1% lidocaine, oral ciprofloxacin 500 mg twice daily and oral metronidazole 400 mg three times daily) based on the 2010 British National Formulary prices was £10.34 per day (6). The total cost of the intramuscular and oral antibiotics used for those 14 episodes in whom admission was avoided was £6,633.48. The assumption made was that prior to the introduction of our protocol, these individuals would have been admitted for intravenous antibiotics. If they were to have stayed for the same average length of time that those who were admitted directly stayed, i.e. 16.11 days, this equated to a saving of 225.54 bed days. In 2010 our institution estimated a 24 hour stay in a hospital bed was £274. Thus, avoiding admission for those 14 episodes led to a saving of £61,797.96. However, given that the expenditure on antibiotics given in the community was £6,633.48, the actual estimated saving was therefore £55,164.48 or £3,940.32 per patient per episode.

stitution estimated a 24 hour stay in a hospital bed was £274. Thus, avoiding admission for those 14 episodes led to a saving of £61,797.96. However, given that the expenditure on antibiotics given in the community was £6,633.48, the actual estimated saving was therefore £55,164.48 or £3,940.32 per patient per episode. Furthermore, looking at the outcomes for the 12 patients who had to be admitted despite having been treated with intramuscular and oral antibiotics as outpatients. These individuals were in hospital for an average of 9.25 days (range 2-25), i.e. 6.86 days less than those people who had been admitted directly from foot clinic. This led to a saving of 82.32 bed days (at £274 per day), making an estimated saving of £22,550.68 or £1879.64 per patient. District (community) and practice nursing time was then factored into those people treated as outpatient. We estimated an hour per day at a cost of £16 per hour. Thus for the 26 people treated with intramuscular and oral antibiotics at a cost of £10.74 per day, we avoided or reduced hospital admission by 307.86 days ([14 × 16.11] + [12 × 6.86]). The total thus spent on antibiotics and nurse time was £3,306.42 + £4,925.76 = £8,232.18. The costs avoided from hospital admission £274 × 307.86 = £84,353.64. This does not include the costs of intravenous antibiotics. Thus in these 26 episodes, we estimate a saving of £76,121.46. This is likely to be an underestimate.

he total thus spent on antibiotics and nurse time was £3,306.42 + £4,925.76 = £8,232.18. The costs avoided from hospital admission £274 × 307.86 = £84,353.64. This does not include the costs of intravenous antibiotics. Thus in these 26 episodes, we estimate a saving of £76,121.46. This is likely to be an underestimate. Lessons and limitations We have presented data to show that rationalising our empirical antibiotic protocol for the management of foot infections in people with diabetes has led to significant costs savings. Using a co-ordinated approach from all members of the specialist diabetic foot team, we got agreement from all of the major stake holders to ensure they understood the importance of the economic impact of diabetes related foot infections, and our attempt to tackle this. There are some limitations to our data. We collected data on relatively small numbers of patients. Despite this, there are very few data in the literature that examine the use of intramuscular antibiotics, and thus we feel that to present this dataset may be valuable.

Lessons and limitations We have presented data to show that rationalising our empirical antibiotic protocol for the management of foot infections in people with diabetes has led to significant costs savings. Using a co-ordinated approach from all members of the specialist diabetic foot team, we got agreement from all of the major stake holders to ensure they understood the importance of the economic impact of diabetes related foot infections, and our attempt to tackle this. There are some limitations to our data. We collected data on relatively small numbers of patients. Despite this, there are very few data in the literature that examine the use of intramuscular antibiotics, and thus we feel that to present this dataset may be valuable. The data on costs has been estimated from those quoted in an the British National Formulary, and may not be applicable to the National Health Service in general because many hospitals may get ‘discounts’ on bulk purchases from suppliers. It may have been better to calculate them using the drug tariff. A further limitation may be due to the estimation of the length of the course of antibiotics. However, given that the costs using the protocol were marginally cheaper, it is likely that if prolonged courses were used, the cost savings would have been greater. Another limitation when discussing the use of intramuscular antibiotics was that those people who were admitted directly from our foot clinic had, by definition, more severe disease. Thus is may be assumed that because of this, they would have stayed in hospital longer than those who had a lesser degree of infection (albeit one that prior to the introduction of the protocol would also have led to admission). We also did not include those people who may have been admitted directly from other clinics - e.g. vascular or orthopaedic. However, members of our foot MDT communicate almost daily ensuring any patient with diabetes admitted to our institution with a diabetes related foot problem is seen by a member of the foot MDT within 24 hours of admission.

