Quality improvement project: improving the confidence of junior doctors to manage emergencies; Drs abc in an acute psychiatric setting

AimsTo improve the confidence and preparedness of junior doctors in managing medical or psychiatric emergencies when on call at an inpatient psychiatric unit.BackgroundFacilities for emergency care differ between acute medical and psychiatric units. Protocols for managing acutely deteriorating patients and those requiring immediate resuscitation differ across these organisations.Managing medical emergencies can be stressful for all involved. Junior doctors rotate between services where the level of support varies depending on specialty and setting. For doctors who have worked in a setting where the minimum emergency response includes a Resuscitation team, moving to an environment with less support available is a challenge.In our unit, the protocol following an urgent call is for the on-call doctor (who has access to basic resuscitation equipment) to attend and assess the need for paramedics and transfer to local hospital. Stress can be worsened by change of environment, change of expectation and concern about best management in new settings.MethodA cohort of junior doctors were recruited. Baseline assessment included rating their confidence level (scale 1- 10), listing common medical and psychiatric scenarios they had experienced and those they felt least confident managing. Over a period of 10 weeks, follow-up data was obtained. Interventions to improve confidence were assessed during this period, including a handbook and a teaching session on emergency medications. At the end of the project a wordcloud was created in response to the request to “choose 5 words to describe your feelings when called to an emergency”. Identified themes have been fed back to relevant senior staff and will form the basis of future projects.ResultThe initial average confidence score improved from 4.9 to 9.2 and was sustained out to 14 weeks. According the word cloud the most commonly used words were “morale” and “education”.ConclusionPrior to the study, confidence levels amongst the Junior Doctors was low. Introduction of the handbook and teaching session led to an improvement which was sustained. Key themes identified using a word cloud were “morale” and “education”.For junior doctors moving from between services, different expectations and protocol for management of emergencies can influence confidence levels. Psychiatric units should be cognisant of these concerns and implement evidence-based intervention to support junior doctor confidence and improve quality of working experience.

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P67 Integrated surgical teaching for juniors: surgical education during COVID-19

BJS Open ◽

10.1093/bjsopen/zrab032.066 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

Author(s):

Rituja Kamble ◽

Yarrow Scantling-Birch ◽

Gargi Samarth ◽

Emma Larsson ◽

Charlotte Maden ◽

...

Keyword(s):

Surgical Education ◽

Surgical Patients ◽

Junior Doctors ◽

Learning Needs ◽

Learning Tools ◽

Improvement Project ◽

Baseline Questionnaire ◽

Confidence Levels ◽

Surgical Teaching ◽

Teaching Curriculum

Abstract Background COVID-19 has impacted on the amount of formal theoretical and practical surgical teaching available for junior doctors and medical students. This added to an existing climate of variability in the undergraduate and foundation teaching curriculum. Junior doctors were subsequently reporting a lack in confidence when dealing with surgical patients. We aimed to assess the surgical learning needs of junior doctors and designed a quality improvement project that included implementing a surgical teaching programme to improve the quality of surgical education. Methods A baseline questionnaire was completed by foundation year one doctors to establish confidence levels in managing surgical patients and carrying out practical procedures. Two sequential improvement strategies were subsequently implemented and assessed using the Plan-Do-Study-Act methodology. Junior doctors participated in a local surgical workshop in limited numbers during cycle 1, and then attended four online webinar tutorials themed around general surgery for cycle 2. Results A total of 15 participants responded to the baseline questionnaire, 13 attended the workshop and a combined total of 572 viewed the four webinars. Mean confidence increase following the workshop was 113% (W = 91.0, p < 0.001). Mean knowledge increase from the online webinars was 62.3% (t = 4.67, p = 0.009) and mean confidence increase was 66.67% (p < 0.0001). Conclusion Junior doctors did not feel confident in assessing and managing surgically unwell patients. Implementing blended learning tools, such as online webinars, allowed the delivery of effective surgical teaching en masse and to continue the practice of social distancing during a viral pandemic.

