Lessons from the COVID-19 pandemic in paediatric post-discharge care.

The COVID-19 pandemic dictated rapid reform in outpatient paediatric services. To reduce ward footfall and its associated infection risk, a trainee-led outpatient clinic was established with the aim to provide children with continuity of care following discharge from hospital. The service was created as a safe alternative to the long-standing practice of ward attenders while reducing mounting pressures on appointments at consultant-led clinics. Several issues arose in its implementation. A retrospective analysis with insights from service users found significant communication issues at various stages in referral, booking and follow-up management. This project aimed to reduce clinic non-attendance rates and ensure timely outpatient review with effective communication to all parties.Quality improvement methods allowed the problem to be understood and defined. Through consultation with service users in the start-up phase of the project, four key criteria were determined as essential for improving communication: indication, lead consultant, patient attendance and outcome letter provision. The project aimed to achieve 100% compliance across the four criteria during the 6-month project period. A baseline measure was established and measurements collected while five interventions were tested using plan-do-study-act test cycles.Following the small-scale tests, the run chart illustrated process improvement leading to meaningful change in outcome at both patient and service level. During the project, performance increased from a baseline median of one to a minimum of three out of four criteria being met for every patient. Several patients and families had a change in management as a direct result of their timely review and communication of clinic outcomes. These interventions resulted in a 50% reduction in the clinic's did not attend rate.The initial pandemic response to facilitate post-discharge care for children and young people led to frustrations surrounding communication breakdown among service users. Targeted interventions led to the development of a safer, more efficient service. Ongoing feedback continues to guide strategies for change with future work in service development focusing on capturing patient experience and improving patient-centred outcomes.

Driving communication forward: improving communication for palliative care patients around driving and opioids - a quality improvement report.

INTRODUCTION: The number of people requiring palliative care is increasing with an ageing comorbid population. Pain is a prevalent symptom for palliative care patients and is often managed with opioids. Opioids reduce reaction time and can cause drowsiness and visual disturbance. Evidence recommends that driving should be avoided until a stable dose of opioids has been reached. It is vital for patient and public safety that these facts are communicated to patients who are prescribed opioids, as well as the legal consequences if guidance is not followed. These discussions facilitate joint decisions, optimising patient freedom and quality of life. Surprisingly though these important discussions around driving and opioids do not always occur, and so this project sought to develop a systematic approach to integrating them into practice. DESIGN: Retrospective case note analysis and prospective interventional quality improvement study. SETTING: A 16 bedded specialist palliative care inpatient unit. POPULATION: Hospice inpatients with an Eastern Council Oncology Group performance score of 0-3 who had been prescribed opioids. INTERVENTION: Three plan-do-study-act cycles were performed. First, the issue was discussed in the daily multidisciplinary team meeting to raise awareness, second a prompt was added to a pre-existing clerking proforma. Finally, a reminder poster was placed in the ward office to promote discussion prior to discharge. OUTCOME MEASURES: Primary measures were the proportion of patients with the presence of documented driving status, and the presence of a documented discussion surrounding driving and opioids. RESULTS: Baseline data found that 11.5% of patients had a documented driving status and 11.5% had a documented discussion surrounding driving and opioids. Over the course of the study, the proportion improved to 65.2% and 60.9%, respectively. CONCLUSION: Use of quality improvement change methods have resulted in the successful integration of new interventions to increase discussions around driving when prescribed opioids. A previously overlooked issue in this facility, thus improving clinical and patient information sharing, and patient empowerment to take charge of their own health.

Please reconcile, not wait a while.

A quality improvement project to increase the rate of paediatric medicines reconciliation was carried out in a district general hospital between April and July 2018. Baseline data collected from our paediatric ward shows that medicines reconciliation by doctors is only accurately completed 50% of the time. Evidence shows that medicines-related patient safety incidents are more likely when medicines reconciliation happens more than 24 hours after a person is admitted to an acute setting. The aim of this quality improvement project was therefore to ensure that 100% of paediatric patients have their regular medications prescribed by mid-day the day after admission. The paediatric pharmacy team reviewed all paediatric inpatient drug charts from Monday to Friday for 12 weeks. The number of regular medications and the number of medicines reconciled was recorded each day. The effectiveness of various interventions were reviewed using Plan-Do-Study-Act cycles. On average, 40 patients were reviewed each week. The mean reconciliation rate was 79%, and the worst rate was 0%. 100% reconciliation was achieved on 34 occasions and was achieved continuously for the last 3 weeks of data collection. A repeat audit carried out in September 2018 found the reconciliation rate was maintained at 100%. Multiple interventions occurred during this quality improvement project: teaching sessions for doctors, posters to raise awareness and questionnaires for parents/children to complete about their regular medications. The main factor for success in this project has been involving all members of the paediatric department including children and their parents.

