P36 Numeta G13% preterm neonatal parenteral nutrition solution – a licensed all-in-one triple chamber, ready to use and terminally sterilised parenteral nutrition for preterm newborn infants

AimsWe aim to evaluate the efficacy and safety of Numeta G13%E preterm neonatal parenteral nutrition (PN) in our neonatal population.In September 2017 a National Patient Safety Alert (NPSA) highlighted the risk of harm to babies when lipid was mistakenly run at the rate intended for the aqueous component resulting in significant lipid overdose.Although we have worked to implement many of the alert’s recommendations, we feel we can avoid this risk further by using an all-in-one PN solution.1Numeta meets current nutritional guidelines as per British Association of Perinatal Medicine (BAPM) but this project allows comparison of outcomes important to both patient and service between those achieved with our current regimen and those with the all-in-one regimen.2MethodsWe carried out a quality improvement project from April 2018 to April 2019. We collected data from 330 babies in our neonatal unit during six months before (154 babies) and after (176 babies) the adoption of the all-in-one solution.Our previous PN regimen consisted of a ‘menu’ of aqueous bags (starter, maintenance, ‘light’ and bespoke) and a separate lipid solution. All of them were suitable for peripheral or central administration. Numeta came with similar choices: starter, maintenance -for central administration only- and ‘lite’ and Numeta peripheral, suitable for peripheral administration. Bespoke bags were also available if clinically indicated. We set out our desired outcomes and measured parameters accordingly:Patient outcomesMetabolic stability: electrolyte, glucose, bilirubin and lipid measurements summarised by the need to change from standard PN regimen and/or requirement for insulin.Fluid balance summarised by the lowest weight during the first two weeks of life and time taken to regain birth weight.Growth summarised by change of standard deviation score of weight and head circumference between birth and discharge or transfer back to local hospital.Liver tolerance of lipid solutions summarised by incidence of cholestasis (>25 μmol/l conjugated fraction of serum bilirubin)Days and type of PNSepsisService outcomesNursing time taken to prepare PNCostWastageAccess to productResultsAlthough we finished collecting the data in April 2019, we are still in the process of analysing it and evaluating the final results. There have been no cases of lipid overdose and our neonates (including the preterm ones) have so far tolerated well the new parenteral nutrition solution. Average nursing time preparing Numeta went down from 18.5 minutes to 8 minutes and comparison of cost came in favour of Numeta. PN wastage was higher with Numeta (4.7% Maintenance, 10% ‘light’, peripheral 50%) especially in the first month during the transition phase. There was no significant increase of bespoke bags when Numeta was introduced.ConclusionsIn summary, so far we have not identified significant clinical differences between the first six months of the project -using our old standardised nutrition regimen- and the last months -on the new all-in-one solution. We have continued with Numeta preterm solution on the basis of assumed safety.ReferencesRisk of severe harm and death from infusing total parenteral nutrition too rapidly in babies. NHS improvement patient safety alert September 2017.The Provision of Parenteral Nutrition within Neonatal Services – A Framework for Practice. British Association of Perinatal Medicine (BAPM) April 2016 www.bapm.org

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P013 Developing standardised neonatal parenteral nutrition across a network

Archives of Disease in Childhood ◽

10.1136/archdischild-2019-nppc.23 ◽

2019 ◽

Vol 104 (7) ◽

pp. e2.16-e2

Author(s):

Louise Whitticase ◽

Gemma Holder ◽

Gillian Preston ◽

Sara Clarke

Keyword(s):

