Audit and Practice Survey Posters 256 – 262
256 Reducing Risk of Stroke During GP Placement
Having atrial fibrillation increases the risk of stroke. Oral anticoagulants, such as warfarin and new oral anticoagulants (NOACs) significantly reduce this risk. During a GP placement concern was raised that some patients were not treated in accordance with NICE guidelines. Two tools are currently accepted as the most effective way to stratify patients with AF who require anticoagulants; CHADVASc and HASBLED scores. We conducted an audit with the criterion that all patients with AF should be offered OAC according to NICE guidelines. This was completed across two GP practices serving 23,000 patients. A target of 90% of AF patients on anticoagulation or declined treatment was agreed. By searching through AF read-codes on SystemOne we gave a CHADVASc and HASBLED score to all AF patients.Untreated patients received an AF information pack, and a follow up consultation. The practice pharmacist clarified regional guidance.Initially, 198/249 (79.5%) patients were on the correct treatment. Of the 51 patients on incorrect treatment, 24 started a NOAC, 6 warfarin, 13 declined treatment and eight did not respond to the letter. By the end of the intervention 241/249 (96.7%) of AF patients were correctly treated or had made an informed decision to decline treatment.The median CHADVASc score in our cohort was four indicating an average 6.7% risk of stroke/TIA/systemic embolism per year. This reduced to 1.78% with warfarin (1.71%) and NOAC (Dabigatran 1.54%, and Rivaroxaban 2.1%) treatment. NICE guidelines were updated in 2014, it is unsurprising some patients were on inappropriate or no treatment. Regular audit and adherence to these guidelines is critical to reducing the risk of stroke.
257 Optimising care of Type II Diabetes Mellitus patients
Rachel McNulty, Dr Jonathan Emms, Dr Yogesh Patel
Aim: Reduce the number of Type II Diabetes Mellitus patients with a HbA1c above 59mmol/mol by optimising their care. Content:Two audit cycles were undertaken, one in March and one in June 2016. The treatment regimes of all patients with a HbA1c over 59mmol/mol were compared to those recommended by NICE guidelines. Between cycles, action was taken to improve patient care, including a review with the practice nurse, their GP and intensifying their medication where appropriate.
Relevance/impact:Optimising care of diabetic patients is well recognised as a national priority. NHS England recently selected diabetes as one of six clinical priorities for CCG improvement and assessment. The condition is associated with many complications, resulting in significant morbidity and mortality. Optimal management of the condition has been shown to reduce the risk of these complications.
Outcomes:In the first cycle only 28% of patients were in receipt of the appropriate level of medication. By the second cycle, this had improved to 59%. Also, at first only 56% had an up-to-date HbA1c level. By the second audit, this had improved to 83%. Incidentally, a drop in HbA1c levels was seen in a number of patients whose care had been optimised.
Discussion:This audit has shown that significant improvement can be made in the proportion of patients receiving optimal level of care for Type II Diabetes. Incidental findings showed that in a number of patients, this led to a fall in HbA1c levels.
258 Managing cow’s milk protein allergy in primary care
Introduction Many infants experience feeding difficulties in the first few weeks and months of life. One of the main concerns regarding feeding is the presence of cow’s milk allergy (CMA) and it is often misdiagnosed and therefore managed incorrectly. Aim To assess whether the GP practice was adhering to the local CCG guidelines for managing CMA, including: 1. Correct formula feed being prescribed 2. Referral to paediatrician 3. Follow up
Method A computer search was run using EMIS web and a completed population search for CMA patients from March 2014 – March 2016 for paediatric patients up to 18 years of age was done.
Results After exclusion of patients that did not meet the criteria, the search resulted in 14 patients. 7/14 patients followed the CCG guidelines perfectly. The remaining 7 did not meet the criteria. 3/7 patients were prescribed lactose intolerant formula feeds, though it is explicitly denied in the guidelines. The number of diagnoses made was significantly less that anticipated for a population of such a large number within such a big practice.
Discussion and conclusion Alteration of maternal diet was the most common step missed. It was found that coding the diagnoses and writing the reasons in the history was often not completed correctly therefore we recommended that the importance of this is shared with the staff during training days especially for future audits and administrations purposes. We created a flow chart to show CMA management guidelines that can be used as a poster in surgery rooms for quick reference.
259 Audit on annual physical health monitoring in patients taking antipsychotics
Aims/Objectives: To audit whether patients taking long-term antipsychotics (APs) were having appropriate annual physical health monitoring according to the Maudsley guidelines (1). Content of presentation: An EMIS search was conducted in a GP surgery serving a population of 4400 patients, to identify patients on antipsychotics for a minimum duration of 1 year, of which 21 satisfied the criteria. Their notes were then reviewed and monitoring was compared to the standard set of 80%.
Relevance/impact: Although atypical APs are advantageous in causing less extrapyramidal side effects, other effects such as weight gain, diabetes and hyperlipidemia are more common, affecting compliance as well as morbidity and mortality. Antipsychotics can also induce hyperprolactinaemia that impacts sexual well-being, fertility and bone health.