se people who may have been admitted directly from other clinics - e.g. vascular or orthopaedic. However, members of our foot MDT communicate almost daily ensuring any patient with diabetes admitted to our institution with a diabetes related foot problem is seen by a member of the foot MDT within 24 hours of admission. Conclusion We have introduced a new standardised initial empirical antibiotic policy that has modified the IDSA guideline. We found that by collaborating within the multidisciplinary diabetes foot clinic team we rationalised the prescribing of antimicrobials at no additional drug cost. This rationalisation has meant that the cost of treatment has stayed relatively unchanged. At the same time we have also simplified the regimes in an attempt to improve patient compliance. Our intramuscular regimen saved over £60,000 in just 23 patients over a period of 22 months. We believe that this is a cost effective strategy for admission avoidance. Supplementary Material Web supplement None Declaration of interests: Nothing to declare.

Problem Audits of diabetes referral rates in this London borough have shown that over the years there has been a steady increase in avoidable referral rates from primary care to secondary care for newly diagnosed diabetic patients. Secondary care is becoming overwhelmed with the heavy workload and increasing cost, which also led to compromising care for complex patients. Based on projected population change and trends in obesity, prevalence of diabetes in London borough of Wandsworth is set to increase by 15.4% from 2010-2025 unless successful preventative measures are implemented (1). This led to the design and implementation of a diabetes based inter-professional education (IPE) programme. Background The need for integration of services to improve quality and efficiency in healthcare is inevitable. For integration to be successful, collaboration is one of the fundamental principles. There are various types of interventions to increase collaboration and inter-professional education (IPE) is one of them. Complexities of diabetes mean that management requires an integrated pathway of services. Diabetes is a significant health problem in the UK with the current prevalence estimated to be 5.5% in adults (2). Baseline measurement Diabetes referral rates were obtained through secondary care referral database and diabetes registers of GP practices. Data was audited before the IPE programme intervention and 15 months after. Pre-programme new-referral cases were 1793 and follow-up cases were 5155 (Figure 1).

Background The need for integration of services to improve quality and efficiency in healthcare is inevitable. For integration to be successful, collaboration is one of the fundamental principles. There are various types of interventions to increase collaboration and inter-professional education (IPE) is one of them. Complexities of diabetes mean that management requires an integrated pathway of services. Diabetes is a significant health problem in the UK with the current prevalence estimated to be 5.5% in adults (2). Baseline measurement Diabetes referral rates were obtained through secondary care referral database and diabetes registers of GP practices. Data was audited before the IPE programme intervention and 15 months after. Pre-programme new-referral cases were 1793 and follow-up cases were 5155 (Figure 1). Design The IPE program called the Wandsworth Rolling Initiative in Training and Education (WRiiTE) was created to increase the knowledge of healthcare professionals (HCPs) in diabetes and promote further collaboration within the community. The overall aim of the programme was to equip primary care to deal with more complex cases, reducing straightforward referrals to secondary care in accordance with the referral document, and thus freeing up resources in secondary care to deal with complicated cases. Having appropriate cases dealt with at appropriate levels will increase efficiency and effectiveness of the whole system. This is expected to provide quality improvement in diabetes care and reduce patient time spent in healthcare.

