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

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.

The Effect of a Virtual Grand Round on Satisfaction and the Level of Learning of Physiotherapy and Speech Therapy Students During the Coronavirus Pandemic

Introduction: With the Coronavirus pandemic, disability and the students’ absence in clinical settings, the educational system of the Faculty of Rehabilitation Sciences of Jundishapur University of Medical Sciences decided to hold a virtual grand round, teaching the clinical courses to address the shortcomings of clinical education. This study aimed to investigate the level of satisfaction and learning of students from holding the Grand Round. Methods: The present study was quasi-experimental study. The study population consisted of 36 undergraduate students in physiotherapy and speech therapy; The Grand Round in specific cases of the disease was presented to students, in the clinical training. Data were collected using a researcher-made questionnaire to assess the level of satisfaction with the virtual grand round and an electronic test to assess learning from the topics. Results: The majority of students were moderate to highly satisfied (more than 70%) with the virtual grand round in speech therapy and physiotherapy groups. There was a significant difference between test scores before and after the grand round of the speech therapy group (P= 0.002), whereas, in the physiotherapy group there was no significant difference between the scores before and after the test (P= 0.3). Discussion: Regarding the level of students' satisfaction retaining the Grand Round and increasing their level of knowledge, it is suggested that virtual group discussions be held in clinical education courses in other faculties of rehabilitation sciences and related fields, especially during pandemic conditions of coronavirus and the impossibility of face-to-face training.

Inspiring our future psychiatrists: a quality improvement project to optimise the medical student experience in community CAMHS settings

AimsTo improve the structure, quality and experience of medical student placements in Community Child and Adolescent Mental Health Services (CAMHS). To increase the likelihood of pursuing a career in Psychiatry or CAMHS by 50% over their 3 week placement.BackgroundThere is evidence in the literature of the widely variable medical student experiences when it comes to Psychiatry placements. Medical students from Kings’ College London (KCL) have a 3 week placement in Lambeth Community CAMHS services. Despite this being a good opportunity for learning and development, the feedback from students reports that they often feel lost and were unable to fulfil the potential of the placement. The main challenges reported were identifying beneficial educational experiences and gaining clinically relevant exposure. This exposure includes getting involved beyond observation and following a patient longitudinally. These challenges will likely have a knock-on effect on their attitude towards Psychiatry and overall enjoyment of CAMHS placements when there is already a struggle to recruit trainee Psychiatrists.MethodA structured and immersive educational placement was designed through consultation with previous students, the multidisciplinary team and the university program directors. This included: •A new induction•Having a role in initial assessments of young people•Formalised medical and psychology teaching•Communication sessions•Case discussions in a ‘grand round’ format providing opportunity for end of placement assessmentFeedback was gathered using the Qualtrics analytical software, which was easily accessible through student's mobile devices.Pre placement questionnaires were used to assess the student's initial level of knowledge, expectations from the placement and motivation or interest in a career in CAMHS. Post placement questionnaires were used to assess any change in the above baseline scores. Brief, online feedback was collected after every clinical activity and was used to assess the interest and utility of each attended session during the placement. The questionnaire feedback was analysed and using these data, adjustments were made to improve the program for the next students in a “Plan-Do Study-Act” quality improvement methodology format. We analysed whether improving placement experience and learning affected students’ interest in careers in Psychiatry.ResultThe Quality Improvement Project is currently on-going and results are pending. So far, there is an improvement in student attendance and engagement following the introduction of induction, structure and active involvement in case management.ConclusionThe COVID-19 pandemic has resulted in community services having significantly reduced face to face contact, therefore our proposed changes for future cycles include various virtual elements. Ensuring medical students have access to online platforms such as Microsoft teams is vital in ensuring an effective medical student placement can be established Although the change to more remote working has been challenging , it is vital that medical students gain appropriate clinical experience during their Psychiatry placement to support further developments in Psychiatric recruitment.

The introduction of electronic prescribing in the Orchard clinic-a QI project

AimsHospital Electronic Prescribing and Medicines Administration (HEPMA) system successfully rolled out in July, 2020 at the Orchard clinic as the first site in NHS Lothian. The initial aim was to collect some “pre-HEPMA” and “post-HEPMA” data to look at “staff's attitudes to a new IT system, and does that change with successful implementation of it?” in the form of a survey. In the light of the findings of the pre-HEPMA staff survey, it became the QI project (as above).This aimed to look at both qualitative data; in the form of a staff attitudes survey towards a new IT system and quantitative data; to measure benefits of its implementation and to address issues raised by staff in the survey in the form of an audit in both pre and post HEPMA cycles.MethodTwo cycles were completed as follows:1. Pre-HEPMA cycle in March, 2020:Survey: Questionnaires asking question re- own IT skills, preparation and expectations of outcome of its implementation.Audit: Measured time taken to write and re-write paper prescriptions. Proforma filled by staff to measure time taken to log on and other IT related issues.2. Post-HEPMA cycle in October, 2020:Survey: Replicated above questions re-own IT skills, support during and after launch, disaster recovery and views about actual outcome of its implementation.Audit: Replicated to measure time taken to complete electronic prescriptions.Result24 staff questionnaires returned in both cycles. Staff felt more confident in their own IT skills, training and hence competence to use HEPMA; more supported, more confident about contingency plans and HEPMA to be more beneficial than initially anticipated. Overall, actual perceived success of (91%) compared to anticipated success (71%).The majority issues raised via the first survey were felt to be addressed. Time to log was on averageThe audit showed a clear benefit in terms of clinical time saving, e.g. daily clinical time spent writing prescription reduced from an average 45 to 6 minutes with HEPMA.The quality of documentation on the prescriptions remained unchanged.ConclusionStaff's attitude towards IT does change after successful implementation of a new IT system. But IT issues make the whole process laborious.There was evident benefits realization with an electronic prescribing system compared to paper prescriptions.I was awarded “Employee of the month” for this project which I also presented at the NHS Lothian grand round (>150 attendees) for dissemination and future replication.

