Opportunistic patient advice, in brief

What can you say to a patient in 30 seconds? Importantly, can you give them useful health advice in that time? Dave Hancock examines research and guidance about Making Every Contact Count

Implementation of a patient progress diary for stoma patients living with dementia

With an ageing population and an increase in the prevalence of dementia, stoma care nurses (SCNs) are experiencing greater challenges in their role supporting this group of patients with their stoma care. Following concerns raised in our department by relatives about the care and teaching provided in this area, with patients occasionally denying having even seen an SCN, the need for a visual tool to enable timely interventions and increase knowledge for family, carers and ward staff became apparent. There is a comprehensive list of local and national guidelines underlining the need to provide more support and an increased comprehensive teaching plan specially tailored to dementia patients’ needs. The development of a patient progress diary, with a traffic light system showing each stage that the patient has reached, has provided a visual, up-to-date guide to the patient’s stoma management and highlights the need for further input to enable the patient to be discharged home safely and in a timely manner. The diary was formulated by the SCNs and printed by Coloplast, culminating in an easy-to-read booklet with a pictorial step-by-step guide to be inserted into patients’ washbags. The diary was reviewed by Great Western Hospitals Patient Advice and Liaison Service (PALS) and the Carers Committee, who provided positive feedback and subsequently supported the development of this patient-focused tool. Since introducing the diary, our team has decided to implement it with all patients, with positive feedback from patients, relatives, carers and ward staff. This has assisted in safe, timely and effective discharge planning.

How do National Health Service (NHS) organisations respond to patient concerns? A qualitative interview study of the Patient Advice and Liaison Service (PALS)

ObjectivesTo describe the current work of the Patient Advice and Liaison Service (PALS) and assess the service’s potential to resolve concerns and contribute to organisational learning.DesignA qualitative study using semistructured interviews.SettingFour mental health trusts and four acute trusts in the English National Health Service, a total of eight PALS across different trusts.ParticipantsTwenty-four participants comprising of PALS staff and clinicians working with PALS teams.MethodsSemistructured interviews were undertaken with participants using video conferencing software. The framework method was used for the analysis of the large qualitative dataset, which is a conventional method of analysis, similar to thematic or qualitative content analysis.ResultsPALS teams fulfil their core responsibilities by acting as point of contact for patients, providing information and resolving a variety of recurrent problems, including PALS staff communication, staff attitudes and waiting times. The remit and responsibilities of each PALS has often broadened over time. Barriers to resolving concerns included a lack of awareness of PALS, limited to no policies informing how staff resolve concerns, an emphasis on complaints and the attitude of clinical staff. Senior management had widely differing views on how the PALS should operate and the management of complaints is a much higher priority. Few PALS teams carried out any analysis of the data or shared data within their organisations.ConclusionsPALS teams fulfil their core responsibilities by acting as point of contact for patients, providing information and resolving concerns. PALS staff also act as navigators of services, mediators between families and staff and, occasionally, patient advocates in supporting them to raise concerns. PALS has the potential to reduce complaints, increase patient satisfaction and provide rapid organisational feedback. Achieving this potential will require more awareness and support within organisations together with updated national policy guidance.

TP9.1.2We must do better - An audit assessing local compliance with NICE Guidelines (2014) on giving patient discharge advice regarding driving following traumatic brain injury

Introduction Driving is a complex activity involving the coordination of a number of cognitive and physical skills, which may be impaired after head injury. It is a legal requirement that patients’ inform the licensing authority when they have sustained a head injury. Failure to do so results in possible fines, invalid insurance and prosecution. NICE recommends printed patient advice about driving once discharged following a head injury. Methods A retrospective analysis of all traumatic brain injury admissions under the surgical team over a 6 months was performed. The aim was to identify current practice regarding assisting patients to return to safe driving after head injury. Information related to patient demographics, documented driving status and advice (verbal and written) related to driving, was sought. Descriptive statistics were used to portray the results. Results 56 patients were admitted following a traumatic head injury. The average age was 77 (range of 24 to 94) Patients spent on average 4 days in hospital. Only 2 patients had their driving status documented. These two patients also had a documented occupation dependent on driving. No patients received advice specific to DVLA guidelines. Conclusion This study demonstrates that there is poor compliance with NICE guidelines. Indeed, there is a need for change in our practice. We have a duty of care for our patients and in ensuring the safety of the general public. The main limitation of this study relates to the adequacy of documentation. We provide solutions in order to tackle the findings of this audit.