ocument, and thus freeing up resources in secondary care to deal with complicated cases. Having appropriate cases dealt with at appropriate levels will increase efficiency and effectiveness of the whole system. This is expected to provide quality improvement in diabetes care and reduce patient time spent in healthcare. This programme was developed jointly between allied HCPs from the diabetes unit at St Georges Healthcare NHS Trust. The programme was designed to involve consultants, diabetes specialist nurses, community diabetes specialist nurses, chiropodists, dieticians, GP's, nurse practitioners, and practice nurses. Strategy This programme was taught for one afternoon a week over 10 weeks. All topics were based on diabetes guidelines and were selected according to results from a needs assessment formed prior the sessions. Each session included lectures and workshops. On week 11, a formative OSCE style end of course assessment (OPERA) was performed. HCPs from different professions were taught in the same classroom using the same material. This provided an opportunity to learn the same material at the same rate with discussions from other professions perspective. Ideally, one GP and one PN from each surgery were encouraged to attend the same cycle. It was hoped that through attending the course together they would be able to use the time to understand each other better. However, in practice this was challenging as GP surgeries are often busy and having two members away for the same afternoon was difficult.

om each surgery were encouraged to attend the same cycle. It was hoped that through attending the course together they would be able to use the time to understand each other better. However, in practice this was challenging as GP surgeries are often busy and having two members away for the same afternoon was difficult. A subcomponent of the programme was the reach-out clinics, where consultants would visit primary care practices to observe consultations with complex patients. Involvement in this component was voluntary and not all practices chose to participate. A set of local referral guidelines was produced to assist in referrals. A project manager was hired and there was collaboration with NHS Wandsworth to facilitate the organisation of the programme. Results Qualitative interviews were performed with key stakeholders two years after the programme to assess the learner's outcome (Table 1). All interviews were performed using semi-structured, face-to-face interviews. A semi-structured format was preferred because it allowed information obtained from the interviews to be relevant to the research objectives and at the same time giving interviewees flexibility to raise issues and generate a wide range of information.

views were performed using semi-structured, face-to-face interviews. A semi-structured format was preferred because it allowed information obtained from the interviews to be relevant to the research objectives and at the same time giving interviewees flexibility to raise issues and generate a wide range of information. The sampling method used was a non-probability, purposive sampling with a goal of maximum variation of categories. This was chosen to ensure contribution from all stakeholders in every area, and was necessary to gain different perspectives. A total of eight primary care HCPs were interviewed. They were from three professions - general practitioners, practice nurses, and nurse practitioners. Interview questions were composed according to pre-identified themes discovered through literature review and issues that were thought-provoking. A framework analysis method using Kirkpatrick & Barr's learner outcome hierarchy was used for analysis of the interview data (3). All interviewees acknowledged that learning with different professions in the same classroom was beneficial to them. The learning made them appreciate each other's skills and roles and develop a sense of respect for each other. It also made them aware who to consult when a problem occurs.

d consistent leadership. The provision of high-quality, affordable, health care is an increasingly difficult challenge, and therefore a robust patient safety process is relevant to all health care professionals; the initiative would ensure that safety and quality were the primary concern for the multidisciplinary team. Staff engagement in the process was paramount, and this was driven by a passion to ensure the woman was at the centre of every decision or safety improvement that was made. Women and their families would be involved in the quality improvement process. The Team wanted to ensure that the multidisciplinary team were engaged and felt confident to report incidents, and would receive the appropriate feedback and support. In addition all staff involved in the incident would be involved in the investigation and be at the heart of the decision making. The management team has a strong clinical focus, and has engaged the correct staff to promote this; the team are passionate about improving the care for the woman and baby. As a Team they felt they wanted to imbed this culture throughout the service, engaging and promoting the importance of quality and safety to the wider team.

Interview questions were composed according to pre-identified themes discovered through literature review and issues that were thought-provoking. A framework analysis method using Kirkpatrick & Barr's learner outcome hierarchy was used for analysis of the interview data (3). All interviewees acknowledged that learning with different professions in the same classroom was beneficial to them. The learning made them appreciate each other's skills and roles and develop a sense of respect for each other. It also made them aware who to consult when a problem occurs. The nature of diabetes as a constantly developing condition requires the need for all HCPs to be updated regularly. From the interviews it was not apparent that there were any differences in knowledge between GPs and PNs that prevented them from learning together. Although GPs tend to regard themselves of higher status, nurses may be more familiar in diabetes management through their practical experience. All interviewees became more confident in diabetes management after the course. This confidence appears to have filtered into patient care. Interviewees felt the programme was effective in improving patient outcomes as they were improving over time. One interviewee mentioned that the impact of the course was sustained since it appears that knowledge and confidence gained during the course was internalised into daily practice and has become a routine part of care. On most occasions, interviewees appear to know what they are doing, and the course was useful in reassuring them that their current practice was correct.

