Audit and Practice Survey Posters 214 – 220
214 Assessing the feverish child: are we adhering to NICE guidelines?
Aims An audit was undertaken to assess if GPs were documenting all key parameters recommended in consultation as per the NICE guidelines GC160 “fever in under 5s: assessment and initial management”. MethodUsing EMIS software, 135 appointments were made for patients aged below 5 in January 2014. Out of these, 47 met the inclusion criteria as highlighted below: Diagnosis of infection; Appointments coded for fever/pyrexia; Appointments coded for for “unwell child”
Re-audit was undertaken after a teaching session and provision of a ‘traffic light chart’ in each consultation room between February and March 2015. 53 out of 130 consultations were included using the same criteria.Consultations were assessed for documentation of temperature, respiratory rate, pulse rate, capillary refill time (CRT) and safety netting.
Results As highlighted in the attached graphs, initial results highlighted respiratory rate as the poorest documented observation, with only 12.8% of consultations documenting all 4 parameters. There was a marked improvement in all areas except CRT on re-audit. Discussion and recommendations Most febrile children will have a self-limiting viral illness, but differentiating between benign viruses and early invasive infections can be difficult. NICE guidelines outline how the parameters mentioned are important in assessing severity of illness, and can aid management in primary care.This audit has shown that provision of the traffic light chart in consultation rooms and educational sessions can improve our documentation when caring for feverish paediatric patients. Further recommendations following re-audit include provision of paediatric pulse oximeters and easy-to-use consultation proformas.
215 Survey of antenatal and postnatal women
AIM/OBJECTIVES Identify the prevelanced of of low mood during pregnancy and first year post natally,
CONTENT We have 243 eligible women. 56 responded to a survey asking about their mood and the care they recieved. We also carried depression screeninig and calculated Edinburugh Depression Risk Score.
RELEVANCE Affects 20% of pregnancies, has a big impact on lives of families and educational development of children. It is a major cause of maternal deaths.OUTCOMESOverall, over 40% of women suffered from low mood (higher than some other studies), of these approx half were offered support and those who received it, about half felt the support offered was enough. Generally midwives screened better for low mood and woment generally felt more comfortable with them than their GP.
DISCUSSION Perinatal mental health is a major cause of morbidity and mortality and GP need to be more aware, better at screening and ensuring that enough support is provided.
216 Reducing morbidity and mortality from asthma: an audit of the implementation of regular reviews and provision of self-management plans for children with asthma
The recent publication of the National Review of Asthma Deaths (NRAD) highlighted that there are still inadequacies in the provision of care for asthma patients in general practice, leading to preventable deaths and admissions to hospital. In particular, it highlighted the importance of regular reviews and encouraging self-management and recognition of deterioration of the condition through the provision of personalised asthma action plans (PAAPs).
The British Thoracic Society (BTS) guidelines were subsequently updated to reflect this advice. In particular, the guidelines stated that children with asthma should be reviewed on at least an annual basis and every review should include the provision of, or discussion of, a pre-existing PAAP. The aim of this audit was to assess adherence to BTS guidelines in a primary care practice by retrospectively looking at the number of children with asthma reviewed in the last year and the content of these reviews.
The results largely agreed with the literature on the topic, showing that, despite awareness of the guidelines, uptake of annual asthma reviews is still poor, with only 59.7% being reviewed in the last year. In addition, amongst those reviewed the provision of PAAPs occurred in only 58.6% of reviews. An analysis of the causes of these poor results was conducted and recommendations for improvement were made, including email and text message reminders for reviews, education of practice staff about PAAPs and providing blank PAAPs to patients upon checking in for their reviews.
217 Registration refused: a study of GP registration in England
Aims/ Objectives Assess how frequently GP practices refused to register eligible patients; Assess whether GP practices were consistent in refusing registration; Evaluate the reasons for registration refusal.
Content The data was routinely collected at an NGO clinic. The data was collected between March and October of 2015 by volunteer clinic support workers, while attempting 849 registrations on behalf of service users.
Relevance/ impact Despite universal entitlement to free NHS primary care in England, 82.7 per cent of patients who came to the clinic in 2014 were unable to register with a GP. Our service users represent some of the most vulnerable people in society.
Outcomes Of the 849 attempts made by the NGO to register patients with a GP, 39 per cent were refused. It was found that 16 per cent of GP Practices were inconsistent in their approach to patient registration. The largest barrier to registration was the inability to provide paperwork: 39 per cent of refusals were because of lack of ID; 36 per cent because of lack of proof of address; and 13 percent because of immigration status.