Outcomes: Of the patients that satisfied the inclusion criteria, 5%, 81% and 14% had complete, incomplete and no annual monitoring, respectively. 76% of FBC, 52% of blood lipids, 57% of glucose, 75% of LFT, 62% weight and 5% of prolactin monitoring was completed.
Discussion: Although, the audit standard was not met, the majority of incomplete monitoring was due to the absence of prolactin testing which may be due to discrepancies in guidelines. Suggestions proposed to improve monitoring included computer alerts, automated SMS reminders and an allocated staff member responsible for completing monitoring, trained in help available such as weight loss services. References Maudsley Prescribing Guidelines, 11th edition. Taylor D, Paton C & Kapur S. Informa Healthcare, London 2012.
260 Challenges in changing clinical practice in the diagnosis and management of urinary tract infections in primary care
Urinary tract infection (UTI) is a major source of inappropriate antibiotic prescribing fueling microbial resistance. This retrospective audit evaluated compliance of a rural general practice to Public Health England (PHE) guidance on diagnosing/ managing UTI in primary care. Consultation records from February to October 2015 coded ‘suspected UTI ’ from non-pregnant females >18 years were included in this study.All 34 (100%) patients audited were given empirical antibiotics; whilst correct antibiotics, dose, treatment frequency, and length of course was given to 32 (94%), 29 (85%), 29 (85%) and 9 (26%) patients respectively. 8 (24%) patients were given empirical antibiotics appropriately in line with guidance without the use of dipstick.
However, in no patients were dipsticks used appropriately to diagnose and manage UTI. Compliance with PHE UTI diagnostic guide was 12%. PHE antibiotic primary care guidance had higher compliance at 73%, but was still below the 80% standard. The practice was re-audited six months later following recommendations to improve compliance. However, compliance to both UTI diagnostic and antibiotic guidance remained below standard at 3% and 66% respectively.Factors underlying resistance to change in clinical practice and antimicrobial stewardship is complex. Informal discussions with clinicians highlighted many factors including managing patient expectation, lack of familiarity with guidelines, entrenched behavior informed by clinical experience, desire to maintain patient rapport and good outcomes.
This audit identified areas for clinical improvement for the practice and also exposed potential cultural/behavioural factors that need to be addressed to achieve this. The practice is actively pursuing such strategies including constructing and implementing a local protocol based on PHE guidance.
261 The management of physical health concerns in patients with severe mental illness: an extended clinical audit
Objectives Do patients on the Mental Health register (MHR) also have their physical health care needs met?Content An extended clinical audit (QoF as the auditable standard) was undertaken for patients (n=154) on the MHR at an inner city practice. Interrogation of clinical notes identified measurement of blood glucose, cholesterol, body mass index, smoking and alcohol data over 12 months, and, whether patients received appropriate intervention.
RelevanceThe physical health care of patients with mental health problems lags behind the general population. Patients with severe mental illness suffer early mortality and increased morbidity. There have been initiatives to improve this, such as the Lester Tool (1).
Outcomes 44% of patients on the MHR had a co-morbid long term physical condition: obesity (24%), hypertension (17%) or diabetes (20%). 50% of patients on the MHR were smokers (higher than the general population). 37% of patients on the MHR were not screened for physical health parameters.
Discussion The drive towards parity of esteem and parity of outcomes still needs to be better translated into care of the physical health needs of patients with mental illness in primary care. Patients with severe mental illness experience both a health gap, and a treatment gap. A confluence of factors, including funding, resource, and access, mean that patients with SMI find it difficult to obtain healthcare and doctors find it challenging to provide gold standard care. (1) Shiers DE, Rafi I, Cooper SJ, Holt RIG. 2014 update (with acknowledgement to the late Helen Lester for her contribution to the original 2012 version) Positive Cardiometabolic Health Resource: an intervention framework for patients with psychosis and schizophrenia. 2014 update. Royal College of Psychiatrists, London.
262 Can we improve groin hernia referral and expedite appropriate care in high risk groups?
Aim: In 2013 the ASGBI published Groin Hernia Guidelines. This study investigated whether these improved referral quality and identified which patients should be seen urgently, and ascertain if obtaining imaging caused delays.
Method: 3 GP practices’ hernia groin referrals to secondary care, from May 2013 – November 2015 were reviewed retrospectively. Patients’ records were reviewed for demographics, hernia type, unilateral/bilateral, recurrence, referral urgency, ASA and prior imaging. Compliance with guidelines was recorded. Results: 112 patients, 7 female, 105 male, age range 22-88 years (median 65). ASA 1-34, 2-51, 3-23, 4-4. 12 urgent referrals, 88 routine, 11 not referred, 1 private referral. Only 62.5% (70 of 112) of referrals were appropriate. 21% underwent ultrasonography prior to referral. 8 patients with irreducible symptomatic hernias were referred routinely rather than urgently.
Conclusion: This study demonstrates that the presence of guidelines for primary care is insufficient as a significant number of referrals were inappropriate, potentially impinging on limited secondary care resources. There was a failure to identify patients at risk and expedite referrals. Imaging prior to referral caused unnecessary delays. The existing guidelines need to be implemented more rigorously. Delivering an educational program to support these may improve compliance and therefore improve groin hernia management.