urse was sustained since it appears that knowledge and confidence gained during the course was internalised into daily practice and has become a routine part of care. On most occasions, interviewees appear to know what they are doing, and the course was useful in reassuring them that their current practice was correct. Post-programme new-referral rates decrease to 1171 and follow-up cases increase to 5849 (Figure 1). Referral ratio changes suggest it could be due to primary care's increase ability to deal with uncomplicated diabetes cases which frees the resources in secondary care to deal with complicated cases. This was supported by interviews indicating that majority of referrals were of a more complex nature. Results show that effects of programme were sustained beyond 2 years and these changes were carried into practice. There was a change in HCPs attitude and perception and more importantly it has shown improvement in patient outcomes. See supplementary file: ds1915.docx - “Results” Lessons and limitations This model is associated with improvement of diabetes quality measures. It is also successful in achieving its aim of up-skilling competence of HCPs in primary care and increasing their scope of practice for patients with diabetes. Improved collaboration between primary and secondary care creates synergy and improves utilisation of resources. The course content was relevant and applicable for the new service redesign encompassed within the Health and Social Care Bill.

primary care and increasing their scope of practice for patients with diabetes. Improved collaboration between primary and secondary care creates synergy and improves utilisation of resources. The course content was relevant and applicable for the new service redesign encompassed within the Health and Social Care Bill. A major limitation of this evaluation is that there was no control group for comparison. There may be various confounding factors affecting the reliability and validity of the results and future research will involve designing an evaluation in a controlled environment. Conclusion After this programme, the HCPs in secondary care considered that referrals were more appropriate. With increased knowledge and confidence, primary care is now more aggressive with treatment, keeping diabetic quality measures within the desired range for longer periods. More patients are now seen locally, which will increase their convenience and reduce travelling time. The increase in collaboration between primary and secondary care will lead to more holistic and patient-centred care. This novel IPE programme for diabetes care has been shown to be able to increase confidence, capacity and scope of care provided by HCPs in the community. Supplementary Material Web supplement Oliver Groene Declaration of interests: Nothing to declare

Problem The level of parent satisfaction with the overall service of the paediatric day surgery in Tayside Children's Hospital was unknown. Furthermore, there is a lack of existing validated tools available to measure parent satisfaction with paediatric day surgery. The challenge of addressing this problem was compounded by the fact that several multidisciplinary teams, attached to different surgical specialities, were operating within a small paediatric day case unit on different days of the week. Some of these teams had professionals who specialised only in paediatric surgery whilst others dealt mainly with adults and occasionally operate a paediatric list. Therefore the pre-operative referral system varied significantly between patients. Furthermore, staff from the various pre and post-operative clinics were rarely afforded the opportunity to meet with health professionals working either on the surgical unit or in other clinics. Previous attempts to measure patient/ parent satisfaction were led by health professionals often working either in isolation or only within their own discipline. The questions put forward to the parents were therefore heavily biased by the professional paradigm of the questionnaire's author. However numerous studies show that patient perception of quality of health care differs from that of professionals [3]. As a consequence of auditing parent satisfaction without a deeper understanding of the concept of patient satisfaction, very little was known about levels of parent satisfaction with the overall service of the paediatric day case surgery.

Previous attempts to measure patient/ parent satisfaction were led by health professionals often working either in isolation or only within their own discipline. The questions put forward to the parents were therefore heavily biased by the professional paradigm of the questionnaire's author. However numerous studies show that patient perception of quality of health care differs from that of professionals [3]. As a consequence of auditing parent satisfaction without a deeper understanding of the concept of patient satisfaction, very little was known about levels of parent satisfaction with the overall service of the paediatric day case surgery. Background Patient satisfaction has gained precedence within healthcare [1–3]. Numerous studies show that patient perception of quality of health care differs from that of professionals [3]. Auditing patient satisfaction has therefore become a keystone of quality patient centred healthcare delivery [1–3]. This means improved employee support and training is required, which should also enhance employee satisfaction [1]. However, if validated tools are not utilised, then inaccurate results may stymie service improvement.

