Using implementation science to develop and implement a guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty.

Introduction: Guidelines and consensus statements do not support routine preoperative testing for asymptomatic bacteriuria (ASB) prior to elective arthroplasty. Despite this, urine testing remains commonplace in orthopaedic practice. This mixed methods stepwise quality improvement project aimed to develop and implement a guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty within a single centre. Methods: Step 1 - description of current practice in preoperative urine testing prior to arthroplasty within a single centre; Step 2 - examination of the association between preoperative urine culture and pathogens causing prosthetic joint infection (PJI); Step 3 - co-design of a guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty; Step 4 - implementation of a sustainable guideline to reduce unnecessary preoperative testing for asymptomatic bacteriuria prior to elective arthroplasty. Results: Retrospective chart review showed inconsistency in mid-stream urine (MSU) testing prior to elective arthroplasty (49 % preoperative MSU sent) and in antimicrobial prescribing for urinary tract infection (UTI) and ASB. No association was observed between organisms isolated from urine and joint aspirate in confirmed cases of PJI. Co-design of a guideline and decision support tool supported through an implementation strategy resulted in rapid uptake and adherence. Sustainability was demonstrated at 6 months. Conclusion: In this stepwise study, implementation science methodology was used to challenge outdated clinical practice, achieving a sustained reduction in unnecessary preoperative urine testing for ASB prior to elective arthroplasty.

Sick Note to Fit Note: one trust's project to improve usage by hospital clinicians.

INTRODUCTION: In April 2010, the government introduced a new Statement of Fitness to Work or 'Fit Note' for patients requiring time off of work or adaptations to their work due to illness. Responsibility to issue these documents has shifted from primary to secondary care. Hospital clinicians are required to issue for inpatients and for outpatients where clinical responsibility has not been taken over by the general practitioner (GP). However, awareness of this change is lacking. Misdirecting patients to their GP for the sole purpose of receiving a 'Fit Note' is an unnecessary use of appointment time and negatively impacts on patients. King's College Hospital NHS Trust receives a number of quality alerts from primary care regarding this issue. METHODS: A trust-wide educational initiative was designed and implemented to increase staff awareness of Fit Notes and their correct usage in order to reduce the number of patients being misdirected to their GP to obtain one. Interventions included direct staff engagement, a trust-wide promotional campaign and creation of an electronic version of the document. RESULTS: Uptake of the electronic version of the Fit Note has steadily increased and there has been a fall in the number of quality alerts received by the trust. However, staff awareness on the whole remains low. CONCLUSIONS: Patients being misdirected to their general practice for Fit Notes is an important issue and one on which the baseline level of awareness among hospital clinicians is low. Challenges during this intervention have been in penetrating a trust of this size and getting the message across to staff. However, digitising the Fit Note can help to increase its use.

Interprofessional bedside teaching: setting up a novel teaching programme.

BACKGROUND: An ageing population and health-care advances mean that patients have increasingly complex medical health and social needs, requiring a multidisciplinary team. However, despite working as an interprofessional team, team members still largely train in professional silos. Furthermore health-care professionals report a poor understanding of the skills of colleagues from different professions. This article describes the set up and outcomes of a novel interprofessional bedside teaching programme. METHODS: An in-centre interprofessional teacher training course was established to facilitate interprofessional bedside teaching, along with supported ward-based sessions to apply the skills. RESULTS: Three in-centre courses and five workplace sessions have run, with forty-five and twenty-eight interprofessional participants respectively. Statistically significant improvements in confidence facilitating interprofessional teaching were seen, with participants more likely to teach at the bedside and involve the multidisciplinary team. CONCLUSIONS: This article shows evidence of a teaching programme which improves the confidence of the multidisciplinary team in facilitating interprofessional bedside teaching.