Quality Improvement Posters 1007 – 1013
1007 Innovation in quality improvement of Asthma Care in Children
The Paediatric Asthma Project is all about improving quality and access to Children’s community respiratory services through innovative and high quality service re-design. This places the child at the heart of the project. The project was initiated in response to the unfortunate sudden deaths of 2 children with asthma. Slough CCG commissioned an independent review that found no individual practice concerns, however the report recommended an overall review of asthma care.Women’s Clinical group consisting of four GPs took the initiative to run this project.
QIPP targets were established and monitored through performance management meetings. Main areas of work included: Practice Visits: The scope of the visits covered Audit data,asthma management policy, improving access through PMCF Clinics, and funding diploma courses for nurses. Newly designed Paediatric Asthma Template with additional EMIS codes: This is used to record Asthma reviews. Personalised asthma action plan(PAAP) is incorporated in the template, stored in the Patient records and copies printed for parents and school. Community Asthma nurses: Main role is to work across the community, school and hospital, post discharge follow up, GP referrals and Education. Asthma Video: Newly developed Informative short film is being shown in Practices and Children centres. Educational meetings: Main topics were on diagnosis, difficult asthma, BTS and acute wheeze guidelines.The impact of the project was evident by reduction in the Asthma admissions.
Through effective team work and excellent collaborative working the team influenced the structure and the process of Paediatric asthma care .The working group were one of the four finalists for the Annual GP awards.
1008 Development of a Web Based Trainer Re-approval Process Caroline Mills
The GMC demand high training standards in general practice to maintain a safe and motivated workforce. Training practices need to be committed to deliver these standards to ensure safe, effective clinical and educational environments for GP trainees. The GP quality team needed to be able to assess GP trainer re-approvals effectively and efficiently to ensure these standards are met and delivered. This process needed to be a uniform process across the area. Therefore an innovative, simple, accessible process for submission and review of the evidence was needed.
The criteria and evidence for practice and GP trainer re-approval are based on GMC and COGPED guidance. A web based process was developed to upload the GP trainer submissions and allow the GP quality panel to perform a virtual panel review of the evidence. As part of the submission trainers completed a satisfaction questionnaire and the result of this were used to modify and develop the web application.
The survey asked 3 questions on clarity of instructions, guidance and ease of use. A five point rating scale was used, rating from excellent to poor. For the current version of the application the mean and median rating in all areas was 3 which correlates with ‘average’. Survey results confirm an acceptable system for trainers to submit evidence for trainer re approval. There is easy access to evidence for the quality team assessors to enable virtual panels. The web application continues to be developed to improve satisfaction for the trainers and the quality team members.
1009 Evaluation of a Paediatric Consultant-led Telephone Advice service for General Practitioners
Aims: To evaluate uptake, timing and usefulness of a new Paediatric telephone advice clinic at a DGH.
Content: Local GPs currently have two choices when referring for a paediatric opinion – immediate A&E assessment or 8-week wait for outpatient review. We surveyed the existing referral system and asked local GPs on options to improve primary-secondary care communication. Using results we developed a telephone advice service using existing resources. GPs make an online referral and are then allocated a next day slot. They are contacted by the attending Consultant Paediatrician. Local CCG funded telephone advice clinic from 04/2015.
Relevance: Previous surveys identified 16% of phone calls to on-call team were for advice only. 21% of OPD referrals could have been alternatively managed. 28/30 local GPs asked for access to consultant-led telephone advice. After 6 months of the service referrals received were reviewed retrospectively.
Outcomes: 63 referrals were received in six months. 37 referrals (59%) were managed in primary care after advice and no further referral made. Only nine (14%) telephone consultations led to Paediatric OPD referral and one (8%) led to a same day ED referral.
DiscussionThe telephone advice clinic fills a gap requested by local GPs to improve the interface between primary and secondary care. Based on the current uptake rate it has the potential to prevent over 70 OPD referrals a year, (10% reduction in annual referral rate).There is scope to improve take-up by GPs as only 21% of available slots were utilised in this first 6 months.
1010 Improving antimicrobial prescribing practice for sore throat symptoms in a general practice setting
Acute sore throat is a common presentation in primary care settings. We evaluated our practice against national antibiotic guidelines. The guidelines are based on Centor criteria. A retrospective audit of 102 patient records with sore throat symptoms presenting between 1 January to 30 December 2015 showed that over 50% were given antibiotics. Of those prescribed antibiotics, 27% did not meet NICE criteria and 85% of patients were given immediate antibiotic prescription. Centor criteria was documented in just 2% of cases. Compliance with correct antibiotic course length was 15%. Antibiotic choice and dose was correct in 94% and 92% of cases respectively. Antibiotic frequency was correctly prescribed in 100% of patients.