ent satisfaction has therefore become a keystone of quality patient centred healthcare delivery [1–3]. This means improved employee support and training is required, which should also enhance employee satisfaction [1]. However, if validated tools are not utilised, then inaccurate results may stymie service improvement. A plethora of patient satisfaction studies exist. However, the majority focus on adult healthcare and few studies had used questionnaires which had been evaluated for their validity, reliability, specificity or psychometric properties [3]. Furthermore questionnaires should be developed or adapted for specific healthcare settings to allow reliable comparisons. Both day case and paediatric settings differ significantly from other inpatient settings and so do the needs and expectations of paediatric patients and their parents. A literature search using Cochrane Library, Medline, PubMed, EMBASE, OvidSP, CINAHL, and googlescholar databases aimed to evaluate instruments thus far devised to measure parent satisfaction with paediatric day surgery. Search terms included: patient satisfaction, parent satisfaction, paediatric patient satisfaction, paediatric surgery, paediatric day surgery and day surgery. This search revealed that there is a lack of studies within the past 10 years exploring parent satisfaction with paediatric health care. Specifically there is a dearth of studies looking at parent satisfaction with paediatric day surgery.

patient satisfaction, paediatric surgery, paediatric day surgery and day surgery. This search revealed that there is a lack of studies within the past 10 years exploring parent satisfaction with paediatric health care. Specifically there is a dearth of studies looking at parent satisfaction with paediatric day surgery. Only one study within the past 10 years by Bittmann & Ulus focused on parent satisfaction with day surgery [4]. This study included 136 parents whose children underwent: urological, plastics and emergency day-case operations performed by two paediatric surgeons using the same anaesthetic team. Although Chronbach's alpha coefficient was used to prove reliability, no further tests of questionnaire validity were undertaken. Furthermore the three model criteria of satisfaction with: surgical staff /general treatment, general information giving and aesthetic staff were decided by the authors alone based on Kaiser Criterion. The questionnaire focused on identifying post-operative symptoms including nausea, vomiting and pain. Therefore potential aspects of satisfaction, deemed important by parents, may not have been measured. Another study focused on parent satisfaction with ENT day surgery but fell out of the 10 year period and was limited by lack of validity, reliability or psychometric testing of the questionnaire [5]. Two studies used questionnaires adapted from previously validated questionnaires but comparability was limited as they focused solely on satisfaction with anaesthetic care and patients with cerebral palsy respectively [1,6].

was limited by lack of validity, reliability or psychometric testing of the questionnaire [5]. Two studies used questionnaires adapted from previously validated questionnaires but comparability was limited as they focused solely on satisfaction with anaesthetic care and patients with cerebral palsy respectively [1,6]. In summary there is a lack of up-to-date quality research exploring parent satisfaction with paediatric day surgery. Baseline measurement The aims of this project were: 1) To produce a parent satisfaction questionnaire which is suitable for use in paediatric day case units. The questionnaire must undergo satisfactory testing for validity, reliability, specificity and psychometric properties. 2) Produce a questionnaire which allows underlying dimensions of parent satisfaction to be derived and individual scores calculated. 3) To illicit aspects of health care delivery within the paediatric day surgery service that could be improved. Design A Likert-style questionnaire was constructed around the existing structure of the paediatric day surgery service to quantify the dimensions of parent satisfaction. Section A collected demographic information. Section B assessed satisfaction with pre-operative clinic services. Section C assessed service provision on the surgical ward and Section D assessed satisfaction with discharge procedures.

the paediatric day surgery service to quantify the dimensions of parent satisfaction. Section A collected demographic information. Section B assessed satisfaction with pre-operative clinic services. Section C assessed service provision on the surgical ward and Section D assessed satisfaction with discharge procedures. The questionnaire was constructed in a stepwise process to maximise validity and reliability [2,3,7]. Opinions regarding positive and negative aspects of the service were gathered from: surgeons, anaesthetists, charge nurses, staff nurses, theatre nurses, representatives from parental patient groups, health care assistants, play therapists, doctors, medical and nursing students. The opinions were gathered through face-to-face interviews, emails, and anonymous suggestion boxes placed on the ward and in clinics. This, in addition to a literature review, created a pool of items for inclusion in the questionnaire.