Patient Outcome ◽

Parenteral Nutrition ◽

European Society ◽

Capacity Planning ◽

Extremely Low Birth Weight ◽

British Association ◽

List Type ◽

Confidential Enquiry ◽

Neurodevelopmental Outcomes ◽

Perinatal Medicine

Background and aimParenteral Nutrition (PN) forms the mainstay of nutritional support for extremely low birth weight (ELBW) infants immediately after birth to promote optimal growth and neurodevelopmental outcomes. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) published in 2010 indicated that only 24% of neonates received parenteral nutrition that was considered good practice1. NCEPOD, alongside the Paediatric Chief Pharmacists Group Report, highlighted issues with prescribing and administration of PN linked to unnecessary variation in practice between hospitals.1 2 This encourages use of standardised PN with associated guidelines for use and administration. The aim was to be able to provide nutritionally complete PN for preterm and sick term babies in a ready to use formulation, 24 hours a day, 7 days a week without access to an onsite aseptic service and for the nutrition a baby receives to be consistent across the network regardless of which hospital they are in.MethodsThere is a robust network neonatal nutrition group, comprising neonatologists, pharmacists, dietitians and nutrition nurses. The remit of the group was initially to audit their current practice and agree the new standardized formulations and develop guidelines for use. These were based on European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and British Association of Perinatal Medicine (BAPM) guidelines and expert opinion.3 4 Advice on stability and compounding was sought from commercial experts. Assistance to award a contract to supply the network was sought from a group purchasing organisation to ensure capacity planning and cost effectiveness.ResultsConsensus on four concentrated formulations was agreed by the network group and all six units within the network are now successfully using these.ConclusionThis has been a lengthy process but it was possible to establish agreement of a structured set of standard bags that would deliver nutritionally complete PN to the cohort of babies in our network. Re-audit is now underway in house to compare to previous practice and we hope to shortly roll this audit out across the network. Future aspirations are to devise a system to manage stock control across the entire network, work towards reaching national consensus, work with commercial partners to obtain extended expiry with peditrace addition and to work in partnership with commercial companies to formulate licensed products.ReferencesStewart J, Mason G, Smith N, et al. A mixed bag; an enquiry into the care of hospital patients receiving parenteral nutrition. National Confidential Enquiry into Patient Outcome and Death, 2010.Paediatric Chief Pharmacists Group. Improving practice and reducing risk in the provision of parenteral nutrition for neonates and children, 2011.Koletzko B, Goulet O, Hunt J, et al. Guidelines on Paediatric Parenteral Nutrition of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the European Society for Clinical Nutrition and Metabolism (ESPEN), Supported by the European Society of Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr 2005;41(Suppl 2):S1–87.British Association of Perinatal Medicine (BAPM). The Provision of Parenteral Nutrition within Neonatal Services - A Framework for Practice, 2016.

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A quality improvement project focused on assessment of risk level of outpatient psychiatry patients

European Psychiatry ◽

10.1016/j.eurpsy.2017.01.1833 ◽

2017 ◽

Vol 41 (S1) ◽

pp. s898-s898

Author(s):

T. Tuvia ◽

M. Kats ◽

C. Aloezos ◽

M. To ◽

A. Ozdoba ◽

...

Keyword(s):

Patient Safety ◽

Quality Improvement ◽

Residency Training ◽

Psychiatry Residency ◽

Care Quality ◽

Quality Improvement Project ◽

Risk Level ◽

List Type ◽

Psychiatry Residency Training ◽

Improvement Project

Since the implementation of the Clinical Learning Environment Review by the Accreditation Council for Graduate Medical Education, there has been an emphasis on training residents in health care quality as well as patient safety. As such, psychiatry residency training programs have had to incorporate quality improvement (QI) projects into their training. We developed a QI curriculum, which not only included resident and faculty participation, but also encouraged other staff in our department to focus on patient safety as well as improving their performance and the quality of care provided to the patients.In this poster, we present the development of our curriculum and will include a successful QI project to highlight this. This project focused on creating an algorithm to help assign patient risk level, which is based on evidence based risk factors. This project was created due to a survey conducted in our clinic which demonstrated that clinicians, and in residency training in particular, identifying and managing high risk patients can be anxiety provoking for trainees. We will present the specifics of this QI project, and additionally outline the steps that were taken to develop and integrate the QI project into clinical practice.Objectives(1) Learn how to successfully incorporate a QI project and curriculum into a psychiatry residency training program.(2) Understand both resident and faculty perspectives on what resources facilitated participation in QI.(3) Present the development of a quality improvement project focused on risk assessment of outpatient psychiatric patients.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Abstract P857: Rapid Cycle Process Improvement During a Pandemic: Changing How Patients at Low Risk for Complications Are Monitored Post Intravenous Thrombolysis

Stroke ◽

10.1161/str.52.suppl_1.p857 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Michelle Whaley ◽

Rebecca van Vliet ◽

Leah Farrell ◽

David Welcom

Keyword(s):

