Audit and Practice Survey Posters 271 – 277
271 The identification and management of anaemia in pregnancy to prevent antenatal and postnatal complications
Anaemia in pregnancy is estimated to be 24.4% in the UK(Barroso, Allard, & Kahan, 2011), and is associated with reduced immune function, pre-term labour, low birth weights, post-partum haemorrhage (PPH) and iron deficiency in the newborn in the first 3months of life. Our audit looked at the identification and management of pregnant women both antenatally and postnatally. This was a re-audit from 2014, which found identification in the community was poor and access to prescriptions for iron tablets was challenging. An education programme was put in place to stress the importance of identifying and treating anaemic women, with a failsafe mechanism to chase results and liaise with the GP. The new guidelines that followed this audit advised midwives that those who are anaemic should be retested in 4weeks after treatment to assess response. Our audit found that 97% of women were screened for anaemia at 28weeks, 8% were anaemic and of those, 40% were not treated. The rechecking of haemoglobin within 4weeks only occurred in 20% of the anaemic women and women known to be anaemic were not identified in labour increasing their risk of PPH. To improve this we have created a simple flow chart highlighting how to identify and manage anaemia in pregnancy, to be circulated to midwives and GPs. We plan to use this as a teaching tool and appendix to the maternity notes as a anaemia in pregnancy tool. By correctly identifying anaemia in pregnant women, we as GPs can work together with midwives, to help support our pregnant women, prevent associated complications and improve outcomes for both Mum and baby.
272 Dipeptidyl peptidase-4 inhibitor therapy for non-insulin dependent diabetic patients in general practice
Aims/Objectives: Quantify our adherence to NICE guidelines concerning Dipeptidyl Peptidase-4 (DPP-4) inhibitor therapy for Non Insulin Dependent Diabetics in General PracticeEvaluate active protocols for monitoring diabetics in General Practice.
Content of Presentation: NICE guidelines stipulate that DPP-4 inhibitors should only be continued if patients demonstrate a reduction of at least 5.5 mmol/mol in HbA1c over a period 6 months.75 patients are currently prescribed a DPP-4 inhibitor in our practice19 patients have been excluded due to insufficient data A retrospective analysis involving 56 patients was conducted
Relevance/Impact: Diabetic patients require regular monitoring to minimise the occurrence of vascular complications and reduce the risk of hypoglycaemia.
Outcomes: Within six months of initiating therapy:47 patients had an HbA1c check and 9 patients did not37 patients showed a reduction of at least 5mmol/mol and have remained on treatment16 patients did not demonstrate the recommended reduction but their treatment remained unchanged2 Patients demonstrated the recommended reduction but their treatment was discontinued1 Patient did not demonstrate the recommended reduction and their treatment was discontinued
Discussion:The majority of patients (66%) showed an average HbA1c reduction of approximately 9.9 mmol/ mol and their medications have been continued as a result. Unfortunately, a large proportion of patients (30%) had their treatment continued against NICE guidance. We have constructed a digital proforma/ programme which enables early and timely recognition of diabetics requiring future HbA1c checks, follow up appointments, and medication reviews. It also ensures that only patients who have achieved the recommended reduction in HbA1c are continued on a DPP-4 inhibitor.
273 Clinical audit: Review of the uptake of recommended immunisation for vaccine-preventable infections in 100 patients living with HIV in London
Objectives: The uptake of recommended vaccines were audited in a random sample of 100 HIV-infected patients in London in the light of current recommendations.
Content of Presentation: Cases were selected from our specialist clinic. Demographics were collected and immunisation history was requested from the GP. The results were audited to the standards defined by the British HIV Association guidelines on the use of vaccines in HIV-positive adults 2015.
Relevance: Even in the era of effective antiretrovirals, people living with HIV are more susceptible to infections. Vaccination is an important preventive measure in this population however coverage rates appear insufficient and related publications are sparse. Although new recommendations have been published by specialist bodies, there is a paucity in the evidence to guide immunisation practices. In our hospital, we have been concerned about the correct implementation of these recommendations in practice.
Outcomes: 97 records were available. 37 patients were from the UK and of non-UK origin, 50 were from Africa. Years lived in the UK ranged from 5 to 40 years among patients with non-UK origin. 48 patients contracted HIV in the UK, the others primarily in Africa. Of the 71 immunisation histories received, only 6.1% of patients received at least one dose of Hepatitis B vaccine. As few as 36% and 25.7% received influenza vaccination in the past two seasons respectively and only 32.9% had Pneumococcus vaccines. 2.1% received Pertussis, 7.2% Meningococcus and 24.7% at least one dose of Hepatitis A vaccine. Discussion: Vaccination coverage in adults living with HIV in London appears insufficient when audited against current recommendations. Strategies should be developed to aim to improve this.
274 Assessing whether patients taking the oral contraceptive pill had a face-to-face contraception review by the clinical team in the last 12 months
Introduction: Yearly routine follow-up in women taking the OC pills is vital for re-assessing risk factors and monitoring any health changes. A retrospective audit was carried out in an urban GP practice with 9784 patients to assess compliance with the UK Medical Eligibility Criteria (MEC) for contraceptive purposes is highly recommended by FSRH.