ups, health care assistants, play therapists, doctors, medical and nursing students. The opinions were gathered through face-to-face interviews, emails, and anonymous suggestion boxes placed on the ward and in clinics. This, in addition to a literature review, created a pool of items for inclusion in the questionnaire. A pilot study was conducted and responses tested for validity and reliability. Literature review and focus group meetings established content validity [2,8]. Face validity, a subjective assessment by the author of whether the questionnaire measures outcomes of parent satisfaction with paediatric day surgery, was therefore also accepted [2,8]. Construct validity was established by demonstrating that parents who strongly agreed or agreed with positive statements disagreed of strongly disagreed with negative statements about the same aspect of their child's care and vice versa [2,8]. Criterion validity is the correlation of a measure with an accepted gold-standard criterion measure [2,8]. The latter does not yet exist for parent satisfaction with paediatric day surgery and therefore could not be established. Statements worded in positive phrasing were re-worded in negative phrasing to ensure intra-rater reliability. Inter rater agreement was also demonstrared. Internal reliability was established with Chronbach's alpha scores between 0.7 and 0.9 for each section of the questionnaire.

and therefore could not be established. Statements worded in positive phrasing were re-worded in negative phrasing to ensure intra-rater reliability. Inter rater agreement was also demonstrared. Internal reliability was established with Chronbach's alpha scores between 0.7 and 0.9 for each section of the questionnaire. Parents/guardians of children receiving elective day surgery were invited by nursing staff to complete the anonymous questionnaire at the time of discharge, after the discharge information had been given. Questionnaires were administered over an 8 month period. Results were disseminated through departmental and national meetings and international conference. Strategy PDSA Cycle 1 Senior medical and nursing staff were approached to discuss what was already known about levels of parent satisfaction with the paediatric day surgery service and to analyse previous attempts at measuring parent satisfaction. As predicted, little was known about levels of parent satisfaction with the overall service as previous attempts at measuring satisfaction were sporadic and tended to focus on either clinic or ward settings and lacked a multidisciplinary approach and input from parents. As a result, it was agreed to look at the service as a whole from pre-operative clinics to discharge and measure levels of parent satisfaction. PDSA Cycle 2

Senior medical and nursing staff were approached to discuss what was already known about levels of parent satisfaction with the paediatric day surgery service and to analyse previous attempts at measuring parent satisfaction. As predicted, little was known about levels of parent satisfaction with the overall service as previous attempts at measuring satisfaction were sporadic and tended to focus on either clinic or ward settings and lacked a multidisciplinary approach and input from parents. As a result, it was agreed to look at the service as a whole from pre-operative clinics to discharge and measure levels of parent satisfaction. PDSA Cycle 2 A literature review was conducted to analyse existing instruments to evaluate parent/guardian satisfaction. This showed that there was a lack of existing tools with proven validity and reliability that were suitable for use when measuring parent satisfaction with paediatric day surgery. This provided a useful guide for constructing a questionnaire with proven validity and reliability. After consultation with senior nursing and medical staff it was decided to create our own parent satisfaction questionnaire. PDSA Cycle 3 Focus groups were set up with all multidisciplinary professionals as well as parent patient groups to discuss positive and negative aspects of the service and to establish dimensions of satisfaction. As predicted, views on what constituted parent satisfaction differed slightly between parents and professionals. Responses were compiled into a pool of items for inclusion in the questionnaire. PDSA Cycle 4

Focus groups were set up with all multidisciplinary professionals as well as parent patient groups to discuss positive and negative aspects of the service and to establish dimensions of satisfaction. As predicted, views on what constituted parent satisfaction differed slightly between parents and professionals. Responses were compiled into a pool of items for inclusion in the questionnaire. PDSA Cycle 4 The appropriateness and comprehensiveness of the pool of items for inclusion in the questionnaire was discussed and agreed with all those consulted in PDSA Cycle 3. Some professionals initially wanted to exclude items they deemed as being less important with regards to how responses would help them to improve their own practice. These items were however included owing to their perceived importance to parents and other members of the multidisciplinary team. A draft version of the questionnaire was therefore constructed by refining the pool of items into a questionnaire with a Likert-style scale giving responses ranging from strongly agree to strongly disagree. PDSA Cycle 5