Discussion Many GP practices stipulate requirements that exceed current NHS England guidance criteria for primary care registration, and therefore risk reducing access to healthcare. Vulnerable people are among those most likely to be effected. There needs to be more training of administrative staff and practice managers about entitlement to primary care and registration guidelines.
218 The challenges of safely prescribing and monitoring patients on Metformin in the primary care setting
Sabah Farooq Chaudry
Introduction Metformin is used as a first-line agent to decrease patient’s blood glucose levels in diabetes mellitus. An adverse effect of Metformin use is lactic acidosis, which has a significant morality rate of 30-50%. Safe prescribing and appropriate monitoring of patients using Metformin in primary care is an clinically important issue.
Objectives To carry out a retrospective audit into whether patients on Metformin who had an eGFR below 45ml/min were having their dose reviewed, and those with a eGFR below 30ml/min were having their Metformin stopped.
Methods The audit was carried out in an urban primary care practice, looking at 243 patients on Metformin to assess whether an eGFR was done in the last 12 months. The audit standard was set at 100% for stopping Metformin with eGFR <30mls/min and 85% for reviewing Metformin medication with a eGFR <45ml/min. EMIS database investigated to identify if any documented action was taken for patients with a corresponding eGFR <45ml/min.
Results16 patients were identified to have a eGFR below 45ml/min. Of these patients only 3 had a clear documented review of their Metformin medication. Of the 4 patients with a eGFR <30ml/min, only half (n=2) had their medication subsequently stopped.
DiscussionThis audit showed areas were improvement could be made. Several recommendations were made based on these findings, which include better documentation in the clinical practice records regarding Metformin reviews and changes to the nurse-led diabetes review template to include a check on eGFR, which was implemented at the practice.
219 Tumour marker requesting behaviours in a primary care setting
Objectives Tumour markers (TMs) are available to general practitioners (GPs) as a useful investigatory tool. However, inappropriate use can lead to adverse patient care and cost inefficiency. We aimed to explore requesting patterns of TMs in primary care to develop initiatives for improving patient care and costs.
Methods A prospectively-maintained database of 6,000 patients was retrospectively studied in a Greater London surgery over a 1-year period (2015-2016). TM requests investigated included prostate-specific antigen (PSA), CA-125, CA19-9, CA15-3 , carcinoembryonic antigen (CEA), human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP). Reasons for request and TM result were compared to National institute of Clinical Excellence (NICE) and National Academy of Clinical Biochemistry (NACB) guidelines for TM sampling. The cost of inappropriate requests was calculated according local tariffs.
Results A total of 118 requests were made; 69 PSA, 39 CA-125, 4 CA19-9, 3 CEA, 3 AFP. There were no requests for CA15-3 and HCG. From all requests, 6% were abnormal (n=7). Of these, one patient is awaiting a prostate biopsy, one patient was found to have metastatic endometrial cancer, and the remaining (n=5) deemed clinically non-significant. Thirty-nine percent of all requests (n=46) were deemed inappropriate according to NICE and NACB guidelines. This translated to approximately £300 of costs.
Conclusion A large proportion of TM requests in primary care do not meet national guidelines. Educational interventions based on such guidelines may help to avoid falsely reassuring GPs and patients, and reduce unnecessary investigations and costs.
220 Assessment of depression in elderly care home residents
Introduction Depression in the elderly population is under-recognised and often inadequately treated. Assessment of depression symptoms in elderly patients can be challenging as they overlap with symptoms of chronic medical illness. Elderly patients are also less likely to report depression symptoms.This audit aims to study the prevalence of depression in care home patients and assess the use of the PHQ-9 questionnaire as a diagnostic tool.
Methods A database search of all care home residents registered with a General Practice was conducted. Patients with a diagnosis of depression were excluded from the study. Patients suitable for inclusion were visited and a PHQ-9 questionnaire was completed.
Results Twenty patients were included in the study. Of these, 4 patients were excluded from the study due to severe dementia (n=3) and non-English fluency (n=1). Sixteen questionnaires (80%) were completed. Fifteen patients (94%) reported at least one depression symptom. Seven patients (44%) had minimal depression (PHQ-9: 0-4), 5 patients (31%) had mild depression (PHQ-9: 5-9) and 3 patients (19%) had moderate depression (PHQ-9: 10-14).
Conclusion This audit highlights several barriers to the assessment of depression in care home patients. These include cognitive impairment, communication difficulties, logistical barriers and possible bias from the presence of staff and relatives during the interview process. The PHQ-9 questionnaire is commonly used in primary care, however, use of a geriatric specific screening tool may be more appropriate in the care home setting. Care home workers could also use one of these tools to monitor their residents for depression symptoms.