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Improving Foundation Year doctors’ confidence with routine suprapubic catheter change using an easily reproducible simulation model

Journal of Clinical Urology ◽

10.1177/2051415820926292 ◽

2020 ◽

pp. 205141582092629

Author(s):

Ganesh SS Sathanapally ◽

Mei-Ling Henry ◽

Oliver Burbidge

Keyword(s):

Simulation Model ◽

The Self ◽

Junior Doctors ◽

Teaching Session ◽

Point Scale ◽

Level Of Evidence ◽

Teaching Models ◽

Confidence Levels ◽

Practical Session ◽

Short Presentation

Objective: Previous studies report low confidence levels amongst junior doctors in changing suprapubic catheters (SPC). We aimed to assess and improve foundation doctors’ confidence in changing an SPC, and to identify factors contributing to a lack in confidence. A teaching session using an easily reproducible simulation model was delivered to improve confidence. Method: A teaching session on routine SPC changes was delivered to a cohort of 30 Foundation Year 2 doctors within a single hospital. The teaching session comprised a short presentation followed by a practical session with the teaching models. Trainees completed a questionnaire on self-reported confidence levels in catheterisation prior to, and directly after, the session. Results: The self-reported confidence level with SPC changes was measured using a 5-point scale (1 = not very confident, 5= very confident), and following the session, the median score increased from 1 to 4. 100% ( N = 28) of trainees felt the teaching session increased their confidence with routine SPC changes and that the simulation model was a useful tool. Conclusion: Some junior doctors report low confidence levels with SPC changes. A teaching session on routine SPC changes using a simulation model may improve confidence Level of evidence: 2c

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139 Efficacy of Implementation of a Junior Doctors' Teaching Program on The Secondary Prevention of Peripheral Arterial Disease in Vascular Patients

British Journal of Surgery ◽

10.1093/bjs/znab134.375 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

E Daketsey ◽

M Elkawafi ◽

A Khallaf ◽

R Makar

Keyword(s):

Peripheral Arterial Disease ◽

Secondary Prevention ◽

Statin Therapy ◽

Arterial Disease ◽

Evidence Base ◽

Junior Doctors ◽

Teaching Session ◽

Prescription Practices ◽

Best Medical Therapy ◽

Peripheral Arterial

Abstract Introduction According to NICE Guidelines, the Best medical therapy (BMT) for secondary prevention of peripheral arterial disease includes antiplatelet and statin therapy unless contraindicated. Junior Doctors are usually allocated the job of prescribing patients’ medications. Due to discrepancies in their exposure to vascular surgery in earlier training, we implemented an introductory teaching session for them regarding this BMT and audited the efficacy of this intervention. Method A retrospective review of admission and discharge medications of all vascular ward patients from August 12th to 30th September 2019 was done, and the data was analysed via Excel. Results Out of 127 patients (median age 70), 67% and 64% had antiplatelet and statin medications respectively,while on admission. 1 in each patient cohort was found discharged without either medication. The GP of the patient discharged without antiplatelets was contacted to ensure this was rectified. The other patient had refused statin therapy and thus a discharge note to their GP was conducted to reflect this. Conclusions A teaching session as part of a vascular departmental induction emphasising the evidence base for antiplatelet and statin therapy can contribute to improving prescription practices of junior doctors starting in the department.

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Reaching the summit of discharge summaries: a quality improvement project

BMJ Open Quality ◽

10.1136/bmjoq-2020-001142 ◽

2021 ◽

Vol 10 (1) ◽

pp. e001142

Author(s):

Richard Thomas Richmond ◽

Isobel Joy McFadzean ◽

Pramodh Vallabhaneni

Keyword(s):

Quality Improvement ◽

Health And Safety ◽

Improve Patient Care ◽

Discharge Summary ◽

Shop Floor ◽

Junior Doctors ◽

Improvement Project ◽

Step Model ◽

Assessment Unit ◽

Discharge Summaries

BackgroundDischarge summaries need to be completed in a timely manner, to improve communication between primary and secondary care, and evidence suggests that delays in discharge summary completion can lead to patient harm.Following a hospital health and safety review due to the sheer backlog of notes in the doctor’s room and wards, urgent action had to be undertaken to improve the discharge summary completion process at our hospital’s paediatric assessment unit. It was felt that the process would best be carried out within a quality improvement (QI) project.MethodsKotter’s ‘eight-step model for change’ was implemented in this QI project with the aim to clear the existing backlog of pending discharge summaries and improve the timeliness of discharge summary completion from the hospital’s paediatric assessment unit. A minimum target of 10% improvement in the completion rate of discharge summaries was set as the primary goal of the project.ResultsFollowing the implementation of the QI processes, we were able to clear the backlog of discharge summaries within 9 months. We improved completion within 24 hours, from <10% to 84%, within 2 months. The success of our project lies in the sustainability of the change process; to date we have consistently achieved the target completion rates since the inception of the project. As a result of the project, we were able to modify the junior doctor rota to remove discharge summary duty slots and bolster workforce on the shop floor. This is still evident in November 2020, with consistently improved discharge summary rates.ConclusionQI projects when conducted successfully can be used to improve patient care, as well as reduce administrative burden on junior doctors. Our QI project is an example of how Kotter’s eight-step model for change can be applied to clinical practice.