Patient Safety ◽

Critically Ill ◽

Process Improvement ◽

Nursing Staff ◽

Intravenous Thrombolysis ◽

Low Risk ◽

Nursing Time ◽

Improvement Project ◽

Practice Nurses ◽

Low Intensity

Background: During the initial emergence of the 2019 novel coronavirus (COVID-19) and the subsequent surge of patients requiring critical care, our Joint Commission certified thrombectomy-capable stroke center sought to utilize a low-intensity monitoring protocol in stable, post intravenous (IV) thrombolysis patients in our intensive care unit (ICU). The acuity level in our ICU jumped to an all-time high, with many critically ill COVID-19 patients. Our goal was simple, provide safe patient care, free up precious nursing time, and preserve the personal protective equipment supply. Purpose: The purpose of this study was to use a rapid cycle process improvement project to implement a low-intensity monitoring (LIM) protocol in stable, suspected stroke patients, who are deemed at low risk for complications, in the first twenty-four hours following IV thrombolysis. Methods: We utilized the Plan-Do-Study-Act (PDSA) model to implement this project. Collaboration between physician, nursing, and stroke program leaders occurred during the month of April 2020. Our new process utilized the O ptimal P ost T -pa I v M onitoring in I schemic ST roke (OPTIMIST) protocol. We continued to admit our post IV alteplase patients to the ICU, rather than a step-down unit, in order to accommodate the 3:1 patient to nurse ratio, ensure protocol adherence, and maximize patient safety with this high-risk medication. We used change of shift huddles to educate the ICU nursing staff over a two-week period. Stroke program advanced practice nurses were on-site to ensure compliance. Results: Since implementation of the new protocol, two IV alteplase patients have met protocol criteria; both remained stable throughout the twenty-four-hour LIM period. The protocol’s nursing ratio changes allowed the other, critically ill patients, to be staffed with traditional ICU ratios. Conclusion: Rapid cycle PI projects can be accomplished during times of extreme challenge, as evidenced during the COVID-19 pandemic. Nursing staff was able to adapt and even welcomed the change, while maintaining patient safety. Further study is needed to document the ongoing effect of this protocol.

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P17 Introducing concentrated preterm stock parenteral nutrition and the impact on bespoke compounding

Archives of Disease in Childhood ◽

10.1136/archdischild-2020-nppg.26 ◽

2020 ◽

Vol 105 (9) ◽

pp. e14.2-e15

Author(s):

Suzannah Hibberd ◽

Amy Hill

Keyword(s):

Parenteral Nutrition ◽

Neonatal Unit ◽

List Type ◽

High Demand ◽

Perinatal Medicine ◽

Group A ◽

Preterm Babies ◽

Collection Period ◽

Group B ◽

The Impact

BackgroundIt is widely recommended that stock parenteral nutrition (PN) bags are used where possible to reduce the risks associated with bespoke PN compounding.1 A review was undertaken within a level three neonatal unit which identified that a large proportion of compounded bags were made due to the need to provide full nutrition in a smaller volume. A preterm concentrated aqueous PN bag was developed which, when run with stock lipid syringes, meets the nutritional requirements of preterm babies in a total volume of 100 ml/kg/day.2AimThe aim of this work is to evaluate the impact of the introduction of a preterm concentrated stock bag on the need for bespoke PN in preterm babies.MethodThe new concentrated PN bag was transitioned into use from November 2017. Data regarding the number of preterm patients admitted and the type of PN they received was collected from January to October 2017, (Group A), this was then repeated for all preterm patients admitted from August 2018 to May 19, (Group B), after the preterm concentrated bag was fully introduced. Preterm babies were classified as babies that were born < 34 weeks gestation as the concentrated bag was formulated with these patients in mind.ResultsGroup A, (n=143), had 1045 bags supplied over the collection period. 47% of the PN bags supplied were bespoke PN bags, largely due to the need to provide PN in a smaller volume than the 130 ml/kg/day that the preterm stock bags available at that time. Group B, (n=118), had a total of 965 bags supplied, 16% of these bags were bespoke PN. The reasons behind requiring bespoke bags included the need for manganese free bags, requiring a reduction in glucose and a high electrolyte requirement in patients especially those with stomas. This has resulted in an overall reduction in spend on preterm PN of 34% and a reduction in compounded PN spend of 69%.ConclusionThis work has highlighted several benefits of introducing preterm concentrated PN bags. Firstly having concentrated preterm stock bags available on the ward has meant that a larger proportion of babies are maintained on stock PN without recourse to compounded PN. Secondly this has preserved the compounding capacity of our technical services unit so when a patient requires a bespoke bag that facility is available. Also, capacity for the compounding service has been preserved across the hospital minimising the need to outsource compounding. Finally the neonatal unit has seen a reduction in overall PN costs in this patient group. The introduction of this bag has been instrumental in reducing the need to outsource PN bags to commercial compounding units during periods of high demand, meeting national recommendations on the management of aseptic compounding capacity.3ReferencesA Report from the Paediatric Chief Pharmacists Group: Improving Practice and Reducing Risk in the Provision of Parenteral Nutrition for Neonates and Children. November 2011.British Association of Perinatal Medicine. The Provision of Parenteral Nutrition within Neonatal Services - A Framework for Practice. April 2016.Specialist Pharmacy Service/NHS England. National Pharmaceutical Supply Group (NPSG) Communication: Making best use of restricted aseptic compounding capacity. September 2018.