104 Assessing for Delirium in A District General Emergency Department—Why are We Failing and How can We Improve?

Introduction Delirium is among the most common of medical emergencies with a prevalence of 20% in adult acute general medical patients. Despite this delirium is underdiagnosed and treatment is variable. Assessment of delirium is missed or carried out unreliably in EDs. Methodology Using the Model for Improvement, we developed a driver diagram to plan our project. Assessing whether patients over 65 years old were assessed for delirium during their visit to the ED using a validated tool over a 6-month period. Evaluating the impact of our interventions using annotated run charts. Exclusion criteria—GCS under 13, NEWS2 greater than 5. Aim Identify current performance of delirium assessment in over 65 s in Weston General Hospital ED and improve to 100% of over 65 s screened. Assess whether this has been communicated in the discharge summary. Results Baseline data showed 22.2% (4/18) of patients meeting inclusion criteria were screened for delirium. We implemented multiple interventions over a 2-month period—discussing at ED handover, hospital wide email, presentation at grand round and displaying a poster in the ED. In the 6 weeks after the interventions were implemented there was increase to 45.4% (15/33) of patients over 65 screened. Delirium/cognitive impairment identified in 42.5% (48/113) of patients screened. This is higher than the national average of hospital admissions therefore it is likely people screen those who display signs of delirium. Cognitive impairment communicated in discharge letter in only 29.4% (33/113) of all patients. Conclusion There has been a great improvement in delirium screening. However, we did not meet our target of 100% of patients being screened. Interventions currently being implemented—addition of SQID tool to minors clerking document, addition of compulsory tick box delirium question on all discharge summaries. Further data will be collected to assess effectiveness of these interventions.

“It’s not lupus”. A placental site trophoblastic tumor presenting as a lupus-like paraneoplastic syndrome. A grand round case

Introduction: Placental site trophoblastic tumor (PSTT) is a rare subtype of gestational trophoblastic disease. Association of PSTT and nephrotic syndrome is exceedingly rare and has been described in 8 cases thus far. In all cases hysterectomy was performed within months after onset of symptoms, leading to immediate remission of nephrotic syndrome, except for one patient who died of complications of PSTT. Case: We describe the history of a woman in which PSTT was discovered years after onset of nephrotic syndrome. Kidney biopsy revealed lupus-like mesangiocapillary nephritis and over time the patient developed additional symptoms mimicking systemic lupus erythematosus (SLE). Discussion: We provide an overview of the literature on this clinical entity and elaborate on its pathophysiology. In addition, we reflect on the phenomenon of anchoring bias, that led physicians to assume the patient had SLE without questioning this diagnosis in the light of the unexplained finding of increased tumor markers.

Experience with a Clinical Audit Requirement for Interns in the Emergency Department

Background: The clinical audit is an important evaluation tool to ensure quality assurance. A clinical audit requirement for interns during their emergency department (ED) term may be a valuable educational activity. Methods: The Emergency Audit Initiative (EAI) Program was initiated at Redcliffe Hospital in January 2018. Interns, who were paired with a staff specialist audit mentor, chose a topic of interest and carried out a clinical audit during their 10-week ED term. At the end of term, interns formally presented audit findings in a grand round setting. Interns and staff specialists were surveyed at the end of the intern year regarding aspects of the program. Surveys aimed to assess: (1) value of the program as an educational activity, (2) availability of time and resources to conduct the audit, and (3) perceived impact on practice. Results: During the first year of the program, 27 clinical audits were carried out. 16 interns (59%) and 8 staff specialists (57%) responded to the surveys. Interns and staff specialists reported that the audit was a valuable educational experience (88% and 100%). Interns also reported that they had adequate time (94%) and resources (81%) to conduct the audit. Interns and staff specialists however reported only a modest impact on clinical practice because of the audit program. Conclusions: Our experience with the EAI program suggests that incorporating a clinical audit requirement into the ED term is possible. Interns and staff specialists reported it to be a beneficial educational and professional development activity.