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261 Using Technology to Improve Inpatient Surgical Lists

British Journal of Surgery ◽

10.1093/bjs/znab134.393 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

A Gowda ◽

Z Chia ◽

T Fonseka ◽

K Smith ◽

S Williams

Keyword(s):

Quality Improvement ◽

Patient Care ◽

Junior Doctors ◽

Research Projects ◽

Point Scale ◽

Improvement Project ◽

Surgical Department ◽

Team Meetings ◽

And Training ◽

Multi Disciplinary Team

Abstract Introduction Every day in our surgical department; prior to our quality improvement project, Junior Doctors spent on average 3.26 clinical hours maintaining 5 surgical inpatient lists of different specialities with accessibility of lists rated as “neutral” based on a 5-point scale from difficult to easy. Our hospital previously had lists stored locally on designated computers causing recurrent difficulties in accessing and editing these lists. Method We used surveys sent to clinicians to collect data. Cycle 1: Surgical Assessment Units list on Microsoft Teams Cycle 2: Addition of surgical specialities and wards lists onto Microsoft Teams. Cycle 3 (current): expand the use of Microsoft Teams to other specialities. Results Utilising technology led to a 25% reduction in time spent on maintaining inpatient lists, to 2.46 hours a day, and an improvement in the accessibility of lists to “easy”. Across a year, this saves over 220 hours clinician hours which can be used towards patient care and training. Furthermore, use of Microsoft Teams has improved communication and patient care, in the form of virtual regional Multi-Disciplinary Team meetings and research projects. Conclusions Microsoft Teams is currently free to all NHS organisations in England so there is potential for these efficiency savings to be replicated nationwide.

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An audit of admission clerking of patients in Heddfan, Adult Mental Health Unit in BCUHB - north Wales

BJPsych Open ◽

10.1192/bjo.2021.238 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S75-S75

Author(s):

Asha Dhandapani ◽

Sathyan Soundararajan ◽

Manjula Simiyon ◽

Vinila Zachariah ◽

Rajvinder Sambhi

Keyword(s):

Mental Health ◽

Physical Examination ◽

Junior Doctors ◽

Physical And Mental Health ◽

Improvement Project ◽

North Wales ◽

History Of ◽

Mental Health Unit ◽

State Examination ◽

Source Of Information

AimsTo ensure admission clerking includes salient features needed for the management of both physical and mental health of the patient and also to aid in administrative purposes.MethodThe audit included a team of doctors reviewing the admission clerking notes for 50 patients in the General Adult Psychiatric unit in-patient ward.We created a standard questionnaire-based on Intended learning outcome of core training in psychiatry CT1-CT3 from Royal College of Psychiatry and standard textbooks.Our aim is to achieve 100 % compliance in clerkingResultIt was noted that only 30% wrote their GMC number, 4% added route of admission of the patient and a mere 8% filled the Consultants name. Though almost everyone had written the presenting complaints, the other aspects such as history of presenting illness, medical and family history, Allergy status and substance misuse history were missing in many clerking notes. None of them had filled in details of personal history and very few did a risk assessment.Further lacuna was noted with Mental state examination. Physical examination was also noted to be incomplete. While more than 50% had completed the Blood investigations and ECG, half of them had not documented it and that meant searching in the entire file. A mere 20% filled the nursing observation level whilst none had completed the formulation in the notes.ConclusionAdmission clerking is a vital source of information that would be needed for the formulation of patients diagnosis and future management.Apart from this, it also is needed for further continuity of care.Hence this vital source of information will need to be shared with the junior doctors who will be clerking the patient and seeing them in the first instance.We, therefore, intend to create a complete clerking proforma along with physical health proforma to aid us in this respect.We will audit initially in the first round and then plan to introduce a proforma for Clerking and physical examination based on the findings.We will re-audit to see if the standards are achieved after using the proforma and will consider a Quality improvement project based on this topic

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The person behind the label: co-production as a tool in teaching about borderline personality disorder

BJPsych Open ◽

10.1192/bjo.2021.355 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S122-S122

Author(s):

Nyakomi Adwok ◽

Sharon Nightingale

Keyword(s):

