Improving bowel preparation for colonoscopy in a cost effective manner.

Colonoscopy is a key investigation used to exclude large bowel pathologies including surveillance for CRC (Colorectal cancer) Poor bowel preparation (bowel prep) is one of the most important factors affecting its diagnostic yield. Different formulations of bowel prep are currently in use depending upon patient tolerance, indication & co-morbidities. In University Hospital Llandough we retrospectively reviewed the outcome of colonoscopies performed over period of 3 months, in relation to the type and outcome of bowel preparations used. We implemented a change of patient instruction and pre-assessment of bowel preparation prescribed. We repeated the same measurements over 3 different cycles on 3 different occasions and compared the outcome. We noticed that quality of bowel preparation noticeably improved from 80% to almost 93% if patients were given appropriate advice in a written format, prior to procedure. In addition to improvement in the quality of assessment & reducing the number of repeat procedures, by changing the bowel preparation product and postage methods we estimated savings of almost £150,000 for the trust in a year.

Troponin: think before you request one.

Acute myocardial infarction (ACS) is one of the most common presentations in acute hospital settings. Troponin (cTn) has emerged as one of the most sensitive biochemical markers for the diagnosis of ACS. However, if used inappropriately and in the absence of true clinical context then it can be elevated in a number of non cardiac conditions and lead to false clinical diagnosis, inappropriate workup, and increased patient stay in hospital. The cost of unnecessary clinical testing is another aspect of the problem. At Royal Gwent Hospital in Newport (one of the busiest district general hospitals in Wales) we retrospectively analysed the nature of troponin requests over a random period of one week, specifically looking for the indications and final diagnostic impact. In many cases it was found that requests were made without any clinical justification. One of the main and probably unavoidable reasons for this was that requests were made from triage before patient was assessed by a clinician. However, steps were taken to clarify common clinical indications for suspected cardiac diagnosis in which troponin was useful. Additionally, the "tick box" practice for inappropriate laboratory investigations was discouraged. A repeat audit was done on similar basic principles and a measurable improvement was identified, with a potential for significant impact in future.

Improving patient care over weekends by reducing on-call work load and better time management.

The Royal College of Physicians states that "handover, particularly of temporary 'on-call' responsibility, has been identified as a point at which errors are likely to occur."[1] Working a weekend on-call covering medical wards is often busy and stressful for all junior doctors. The high volume of routine and unplanned tasks make the situation even worse. In Nevill Hall hospital Abergavenny, we measured the workload on a junior doctor for medical ward cover on weekends by counting the number of times he/she was bleeped for routine tasks. Initial study demonstrated that on average 30-40% of time on a long day shift was spent on jobs which could have been done on the preceding Friday. The "FRIDAYS" checklist was introduced for clinical staff (particularly junior doctors) to identify these jobs. According to this model, all the junior doctors were encouraged to review: F: Phlebotomy R: Rewriting drug charts I: IV fluids D: discharge summaries A: Antibiotic review Y: Yellow book/Warfarin dose S: Status of resuscitation and escalation plans before leaving the wards on Friday afternoon. This implementation successfully showed reduction in weekend workload, allowing the ward cover to be focused on care and safety of comparatively sick patients while at the same time reducing the stress for the on-call team.