The appropriateness and comprehensiveness of the pool of items for inclusion in the questionnaire was discussed and agreed with all those consulted in PDSA Cycle 3. Some professionals initially wanted to exclude items they deemed as being less important with regards to how responses would help them to improve their own practice. These items were however included owing to their perceived importance to parents and other members of the multidisciplinary team. A draft version of the questionnaire was therefore constructed by refining the pool of items into a questionnaire with a Likert-style scale giving responses ranging from strongly agree to strongly disagree. PDSA Cycle 5 The questionnaire was refined further following discussions and qualitative feedback from those consulted in PDSA Cycle 3. Balancing comprehensiveness of the questionnaire whilst keeping it to an appropriate length was a challenge. The inclusion of a free text box for additional comments was agreed. Some professionals suggested not rewording questions in a positive phrasing also in a negative phrasing to reduce the length of the questionnaire. However as this would ensure intra-rater reliability it was agreed that this should stay in unless the pilot study provided evidence that the questionnaire was too long in which case a further review was planned [2,8]. PDSA Cycle 6

The questionnaire was refined further following discussions and qualitative feedback from those consulted in PDSA Cycle 3. Balancing comprehensiveness of the questionnaire whilst keeping it to an appropriate length was a challenge. The inclusion of a free text box for additional comments was agreed. Some professionals suggested not rewording questions in a positive phrasing also in a negative phrasing to reduce the length of the questionnaire. However as this would ensure intra-rater reliability it was agreed that this should stay in unless the pilot study provided evidence that the questionnaire was too long in which case a further review was planned [2,8]. PDSA Cycle 6 A pilot study was conducted including a free text box inviting parents to give qualitative feedback on the questionnaire. 28 out of 50 questionnaires were completed and returned for the pilot study. All questionnaires were completed in full and participants either did not comment or commented positively on the questionnaire. Results were analysed and validity and reliability of the questionnaire was proven. PDSA Cycle 7 A final version of questionnaire was produced and administered by nursing staff to parents of children undergoing elective paediatric day surgery in Tayside Children's Hospital after all discharge information and paperwork had been completed. The project ran over an 8 month period. Results Of the 150 questionnaires made available 94 were returned. 8 were excluded as they were incomplete with only minimal demographic information given.

A final version of questionnaire was produced and administered by nursing staff to parents of children undergoing elective paediatric day surgery in Tayside Children's Hospital after all discharge information and paperwork had been completed. The project ran over an 8 month period. Results Of the 150 questionnaires made available 94 were returned. 8 were excluded as they were incomplete with only minimal demographic information given. Overall parent satisfaction was high. 95.48% either strongly agreed or agreed with positively worded statements regarding pre-operative clinic service. 96.60% strongly agreed or agreed with positive statements regarding service provided on the ward and 87.50% strongly agreed or agreed with positive statements regarding the discharge process. In particular, 100% of those who received a phone call prior to admission either strongly agreed or agreed with positive statements regarding this aspect of the service. This phone call included further information giving about fasting, admission procedure and gave parents the opportunity to ask any further questions. Its popularity with parents had not previously been realised and only 70% of parents completing the questionnaires received this service. An audit is consequently underway to improve delivery of this service to all parents whose children are undergoing elective day surgery.

the opportunity to ask any further questions. Its popularity with parents had not previously been realised and only 70% of parents completing the questionnaires received this service. An audit is consequently underway to improve delivery of this service to all parents whose children are undergoing elective day surgery. A small number (5%) requested more information be given pre and post-operatively. However 14% did not record either consultant or type of operation despite completing the rest of the questionnaire correctly. A significant number only gave the vague anatomical location operated on. This would infer a need for improved information giving and mandate a further study exploring satisfaction with sources and mechanisms of information giving. Lessons and limitations Although there are few studies to compare these results to, it is interesting to note that the questionnaire centred on similar domains (communication/information giving, environment and patient care) to those devised through similar processes for different paediatric hospital settings [1,3,4,6–9]. Also, by consulting the entire multidisciplinary team as well as parents, some items included in this questionnaire were not included in previous parent satisfaction questionnaires designed by professionals alone. The popularity of the pre-operative phone call service had therefore been overlooked.

