Audit and Practice Survey Posters 235 – 241
235 A review of fast track cancer referrals from 1st November 2014 to 1st November 2015 at The Medical Centre, South King Street, Blackpool
Olivia Holtermann Entwistle
Aims & Objectives: The purpose of this audit was to review the fast-track cancer referrals made from a GP practice within one year and aimed to answer the following questions: How many referrals were appropriate based on the “red flag” criteria? Were the referrals timely based on the presentation of symptoms?Did referrals lead to a consultation with the appropriate department within two weeks? Did referrals lead to a positive or negative diagnosis within four weeks? What were the outcomes of the referrals made through the fast track system?
Content of Presentation The presentation will demonstrate the number of patients referred for suspected in cancer, highlights any errors in referral, reviews the rate of positive diagnoses, and examines the success of the referrals against NICE standards. Finally, it provides recommendations designed to improve the implementation of the fast-track system.
Relevance:The referral of patients with suspected cancer is a key role of the GP and stringent targets are set by both NICE, it is thus essential to highlight to primary care providers what can be done to improve the referral system and also to note and encourage good practice in this area.
Outcomes: Our audit found that of the 134 patients referred in the above year, the vast majority were timely(96%), however, errors in referral were made, all due to the incorrect identification of an iron deficiency anaemia. We also noted that it was in secondary care that targets were not being met, with only 86% of patients receiving a specialist consultation in the 2 week period.
Discussion We discuss what can be done to reduce the errors in referral for iron deficiency anaemia.
236 Case-finding for Depression in Patients with Epilepsy in general practice
Aims/Objectives This audit aimed to assess the level of case-finding for, and monitoring of, co-morbid depression in patients with epilepsy (PWEs) in one general practice.
Content of Presentation 56 PWEs were identified on EMIS®Web electronic patient records system. Records were reviewed for documentation of screening for depression and management. 7 were omitted due to co-morbid learning difficulties, or severe mental illness.
Relevance/Impact Depression has been shown to worsen outcomes for epilepsy, thus it is important to case-find for depression in PWEs, initiate appropriate management, and to monitor PWEs who have pre-existing depression. Anti-depressant medications and alcohol intake can reduce efficacy of anti-epileptic drug.
Outcomes All 49 patients had been reviewed in the previous year, with the template for ‘medication review’ completed. Alcohol intake was recorded in 34 out of all 49 PWEs (69.3%) in the previous year. Out of 49 patients, documentation of case-finding questions was seen in 5 patient’s annual epilepsy review, while a further 5 had a statement about mood documented. 17 of the 49 PWEs had a previous documented diagnosis of depression, of whom 13 were prescribed anti-depressants. All 17 of them had been reviewed in the previous year in accordance with NICE guidance.
Discussion We found that not all PWEs had case-finding questions for depression or alcohol intake documented, despite all patients having regular medication reviews to support management of epilepsy. The practice team have discussed this audit and amended the templates, to include case-finding questions and alcohol intake, and plan a re-audit in 2017.
237 Potential for disinvestment: an audit of follicle stimulating hormone testing to establish menopause
Background Current guidelines recommend a clinical diagnosis (i.e. without serum follicle stimulating hormone (FSH) testing) of menopause/perimenopause, in women aged >45 years with menopausal symptoms. Among women taking low-dose progestogen-only contraception (POC), FSH levels may be used to help diagnose menopause among women > 50 years. This audit was undertaken to establish whether primary care use of serum FSH to diagnose menopause is aligned with current guideline recommendations.
Methods Audit criteria and standards were derived from current guidelines. Female patients, in whom FSH testing had been undertaken in the past year, were identified using an electronic record search in two primary care medical practices; “A” (total population n=3429) and “B” (n=11244). Patient age, test indication, and use of hormonal treatment were extracted from identified patients’ records and descriptively analysed according to the criteria and standards.
Results120 (2%) women had a serum FSH measured, of which, 52 (43%; A=52%, B=38%) were >45 years old. Of these, 10 (19%) were on hormonal treatment, of which 7 (70%) were on low-dose POC. Six (86%) of the women on low-dose POC were >50 years old.
Discussion In two practices, nearly half of FSH tests were outside of guideline recommendations. This poses the risk of inappropriate advice about symptoms and/or contraceptive requirements, as well as representing a disinvestment opportunity. Given the extent of guideline deviation in both practices, we consider it likely that the results may apply widely. The use, drawbacks and limitations of serum FSH tests should be reiterated to general practice teams.
238 The use of urine culture in the diagnosis and treatment of urinary tract infections
Matthew Poynton, Thomas Howe, James Leney
Introduction Urinary tract infections (UTI) are the second most common clinical indication for empirical antibiotic therapy in primary care and urine samples constitute the largest single category of specimens examined in medical laboratories. Medical criteria for the management of UTIs vary throughout the UK. Unnecessary use of diagnostic tests and antibiotic therapies can be minimised by developing diagnostic guidelines. This will help adequately treat UTIs, minimize antibiotic resistance and reduce primary care costs.