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P43 Concentrated standardised PN to optimise nutrition in preterm infants

Archives of Disease in Childhood ◽

10.1136/archdischild-2020-nppg.52 ◽

2020 ◽

Vol 105 (9) ◽

pp. e29.1-e29

Author(s):

Zoe Price

Keyword(s):

Parenteral Nutrition ◽

Preterm Infants ◽

Growth Parameters ◽

Average Energy ◽

List Type ◽

Perinatal Medicine ◽

Nitrogen Intake ◽

Hospital Patients ◽

Nitrogen Ratio ◽

Full Benefit

BackgroundIn 2010, the NCEPOD1 report demonstrated a lack of good nutritional care for preterm infants. Since that time various approaches have evolved including standardisation of PN,2 concentrated standardised PN3 and publication of a national framework from BAPM.4 The delivery of nutrition to preterm infants on our unit has been continuously monitored, evaluated and adapted.AimsThe aim of this audit was to evaluate whether reformulating our PN recipes would improve nutritional intake and thus growth parameters over the first 14 days after birth.MethodsData was collected from our EPMA system and analysed retrospectively from all infants born at our unit <28 weeks gestation or <1Kg from 16/4/2016 to 15/4/2017 (audit 1) and from 1/6/2018 to 31/5/2019 (audit 2).ResultsData from a total of 33 patients was analysed using Excel™. The mean gestation and weight were similar for both audit cycles. Audit 1: gestation 26.5 weeks, weight 0.75 kg; audit 2: gestation 26.7 weeks, weight 0.74 kg. The average time from birth to PN was less in audit 2 (12 hrs 8 mins vs 13 hrs 12 mins), however the time from PN being prescribed to being administered took over 3 times longer (5 hrs 1 min vs 1 hr 30 mins). No patient received PN within 6 hours of birth in audit 2 compared to 20% in audit 1. The average nitrogen intake was higher in audit 2 than audit 1 (0.41 g/kg/day vs 0.36 g/kg/day) and the highest protein intake increased from 0.55 g/kg/day to 0.69 g/kg/day respectively; the average energy intake decreased from 73.5 kcal/kg/day in audit 1 to 68 kcal/kg/day in audit 2. The non-nitrogen energy to nitrogen ratio was lower in audit 2 versus audit 1 (165.3 kcal/g nitrogen vs 204.7 kcal/g nitrogen). There was no change in the percentage of patients requiring insulin: 40%. More patients had started receiving lipid infusion in the first 2 days after birth in audit 2 compared to audit 1 (94% compared to 33%). Both audits had 2 patients that had still not reached their birth weight by day 14, however the patients in audit 2 gained on average 9.12 g/kg/day compared to 4.96 g/kg/day in audit 1.ConclusionReformulating the PN resulted in higher nitrogen intakes and higher weight gain by day 14, although the full benefit may not have been achieved due to the lower kcal intake and non-nitrogen energy to nitrogen ratio. The time from birth to PN and the time taken to administer PN once prescribed were longer so work needs to be done on addressing these issues and reducing barriers to nutrition. The total nitrogen intake with PN and EN also needs to be reviewed to prevent excessive nitrogen intake which may result if enteral feeds increase and the rate of PN is maintained.ReferencesStewart JAD, Mason DG, Smith N, Protopapa K, Mason N, on behalf of CEPOD. 2010. A mixed bag; an enquiry into the care of hospital patients receiving parenteral. https://www.ncepod.org.uk/2010report1/downloads/PN_report.pdf Accessed 03/07/2019Paediatric Chief Pharmacists Group. Improving Practice and Reducing Risk in the Provision of Parenteral Nutrition for Neonates and Children. 2011Morgan C, Radbone L, Birch J. 2016 The Neonatal Parenteral Nutrition (PN) QIPP Toolkit https://www.networks.nhs.uk/nhs-networks/staffordshire-shropshire-and-black-country-newborn/documents/documents/national-toolkit-for-standardising-pn Accessed 03/07/2019British Association of Perinatal Medicine. The Provision of Parenteral Nutrition within Neonatal Services – A Framework for Practice. 2016. https://www.bapm.org/sites/default/files/files/Parenteral%20Nutrition%20April%202016.pdf Accessed 03/07/2019

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P044 Can an electronic prescribing system ensure clear anticoagulation discharge communication?