EP.TU.55Increased Communication within hospitals enhances Catheter Care for Colorectal patients

Audit Aims 1. To quantify staff compliance in documenting catheter insertion using newest (2019) vs older (2011) Catheter Care Plans (CCPs) in our hospital. 2. To assess completion of CCPs against NICE Quality Guidelines on Infection Prevention and Control1. 3. To action (and measure the impact of) interventions to improve CCP completion. Methods CCPs for all emergency and elective colorectal surgery patients with a urinary catheter inserted in our hospital, over a three-week period, were analysed. Interventions (including distributing new CCPs and placing posters) were implemented to raise awareness of desired documentation standards. Post-intervention, the audit loop was closed via a two-week analysis of a similar cohort. Results Pre-intervention, 25% of the 20 CCPs were new. The average completion rate of new and old CCPs, respectively, was 63.48% ±9.53% and 49.28% ±7.65%. Post-intervention, 66.6% of the 18 CCPs were new. The average completion rate of new and old CCPs, respectively, was 49.28% ±18.48% and 42.75% ±3.27%. Aside from one uncompleted, new CCP post-intervention, which skewed the results, we were 100% compliant with overall guidance on NICE1. Conclusions Increased communication between the wards and theatre teams is pivotal to ensure optimal catheter care for patients. Improvement points include: replacement of residual old forms with new CCPs, and more education to ensure correct completion of new CCPs. Further progress requires both awareness and availability of patient advice leaflets and catheter passports, as well as reminding staff of NICE Quality Guidelines1.

1295 Virtual Fracture Clinic: An Audit of Referral Quality and Service Effectiveness

Aim Assessment of referral quality to the virtual fracture clinic (VFC) at the Liverpool University Hospital foundation trust compared to the standards set out by the Glasgow virtual fracture clinic pathway. As a secondary aim the effectiveness of the VFC in diverting patients not requiring further clinical management away from face-to-face specialist physical fracture clinics (PFC) was assessed. Method Outcomes of 1st attendances were collected for standard PFC's before the implementation of the VFC at our centre. This data was comparatively analysed to the outcomes of 1st ‘attendances' of VFCs post-service implementation. To assess VFC referral quality fracture type was recorded and compared to the standard set out by the Glasgow virtual fracture pathway which states that a selection of simple stable fractures should be discharged from ED directly with patient advice and telephone support. Results We analysed 529 PFC first attendances and 402 VFC first attendances. We saw a variety of simples stable fractures (21%) in the VCF including: Distal radial, Fifth metatarsal, Minor radial head, Fifth metacarpal, Mallet finger, which could have been managed with direct ED discharge and telephone support. 19.4% of PFC attendance resulted in discharge without a change in management as compared to 22.1% of 1st attendances for the VFC. Conclusions The VFC clinic has shown itself as an effective service in re-directing patients from face-to-face appointments, evidenced by the comparative rates of patient discharge on first attendance. This study has laid the foundation for improving referral quality to the VFC. Collaborative efforts between Orthopaedics and ED could improve VFC clinic efficiency further.

Can compliment and complaint data inform the care of individuals with chronic subdural haematoma (cSDH)?

ObjectivesTo explore the frequency and nature of complaints and compliments reported to Patient Advice and Liaison (PALS) in individuals undergoing surgery for a chronic subdural haematoma (cSDH).DesignA retrospective study of PALS user interactions.SubjectsIndividuals undergoing treatment for cSDH between 2014 and 2019.MethodsPALS referrals from patients with cSDH between 2014 and 2019 were identified. Case records were reviewed and data on the frequency, nature and factors leading up to the complaint were extracted and coded according to Healthcare Complaints Analysis Tool (HCAT).ResultsOut of 531 patients identified, 25 (5%) had a PALS interaction, of which 15 (3%) were complaints and 10 (2%) were compliments. HCAT coding showed 8/15 (53%) of complaints were relationship problems, 6/15 (33%) a management problem and 1/15 (7%) other. Of the relationship problems, 6 (75%) were classed as problems with communication and 2 (25%) as a problem with listening. Of the compliments, 9/10 (90%) related to good clinical quality and 1/10 (10%) to staff–patient relationship. Patients were more likely to register a compliment than family members, who in turn were more likely to register a complaint (p<0.005). Complaints coded as a relationship problem had 2/8 (25%) submitted by a patient and 6/8 (75%) submitted by a relative.ConclusionsUsing the HCAT, routinely collected PALS data can easily be coded to quantify and provide unique perspective on tertiary care, such as communication. It is readily suited to quality improvement and audit initiatives.