Aim Underwood Health Centre had been sending too many mid-stream urine (MSU) samples in their diagnosis of UTIs. This audit aimed to compare the current practice at Underwood Health Centre against the SIGN guidelines.
Method Data were collected via the Vision system used in the practice, including all permanent patients registered at the practice. Information from records was used, including any written notes, urine dipstick findings and MSU results.
Results 21 patients (19F:2M) were identified as presenting with a suspected UTI in the previous three months. 8 MSUs were sent from these patients, only 3 of which should have been done according to SIGN guidelines. The remaining 5 MSUs were sent before the initiation of empiric treatment.
Discussion Urine cultures are needlessly sent in 25% of cases where a UTI is suspected. The unnecessary use of urine culture increases costs via lab time, equipment and also increases patient visit to primary care through the delay of antibiotic therapy. Empiric antimicrobial therapy without urine culture is the preferred strategy for management of suspected bacterial UTIs.
239 Unplanned Pregnancy Rates Following Removal of Long Acting Reversible Contraception
Background Long acting reversible contraception (LARC) methods are those that require administering less than once per cycle. They are highly effective methods of contraception, with limited dependence on patient compliance, and they have been proven to minimise unplanned teenage pregnancies.
Aims: 1. Study reasons for removal of LARC in patients attending sexual health clinics in and around Glasgow from 01/10/2014-31/12/2014. 2. Research the intended methods of contraception to be used by patients following removal of LARCs. 3. Calculate the number of unplanned pregnancies in the 6 months following LARC removals during October-December 2014. 4. Calculate the number of the patients that attended for termination of an unplanned pregnancy resulting from LARC removal in the above mentioned time period.
Method Retrospective study of removal of long acting reversible contraception (LARC) between October and December 2014. Looking at reasons for LARC removal, rates of unplanned pregnancies and those patients who then attended for termination of pregnancy. Randomised to first 500 patients during the 3 month period and only removal of contraceptive implants were included (Implanon/Nexplanon)
Results 815 LARC removals over the 3 month period (first 500 included) 15% removed due to planning of pregnancy, 23% removed due to reaching license limit17.6% of patients chose to go on to use other forms of LARC23 patients (4.6%) were known to fall pregnant in the 6 months following LARC removal. Of these patients 56.5% went on to termination of pregnancy.
Conclusion Despite the availability of several methods of LARC, unplanned pregnancy and consequential terminations are still a relevant issue. Patients should be counselled on the rates of unplanned pregnancies with other methods of contraception available.
240 An audit of the prescribing of nicorandil
Recent evidence has emerged suggesting nicorandil should only be used in patients whose angina is inadequately controlled by first line anti-anginal therapies, or who have a contraindication or intolerance to first line anti-anginal therapies due to the risk of ulceration of the skin and gastrointestinal tract. Our aim was to offer review appointments to all patients prescribed nicorandil: to highlight potential side effects, discuss stopping the drug and optimise anti anginal medication. Patients were also advised to contact the practice urgently if any new symptoms developed after stopping the drug. The poster will present the methodology, results and discussion of findings.
As it is commonly prescribed drug, this is a relevant topic both in primary and secondary care. We hope to highlight the importance of reviewing patients prescribed this medication as well as enhancing knowledge of its side effect profile. This audit highlighted that in our cohort, most patients were symptom free at the time of review, and the medication was stopped with very little impact on patient quality of life. We also discuss the importance of the doctor-patient relationship in developing a shared management plan.
241 An audit of compliance with NICE guidelines for urgent suspected cancer referrals in our practice
Aim: To determine if an appropriate and timely referral had been made which was compliant with the NICE Guidelines:Referral guidelines for suspected cancer.
Background: Diagnosis of any cancer on clinical grounds alone can be difficult. Primary healthcare preofessionals should be familiar with typical presenting features of cancers, and be able to readily identify these features when patients consult with them. In patients with features typical of cancer, investigations in primary care should not be allowed to delay referral. In patients with less typical symptoms and signs that might be due to cancer, investigations may be necessary. This should be undertaken urgently to avoid delay in diagnosis. If specific investigations are not readily available locally, an urgent specialist referral should be made.
Method: NICE guidelines on referral for suspected cancer diagnosis was reviewed. Searches were done to identify the number of patients diagnosed of cancer in the 12 months at the practice, consultations prior to their diagnosis were reviewed.Criteria: All patients presenting with ‘red flags’ for cancer are referred for investigations as per the NICE guidelines.
Outcomes: 31 patients from the practice were diagnosed with cancer between April 2014-2015. 13/31 patients were referred by the practice. 5 were diagnosed incidentally on hospital review for another condition.5 were diagnosed as part of screening, 8 were diagnosed at hospital follow-up. Of the 13 patients referred by the practice, 3 experienced a delay in referral. We concluded that stricter adherence to referral guidelines for urological cancer was necessary. This was discussed at our regular clinical meeting with all GPs. We decided to consider all new cancer diagnoses as a significant event and a template was developed.