Borderline Personality Disorder ◽

Personality Disorder ◽

Personality Disorders ◽

Mental Health Professionals ◽

Service User ◽

Borderline Personality ◽

Junior Doctors ◽

Service Users ◽

Teaching Session ◽

Negative Attitudes

AimsThe overarching aim of the session was to address and reduce stigma around Borderline Personality Disorder among doctors. The three main objectives were:To increase empathy and understanding around Borderline Personality Disorder by exposing junior doctors to service user perspectives outside a clinical setting;To address knowledge gaps identified by junior doctors in a self-reported questionnaire disseminated prior to the teaching session;To offer junior doctors a basic psychological framework to base their assessment and formulation of service users with personality disorders.Background‘Borderline Personality Disorder: The Person Behind the Label’ was the title of the first co-produced teaching session in the Leeds and York Partnership Foundation Trust (LYPFT). Prior to the teaching session, an online questionnaire was sent out to trainees. The results highlighted three key issues:Negative attitudes towards service users with personality disorders;Poor subjective knowledge of the psychological models of personality disorders;Perception among trainees that they do not receive adequate training to deal with the challenges service users with personality disorders present.MethodA teaching session was co-produced by a team of two service users, a principal clinical psychologist within the Leeds Personality Disorder Network (PDN) and a core Psychiatry trainee. It was delivered in a 75 minute session to 40 attendees consisting of both trainee doctors and consultants.ResultFeedback was collected immediately after the session through the use of anonymous feedback forms. The response to the training was overwhelmingly positive with all 28 respondents rating the session as 4/5 or 5/5 on a satisfaction scale ranging from 1 (poor) to excellent (5). Key themes from the feedback included appreciation for the service user perspective and teaching on psychological theory. The fourth question in the questionnaire: “How will this teaching impact your work?” produced the highest number of responses (25/28) and provided evidence that the above listed objectives of the session were met.ConclusionCo-produced teaching has great potential to address negative attitudes around highly stigmatised conditions by bridging the gap that often exists between service users and mental health professionals.

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Improving knowledge and confidence in the acute management of eating disorders and resulting complications

BJPsych Open ◽

10.1192/bjo.2021.503 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S186-S186

Author(s):

Sarah Fynes-Clinton ◽

Clare Price ◽

Louisa Beckford ◽

Maisha Shahjahan ◽

Brendan McKeown

Keyword(s):

Eating Disorders ◽

Clinical Information ◽

Easy Access ◽

Average Score ◽

Junior Doctors ◽

Refeeding Syndrome ◽

Improvement Project ◽

Positive Effects ◽

The Creation ◽

The Impact

AimsThis project aimed to improve the knowledge and confidence of doctors at all levels when managing patients with eating disorders while on call.BackgroundA recent survey found just 1% of doctors have the opportunity for clinical experience on eating disorders. Anecdotally, a number of junior doctors within our trust had mentioned that they felt unsure when asked to manage patients with eating disorders during their out of hours shifts.MethodThis project aimed to ascertain levels of confidence with managing patients with eating disorders, and to collect suggestions to improve this. This was achieved using a survey sent out to 97 doctors working in a Mental Health Trust.We then utilised two of the suggestions to improve the identified areas of concern. The first method involved direct lectures. This was followed up with the creation of a poster highlighting the pertinent information which was displayed in key clinical areas. The second avenue was the creation of an information booklet covering key clinical information that is available to all on call doctors.ResultThe response rate for the survey was 37.11%. The survey found that doctors lacked confidence in the management of common conditions that arise in patients admitted with eating disorders. Refeeding syndrome was identified as the greatest area of concern by responding doctors.To assess the impact of the lectures, MCQs were given out before and after the presentation. The results were compared, and showed a clear improvement in overall knowledge, with results going from an average score of 56.6% to 80%.ConclusionBy using multiple methods to improve doctors confidence, (lectures, written information and visual posters), this quality improvement project achieved its aims in improving doctors knowledge, and through having easy access to important information, will have long term positive effects on patient care.

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The Introduction of An Intravenous Fluid Bundle to Improve the Prescribing of Intravenous Fluids Within a District General Hospital (Preprint)

10.2196/preprints.36304 ◽

2022 ◽

Author(s):

Abdul-Rahman Gomaa ◽

Sharan Sambhwani ◽

Jonathan Wilkinson

Keyword(s):