Understanding and Analyzing Prescribing and Prescription Errors in Outpatient Setting of a Medical College Hospital ENT Department

Introduction A medication error is a failure in the treatment process that leads to, or has the potential to lead to, harm to the patient. In the hospital OPD, errors can occur in deciding on the medication to be prescribed (prescribing error) or in writing the prescription (prescription error). Materials and Methods We analyzed 100 prescriptions and case sheets in the OPD of ENT department in a tertiary medical college hospital for a period of one week for errors and assessed the perceptions and attitudes of the residents of the department using a questionnaire. Result Several prescription writing errors were found, primarily failure to document non pharmaceutical patient advice and use of generic names. Four prescribing errors were noticed which did not need urgent intervention. Discussion Failure modes and effects analysis was done to rank the failures modes; and causes for failure were elucidated using Ishikawa Diagram. Recommendations for preventing errors were made based on these results. Conclusion This study illustrates the use of management techniques to identify errors and formulate appropriate preventive responses. Such techniques should be a part of ongoing departmental management; and they provide insights into improving resident training in an ENT residency program.

473 Post-Tonsillectomy Advice: What Are UK Patients Being Told?

Background Tonsillectomy is one of the commonest surgical procedures performed in the UK, with just over 45,000 recorded in England in 2018-2019(1). Despite this there is wide variation in, and a lack of evidence for, the post-operative advice given to patients. Method Post-tonsillectomy patient advice sheets were obtained from 110 UK NHS Trusts and equivalent organisations. Their contents were analysed and compared with published literature on post-tonsillectomy management to determine whether the advice is evidence-based or not. Results Post-tonsillectomy dietary and fluid intake advice varied between hospitals; whilst many recommend eating and drinking a normal diet (88%), many recommended eating a ‘hard’ (26%) or ‘soft’ (8%) food diet. Literature written for adults was more likely to encourage adequate fluid intake than that for children (75% versus 25%). Non-evidence-based advice including avoiding fizzy drinks (21%), fruit juices (9%), and using chewing gum (51%), was frequently given. Reported post-operative risks and safety-netting also varied, with 71% advising urgent hospital attendance if any bleeding was experienced whilst 12% suggested that bleeding up to a spoonful was to be expected and should not necessarily be acted upon. Conclusions Much of the advice given appeared to be anecdotal and not based on, or contrary to, published evidence.

The challenge of equipoise: qualitative interviews exploring the views of health professionals and women with multiple ipsilateral breast cancer in a surgical randomised controlled trial

Background. A multicentre feasibility trial (MIAMI), comparing outcomes and quality of life of women with multiple ipsilateral breast cancer (MIBC) randomised to therapeutic mammoplasty or mastectomy, has been conducted. The MIAMI feasibility trial aimed to investigate recruitment of sufficient numbers of women to this surgical trial, however only four patients were recruited. A nested qualitative study sought to understand the reasons for this lack of recruitment.Methods. Interviews were conducted from November 2019 to September 2020 with 17 staff from eight hospital-based breast care centres that recruited and attempted to recruit to MIAMI; and seven patients from four centres, comprising all patients who were recruited to the trial and some who declined to take part. Interviews were audio-recorded, anonymised and analysed using thematic methods of building codes into themes and sub-themes using the process of constant comparison.Results. Overarching themes of 1) influences on equipoise and recruitment and 2) effects of a lack of equipoise were generated. Within these themes health professional themes described the barriers to recruitment in ‘the treatment landscape has changed’; staff preferences and beliefs’ which influenced equipoise and patient advice; and how different the treatments were for patients. Patient themes of ‘altruism and timing of trial approach’; ‘influences from consultants and others’; and ‘diagnostic journey doubts’ played a part in whether patients agreed to take part in the trial.Conclusions. Barriers to recruiting to breast cancer surgical trials can be significant, especially where there are substantial differences between the treatments being offered and a lack of equipoise communicated by healthcare professionals to patients. Patients can become overwhelmed by numerous requests for participation in research trials and inappropriate timing of trial discussions. Alternative study designs to the gold standard randomised control trial for surgical interventions may be required to provide the high-quality evidence on which to base practice.Trial registration numbers: ISRCTN (ISRCTN17987569) and ClinicalTrials.gov (NCT03514654).