AimsTo identify the number of patients taking the OC pill who have had a face-to-face review between January 2015 and January 2016.To investigate whether these follow-ups involve checking on the following parameters: BP, migraine and smoking status.To analyse the performance and compare it to the FSRH clinical guideline. The set standard was 100%.
Methods: Of the 363 patients who had the OC prescribed, a convenience sample of 53 sequential patients prescribed the OC pill was analysed.
Results: Among the 53 patients, 33 (62%) had a face-to-face review by a GP or nurse in the last 12 months. Among the 33 patients, 9 (27%) did not have their BP checked, 16(48%) was not asked about migraine, and the smoking status of 14 (42%) was not reviewed. The smoking status of one patient aged ≥35 years was not checked.
Conclusion: The practice did not meet the set standard. After discussion at a practice meeting, it has been agreed by the clinical team that the contraception template on the system must be used to document face-to-face review and it has been updated to reflect best practice.
275 The compliance of walkden medical centre to the guidelines set by the british society for rheumatology for managing gout
Gout is the most common inflammatory arthropathy seen in primary care and guidelines for optimum management have been published by the British Society for Rheumatology (BSR). Despite this, research has shown that treatment for gout varies significantly across the country with sub-optimal care being described in many practices.
The purpose of this audit was to establish how well the guidelines for gout management were being followed in one general practice. After collecting data from the practice, I was able to see how often vital investigations involved in gout management were performed on patients by their general practitioners and whether the guidance set by the BSR regarding the pharmacological and non-pharmacological management for gout were being adhered to. The guidelines state that: all gout patients should have annual measurements of their serum uric acid and urea & electrolyte levels, the uric acid level in patients should be maintained below 300µmol/L and all patients should be given lifestyle advice regarding their gout diagnosis.
My results showed that this practice currently does not meet the criteria set by the BSR and I expect that similar results would be found in many practices across the country. One way to increase general practitioners’ (GPs) adherence to the BSR guidelines so that the standard of care given to gout patients is uniform and adequate across all practices could be by implementing the gout guidelines into the Quality and Outcomes Framework (QOF) incentive given to GPs.
276 Meeting the challenge of holistic diabetes care in an overseas setting – Defence Primary Healthcare (DHPC)
9,000 soldiers, sailors and aircrew, with their families, are posted to a Mediterranean island to support ongoing missions to the Middle East and beyond. This transient population reside in multiple locations across the 100km long island, supported by three medical centres. This poses logistical challenges for the management of chronic conditions, including medication procurement and monitoring.
The aim of this audit was to assess the holistic management of diabetes, beyond those key care processes of the National Diabetes Audit, and include those further parameters identified by NICE. The initial findings highlighted many gaps in equipment, knowledge and clinical care, resulting in a robust discussion at the cross-island MDT, including consideration of whether DPHC were actually able to clinically support such patients.
As a result of this audit, lead practitioners were identified, staff training organised, and a systematic approach initiated, including the establishment of Diabetes Clinics and improvement of patient communication and access. The audit cycle completed six months later demonstrated great improvements (for example, achievement of NDA Eight Care processes increased from 33% to 83% T1DM; 24% to 61% T2DM).
Furthermore, the authors have developed an easy and comprehensive electronic template to enable more effective diabetes reviews and recommend that DPHC incorporate this across the Defence electronic records (DMICP, or it’s successor); and also recommend that DPHC now consider appropriate staffing solutions to ensure that the necessary knowledge and skills is maintained on island to continue this excellent chronic disease management.
277 Management of chlamydia-positive patients in a ‘SHIP’ practice in central Birmingham
Relevance/Impact: Genital chlamydia is the most common sexually transmitted infection (STI) in the UK. Left untreated, chlamydia can lead to consequences such as pelvic inflammatory disease. General practices are beginning to provide sexual health services through the Sexual Health In Practice (SHIP) scheme. The British Association for Sexual Health and HIV recommends that measures should be taken in all chlamydia-positive patients to treat appropriately, take a full sexual history and undertake partner notification. It also recommends that chlamydia-positive patients are tested for other STIs including HIV.
Aims:Review the treatment of chlamydia-positive patients.Identify the proportion of patients with which partner notification was discussed.Identify the percentage of patients who were tested for other STIs following a positive diagnosis of chlamydia.Ascertain the proportion of patients who received contraceptive advice.
Content: The cohort for this audit were sourced from a general practice in central Birmingham and included all patients diagnosed with chlamydia over a five-year period. The practice is part of the SHIP scheme, with appropriate facilities for the treatment of chlamydia alongside other STIs.
Outcomes: The audit uncovered several areas that need improvement in the management of chlamydia in general practice: location of treatment, contact tracing, contraceptive advice and post-diagnosis STI screening.
Discussion: Increased awareness of STI treatments and the need for clear documentation of STI consultations are key in chlamydia management in general practice. Improved understanding and management of chlamydia-positive patients in general practice will aid prognosis and reduction of disease transmission.