"The constipation conundrum": Improving recognition of constipation on a gastroenterology ward.

Constipation is a common and often overlooked problem, but it can cause serious complications for patients including pain, nausea, urinary retention, and prolonged hospital admission. There are no recognised criteria for the diagnosis of constipation in the acute hospital setting, and it is often the role of the ward doctor to identify and manage this problem. Completion and monitoring of "stool charts" by nursing and medical staff is key to proper recognition and management of constipation. A baseline study found that while charts were completed well, they were only monitored by doctors 17.5% of the time. This quality improvement project introduced an altered "continuation sheet" to the clinical notes to prompt monitoring of stool charts and provide an area for documentation. This resulted in an increase in monitoring to 66.7%.

The foundations of quality improvement science.

As an alternative to 'big bang' initiatives, plan-do-study-act (PDSA) cycles are an increasingly popular approach to conducting tests of change to support quality improvement in healthcare. Using PDSA cycles can help clinicians deliver improvements in patient care through a structured experimental approach to learning and tests of change. The PDSA approach facilitates individual, team and organisational learning, making it an essential tool for the future hospital. This paper provides an example of the benefits of using PDSA in practice to test and develop a change idea to ensure it is fit for purpose. As with any new skill or competency, learning to use PDSA cycles takes time and practice and is necessary to ensure that the method is being used to its full effect. This paper explores some of the challenges encountered by clinicians in learning to use PDSA cycles well, and provides advice on how they can be overcome to help practitioners get more out of using the method.

Reducing avoidable time delays in immediate medication administration - learning from a failed intervention.

Stat medications are regularly prescribed on hospital wards as part of the ongoing care for patients. Because they are prescribed at variable times that do not coincide with regular nursing drug administration times, they rely on good communication and vigilance on staff to ensure they are administered in a timely manner. Delays in drug administration can lengthen patient recovery times, prolong admission, and can lead to avoidable patient harm and suffering. While working on a geriatrics ward I noticed that there were often significant delays in administration of stat medications which occurred on a regular basis. I therefore investigated this by collecting data over a two week period to assess the situation based on our current practice. After root cause analysis (figure 1), it became clear that communication between staff was a significant factor in delayed administration. A solution was implemented in the form of "ward bay wall charts" to aid documentation and communication of stat medication requirements between nursing and medical staff with the intention to reduce delays by improving communication. After gaining support of medical and nursing staff, a trial was undertaken and a further two weeks of data collected to see the effect of the intervention. The results showed that there was an increase in the median time delay (1 hour 34 minutes to 2 hours 26 minutes, a 55% increase in median time delay) after the implementation of the my intervention, suggesting that it actually made communication worse, creating more delays. Subsequent feedback and analysis showed that this was due to a number of factors that led to worsened communication between staff and therefore an increase in medication delays. Early recognition allowed the intervention to be promptly withdrawn and a re-assessment of the nature of the initial problem. This project highlights the importance of measurement in determining if an intervention actually works and is an improvement on current practice.

Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool.

UNLABELLED: The measurement and examination of adverse events (AEs) that occur in children during hospital admissions is essential if we are to prevent, reduce or ameliorate the harm experienced. The UK Paediatric Trigger Tool (UKPTT) is a method of retrospective case note review that measures harm in hospitalised children. OBJECTIVES: To examine the harm resulting from the processes of healthcare in hospitalised children from centres providing data to the National Health Service (NHS) Institute UKPTT data portal, to understand the positive predictive values of triggers and to make recommendations for the further development of the trigger tool. SETTING: 25 hospitals across the UK, including secondary, tertiary and quaternary paediatric centres. PARTICIPANTS: Randomly selected children who were admitted to hospital for longer than 24 h. OUTCOME MEASURES: The primary outcome measure was the rate of harm (the percentage of children experiencing one or more AEs during a hospital admission). Secondary measures were the severity of harm and performance of triggers. RESULTS: Data from 3992 patient admissions were reviewed across the hospitals and submitted to the trigger tool portal from February 2008 to November 2011. At least one AE was reported for 567 (14.2%) patients, with 211 (5.3%) experiencing more than one event. There were 1001 AEs identified. Where harm occurred, it was considered temporary for 923 (92.2%) AEs; however, 43 (4.3%) AEs resulted in the need for life-sustaining interventions, 18 (1.8%) AEs led to permanent harm and for 17 children (1.7% of AEs) the AE was believed to have contributed to death. CONCLUSIONS: There is a significant, measurable level of harm experienced by children admitted to hospitals in the UK. While most of this harm is temporary, some of it is serious. The UKPTT offers organisations the means to measure and examine the AEs occurring in their hospital in order to reduce harm.