Point Of Care ◽

Kidney Injury ◽

District General Hospital ◽

Good Clinical Practice ◽

Point Prevalence ◽

Grand Round ◽

Junior Doctors ◽

Improvement Project ◽

Increased Risk ◽

The Impact

BACKGROUND Intravenous (IV) fluids are some of the most commonly prescribed day-to-day drugs. Evidence suggests that such prescriptions are rarely ever done correctly despite the presence of clear guidelines (NICE CG174). This is believed to be due to lack of knowledge and experience, which often breeds confusion and places patients at increased risk of harm. It also incurs avoidable costs to hospitals. OBJECTIVE This quality improvement project (QIP) aims to ensure that IV fluid prescriptions are: safe, appropriate and adhere to evidence-based NICE guidance. The project’s aims will be achieved through implementing multiple interventions that are categorised under: educational, changing prescribing habits and raising awareness. METHODS Review and improve the prescribing process of “IV fluid prescribing” via three simultaneous approaches. Teaching sessions were delivered to all junior doctors in order to improve knowledge and awareness of appropriate IV fluid prescribing and promote familiarity with the current NICE IV fluid guidelines. This included a ‘feature session’ at our local hospital Grand Round. A point-of-care aide-memoire containing a summary of the information needed for correct prescription was designed and printed. This complimented the teaching sessions and supported good clinical practice. Using serial Plan-Do-Study-Act (PDSA) cycles, a novel “IV fluid bundle” was developed, fine-tuned and trialled on five wards, (three surgical, two medical). The aim of the bundle was to ensure that patients were clinically reviewed in order to assess their volaemic status in order that appropriate IV fluids could then be selected and prescribed safely. The impact of these interventions was assessed on the trial wards via a weekly point prevalence audit of the IV fluid bundles for the duration of the trial. Parameters looked at were: incidence of deranged U&E’s, incidence of AKI and the number of days between the latest U&E’s and the patient’s IV fluid prescription. RESULTS These interventions were assessed on trial wards via a weekly point prevalence audit of the new IV fluid prescription chart (bundle; IFB) for the duration of the trial. Parameters monitored were: incidence of deranged U&E’s, incidence of acute kidney injury (AKI) and the number of days between the latest U&E’s and the patient’s IV fluid prescription. Of all of the patients on the IV fluid bundle, 100% had a documented weight, review of both fluid status and balance. The incidence of deranged U&E’s decreased from 48% to 35%. Incidence of AKI decreased from 24% to 10%. The average number of days between the latest U&E’s and a fluid prescription decreased from 2.2 days to 0.6 day. CONCLUSIONS Prescribing IV fluids is a complex task that requires significant improvement both locally and nationally. With 85% uptake of the IFB, we were able to significantly improve all measured outcomes. Through carefully structured interventions geared towards tackling the confounding issues identified from previous audits and process mapping we have shown that prescribing IV fluids can be made safer.

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524 QUALITY IMPROVEMENT PROJECT: INCORPORATING COMPREHENSIVE GERIATRIC ASSESSMENT INTO COMMUNITY HOSPITAL CLERKING

Age and Ageing ◽

10.1093/ageing/afab116.14 ◽

2021 ◽

Vol 50 (Supplement_2) ◽

pp. ii8-ii13

Author(s):

A Oates

Keyword(s):

Quality Improvement ◽

Geriatric Assessment ◽

Comprehensive Geriatric Assessment ◽

Community Hospital ◽

Quality Improvement Project ◽

Junior Doctors ◽

Medical Team ◽

Improvement Project ◽

Efficient Detection ◽

User Friendly

Abstract Elderly patients transferred to community hospitals often have complex medical, social, psychological, functional and pharmacological backgrounds that require careful assessment in order to create and deliver a high quality, patient-centred care plan. Unfortunately, time pressures experienced by staff in acute hospitals can make Comprehensive Geriatric Assessment (CGA) unfeasible for every patient. Moreover, junior members of the medical team may be unsure as to which aspects of a patient’s background and presentation constitute important elements of a CGA. Failure to recognise and document pertinent issues can lead to prolonged admissions, disjointed care and failed discharges. Admission to a community hospital presents a convenient ‘checkpoint’ in the patient’s hospital journey at which to undertake a CGA. Recording the relevant information in an effective clerking proforma when the patient is admitted ensures that this information is displayed clearly and in a way that is accessible to all members of the multidisciplinary team. The pre-existing clerking proforma at Amersham Community Hospital omitted several important elements of CGA (such as examination of feet and gait, assessment of mood, FRAX-UK score, creation of a problem list etc.) The aim of this quality improvement project was to create a thorough, yet user-friendly and time-efficient clerking proforma which incorporated the important components of CGA. Using BGS guidance and NICE quality standards, alongside suggestions from the medical team, the existing clerking proforma was adapted and reformed. After one month, feedback from the team was used to further improve the clerking proforma, ensuring that it was user-friendly, whilst meeting the standards set out by NICE and BGS. This was repeated as part of a second PDSA cycle. The improved clerking proforma enables junior doctors to undertake a thorough and holistic assessment, promoting efficient detection of issues and the delivery of a higher quality of care.

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