Archives of Disease in Childhood ◽

10.1136/archdischild-2019-nppc.53 ◽

2019 ◽

Vol 104 (7) ◽

pp. e2.49-e2

Author(s):

Susie Gage

Keyword(s):

Patient Safety ◽

Discharge Summary ◽

Electronic Prescribing ◽

List Type ◽

Heparin Infusion ◽

National Patient Safety Agency ◽

High Dependency ◽

National Patient ◽

Discharge Summaries

AimThe National Patient Safety Agency (NPSA)1 identified heparin as a major cause of adverse events associated with adverse incidents, including some fatalities. By ensuring good communication, this should be associated with risk reduction.1 The aim of this study was to ensure there is clear anticoagulation communication on discharge, from the paediatric intensive care unit (PICU) electronic prescribing system (Philips), to the paediatric cardiac high dependency unit and paediatric cardiac ward. To investigate whether the heparin regimen complies with the hospital’s anticoagulant guidelines and if there is any deviation; that this is clearly documented. To find out if there is an indication documented for the heparin regimen chosen and if there is a clear long term plan documented for the patient, after heparin cessation.MethodsA report was generated for all patients who were prescribed a heparin infusion on PICU, between 1st January 2018 and 30th June 2018, from the Philips system. All discharge summaries from the PICU Philips system were reviewed. Only paediatric cardiac patients were included that had a heparin infusion prescribed on discharge, all other discharge summaries were excluded from the study. Each discharge summary was reviewed in the anticoagulant section; for the heparin regimen chosen, whether it complies with the hospital’s anticoagulant guidelines and if there was any deviation whether this was documented. The indication documented of which heparin regimen was chosen and whether a clear long term plan was documented after heparin cessation; for example if the patient is to be transferred onto aspirin, clopidogrel, warfarin or enoxaparin.Results82 discharge summaries were reviewed over the 6 month period between 1st January 2018 and 30th June 2018; 16 were excluded as were not paediatric cardiac, leaving 66 paediatric cardiac discharge summaries that were reviewed. 45 out of 66 (68%) complied with the hospital’s heparin anticoagulation guidelines. Of the 32% that deviated from the protocol; only 33% (7 out of 21) had a reason documented. Only 50% (33) of the summaries reviewed had an indication for anticoagulation noted on the discharge summary and 91% of discharge summaries had a long term anticoagulant plan documented.ConclusionThe electronic prescribing system can help to ensure a clear anticoagulation communication as shown by 91% of the anticoagulation long term plan being clearly documented; making it a more seamless patient transfer. On the Philips PICU electronic prescribing system there is an anticoagulant section on the discharge summary that has 3 boxes that need to be completed; heparin regimen, indication and anticoagulation long term plan. However, despite these boxes; deviations from the anticoagulant protocol were poorly documented as highlighted by only 33% having the reason highlighted in the discharge summary, only 50% of the indications were documented. Despite having prompts for this information on the discharge summary, the medical staffs needs to be aware to complete this information, in order to reduce potential medication errors and risk.ReferenceThe National Patient Safety Agency (NPSA). Actions that make anticoagulant therapy safer. NPSA; March 2007.

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OR and ICU teams ‘running in parallel’ at the end of cardiothoracic surgery improves perceptions of handoff safety

BMJ Open Quality ◽

10.1136/bmjoq-2020-001001 ◽

2021 ◽

Vol 10 (1) ◽

pp. e001001

Author(s):

Safraz Hamid ◽

Frederic Joyce ◽

Aaliya Burza ◽

Billy Yang ◽

Alexander Le ◽

...

Keyword(s):

Patient Safety ◽

Cardiac Surgery ◽

Safety Culture ◽

Positive Response ◽

Improve Patient Safety ◽

Health Care Research ◽

Response Rates ◽

Patient Safety Culture ◽

Improvement Project ◽

Surgery Patient

The transfer of a cardiac surgery patient from the operating room (OR) to the intensive care unit (ICU) is both a challenging process and a critical period for outcomes. Information transferred between these two teams—known as the ‘handoff’—has been a focus of efforts to improve patient safety. At our institution, staff have poor perceptions of handoff safety, as measured by low positive response rates to questions found in the Agency for Health Care Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS). In this quality improvement project, we developed a novel handoff protocol after cardiac surgery where we invited the ICU nurse and intensivist into the OR to receive a face-to-face handoff from the circulating nurse, observe the final 30 min of the case, and participate in the end-of-case debrief discussions. Our aim was to increase the positive response rates to handoff safety questions to meet or surpass the reported AHRQ national averages. We used plan, do, study, act cycles over the course of 123 surgical cases to test how our handoff protocol was leading to changes in perceptions of safety. After a 10-month period, we achieved our aim for four out of the five HSOPS questions assessing safety of handoff. Our results suggest that having an ICU team ‘run in parallel’ with the cardiac surgical team positively impacts safety culture.

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