ettings [1,3,4,6–9]. Also, by consulting the entire multidisciplinary team as well as parents, some items included in this questionnaire were not included in previous parent satisfaction questionnaires designed by professionals alone. The popularity of the pre-operative phone call service had therefore been overlooked. This project was limited by small sample size. It is hoped that by running this questionnaire at multiple paediatric day surgery units across Scotland we can increase sample size and learn from positive and negative aspects of service across different settings. By repeating the questionnaire at a fixed time post discharge, test-retest reliability of the questionnaire could be established and would remove potential bias since staff knew the study was in progress and parents may have felt obliged to respond positively because they were still on the ward when completing the questionnaire. Using this project as a basis, further research is mandated in areas of sources/ methods of information giving and challenges of including illiterate and non-English speaking parents in future studies. Conclusion The parent satisfaction questionnaire was found to have proven validity, reliability, specificity and psychometric properties. This enabled accurate measurement of parent satisfaction.

This project was limited by small sample size. It is hoped that by running this questionnaire at multiple paediatric day surgery units across Scotland we can increase sample size and learn from positive and negative aspects of service across different settings. By repeating the questionnaire at a fixed time post discharge, test-retest reliability of the questionnaire could be established and would remove potential bias since staff knew the study was in progress and parents may have felt obliged to respond positively because they were still on the ward when completing the questionnaire. Using this project as a basis, further research is mandated in areas of sources/ methods of information giving and challenges of including illiterate and non-English speaking parents in future studies. Conclusion The parent satisfaction questionnaire was found to have proven validity, reliability, specificity and psychometric properties. This enabled accurate measurement of parent satisfaction. Overall levels of parent satisfaction with the paediatric day surgery in Tayside Children's Hospital are high. Patient care, however, has still managed to improve. This project highlighted that 100% of participants who received a phone call prior to admission either strongly agreed or agreed with positive statements regarding this aspect of the service, yet only 70% were receiving such a phone call. A further audit is therefore underway to improve delivery of this service. A small number requested more information be given pre and post-operatively.

e call prior to admission either strongly agreed or agreed with positive statements regarding this aspect of the service, yet only 70% were receiving such a phone call. A further audit is therefore underway to improve delivery of this service. A small number requested more information be given pre and post-operatively. However 14% did not record either consultant or type of operation despite completing the rest of the questionnaire correctly. A significant number only gave the vague anatomical location of their child's operation. Further research, using this tool as a basis, is mandated in areas of sources and methods of information giving and challenges of including illiterate and non-English speaking parents in future studies. Amanda McCabe, Rodney Grant, Suzanne Byres, all the staff working in Tayside Children's Hospital paediatric surgical unit. Declaration of interests: Nothing to declare.

Problem Our specialist team provides tertiary care services at an academic health centre for a large geographical region. Access times for consultation at a multi-disciplinary clinic for neurological patients were very long, which was a concern for both family physicians and our neurology team. Because of our long wait list, it was necessary to triage referrals by perceived urgency and secretarial staff often had to ‘squeeze’ urgent patients into full schedules, causing clinics to run over-time. Background Access times are an issue in most publicly funded health systems. In Canada, wait time targets have been defined for a number of referral reasons. However in 2012, after several years of ‘slight progress’ wait times in many provinces increased (1). Wait times for the ambulatory care clinic at our nearest comparable hospital were 8 days for urgent patients, 39 days for semi-urgent and 115 days for non-urgent patients (2). Anecdotal reports from another Canadian province indicate wait times for neurologist consultation of between six months and a year (3). This suggests that long wait times to access neurological consultation is a problem in other Canadian jurisdictions. Rapid process improvement workshops have been used in industries outside of healthcare for many years to identify problems and plan improvements. Recently, hospitals have adapted tools such as Lean and utilised process improvement workshops with impressive results, demonstrating that these techniques also have applicability in healthcare (4,5).