The caudinid sea cucumbers of New Zealand (Echinodermata: Holothuroidea: Molpadida: Caudinidae).

Five species of Caudinidae occur in New Zealandwaters. Two new species are described: Paracaudina alta sp. nov.; Paracaudina reductia sp. nov. Two species reported previously are discussed: Paracaudina chilensis (Müller) and Paracaudina coriacea (Hutton). A lectotype has been established for P. coriacea (Hutton). Hedingia albicans var. glabra (Théel) is raised out of synonymy with Hedingia albicans (Théel), and the variety elevated to species status as Hedingia glabra (Théel). A key is provided for the New Zealand species of Caudinidae.

A feasibility study of signed consent for the collection of patient identifiable information for a national paediatric clinical audit database.

OBJECTIVES: To investigate the feasibility of obtaining signed consent for submission of patient identifiable data to a national clinical audit database and to identify factors influencing the consent process and its success. DESIGN: Feasibility study. SETTING: Seven paediatric intensive care units in England. PARTICIPANTS: Parents/guardians of patients, or patients aged 12-16 years old, approached consecutively over three months for signed consent for submission of patient identifiable data to the national clinical audit database the Paediatric Intensive Care Audit Network (PICANet). MAIN OUTCOME MEASURES: The numbers and proportions of admissions for which signed consent was given, refused, or not obtained (form not returned or form partially completed but not signed), by age, sex, level of deprivation, ethnicity (South Asian or not), paediatric index of mortality score, length of hospital stay (days in paediatric intensive care). RESULTS: One unit did not start and one did not fully implement the protocol, so analysis excluded these two units. Consent was obtained for 182 of 422 admissions (43%) (range by unit 9% to 84%). Most (101/182; 55%) consents were taken by staff nurses. One refusal (0.2%) was received. Consent rates were significantly better for children who were more severely ill on admission and for hospital stays of six days or more, and significantly poorer for children aged 10-14 years. Long hospital stays and children aged 10-14 years remained significant in a stepwise regression model of the factors that were significant in the univariate model. CONCLUSION: Systematically obtaining individual signed consent for sharing patient identifiable information with an externally located clinical audit database is difficult. Obtaining such consent is unlikely to be successful unless additional resources are specifically allocated to training, staff time, and administrative support.

Functional outcome of patients with proximal upper limb deficiency--acquired and congenital.

OBJECTIVE: To investigate the functional outcome of patients with proximal upper limb deficiency--acquired and congenital (elbow disarticulation, transhumeral, shoulder disarticulation and forequarter level). DESIGN: Cohort observational study. SUBJECTS: All proximal upper limb amputees and patients with congenital upper limb absence currently registered with the Sheffield Mobility and Specialised Rehabilitation Centre. METHODS: A self-administered postal questionnaire and medical records were used to collect data. The questionnaire obtained information about demographic details, dominancy of the amputated arm and independence and participation in activities of daily living (ADL), domestic and recreational activities. The prevalence of pain in the phantom limb and stump, and information regarding the remaining arm was also obtained. The Hospital Anxiety and Depression Scale (HADS) was used to evaluate the psychological state of the subjects. RESULTS: Trauma was the commonest cause of proximal upper limb loss (71.25%). Transhumeral amputation was the predominant level (78.75%). Although 73.2% returned to work following amputation, 66.6% had to change job. Overall rejection rate of prosthesis was 33.75%. Twenty-five per cent of patients found the prosthesis beneficial for driving and a small proportion used the prosthesis for employment and recreational activities, but the vast majority used the prosthesis primarily for cosmesis. Pain in the phantom limb was reported in 60% of our patients but there was no significant correlation between this and depression. Symptoms of overuse injury in the nonamputated limb were higher than expected in the normal population. CONCLUSION: As many as 33.75% of patients with proximal upper limb deficiency rejected their prostheses and many who continue to wear them do not find them useful in ADL and employment, etc. It is vital that rehabilitation programmes should focus on both prosthetic and nonprosthetic training to achieve maximal independence.