We introduced interventions that included oral and poster presentations to multidisciplinary team, dissemination of guidelines through internal e-mail system and systemic changes to GP electronic patient record system EMIS. This involved creating an automated sore throat template and information page. On re-auditing of 71 patients, compliance with NICE criteria was 87% with a significant reduction in immediate prescribing (66%). Centor criteria documentation was 42%. Correct antibiotic course length was prescribed in over 30% of cases. Other antibiotic regimen parameters (choice, dose and frequency) were correct in 100% of cases.
The initial results demonstrated that significant changes were needed. In particular, reducing the amount of antibiotic prescribed by increasing compliance with NICE criteria and ensuring all parameters of antibiotic prescription were correct. We showed that significant sustainable improvement is achievable through carefully devised automated systemic changes that provides critical information accessible format. Interventions resulted in decrease in immediate antibiotic prescription, significant increase in Centor criteria documentation and increasing compliance with the correct course length of antibiotics.
1011 Implementation of CHA2DS2VASc and HAS-BLED risk scoring tools in patients with atrial fibrillation
Aims/objectives: To assess whether the stroke and bleeding risks of patients with atrial fibrillation are being calculated according to the current NICE guidelines at a local GP practice.Method: 61 patients were identified using the electronic system (EMIS Web) as having Atrial Fibrillation. Searches were carried out to see how many patients had their stroke and bleeding risks assessed since June 2014 using the CHA2DS2VASc and HAS-BLED tools, respectively.
Results: No patients had any CHA2DS2VASc or HAS-BLED scores recorded on the system. It was identified that there were no templates on the system for either of the scoring tools making it harder for the GPs at the practice to calculate the stroke and bleeding risk scores.
Conclusions: A new template for both scoring tools was created. Recommendations were made to use this template annually in all patients with atrial fibrillationDiscussion: It is important to stay up to date with the latest guidelines and the latest risk scoring tools. Implemeting these changes as soon as possible aids in improving the quality of patient care.
1012 DMARDs monitoring; patient safety at the interface between hospital and community care
Aims To assess compliance with gold-standard guidelines for the monitoring of disease modifying agents at a city centre general practice, with a view to indentifying causes of shortfallings detected and devising a plan with which to address them.
Content The notes of all registered patients prescribed DMARDs within a 12 month period were reviewed for the presence of a shared care protocol, compliance to regular blood monitoring and medication reviews.
Relevance The management of several chronic conditions such as inflammatory bowel disease and rheumatoid arthritis with disease modifying agents has become more commonplace. According to NICE, this should always be as part of a shared care protocol. The adverse effects of these medications can include neutropenia, thrombocytopenia, deranged LFTs and renal impairment. As such, the regular blood monitoring of patients on these agents is imperative.
Outcomes Overall, there was a 31% compliance with recommended blood monitoring within our patient group. Only 6% of patients had a shared care protocol available in their notes and 50% of patients had an up to date medication review.
Discussion Significant variation existed between patients depending on which hospital (and consultant) their care was under, both with regards to detail of clinic letters and where blood monitoring was carried out. Glitches in apparent monitoring were also explained by hospital admissions, missing clinic letters/blood results and patients receiving private consultant input. Poor shared care protocol compliance seemed largely attributable to consultant/GP communication channels, with investigations currently underway to assess this shortfalling. Patient empowerment and subsequent ownership over their condition was identified as an issue crucial to sustainable improvement in this area.
1013 Antenatal risk assessment by General Practitioners – can we improve the care we give to pregnant women?
Aims/Objectives This quality improvement project was designed to improve antenatal care provided to pregnant women attending their first GP appointment.
Relevance/Impact This initial appointment occurs usually around 8 weeks gestation, and presents an ideal time for high quality early pregnancy care, prior to midwife booking (which locally doesn’t occur until 10-12 weeks.) This care includes high dose folic acid (where indicated), good diabetic care, and early assessment of VTE and pre-eclampsia risk, all of which are time critical activities in early pregnancy which can significantly improve pregnancy outcomes.
Content of Presentation Current practice was audited, showing high referral rates to secondary care (36%), poor documentation of risk assessment (12-38%), and wide variability in lifestyle screening and advice provided (4-46%). Local GP trainees also completed a questionnaire highlighting wide variation in practice and knowledge and low confidence. These findings correlated well with secondary care audits identifying high levels of inappropriate, late and incomplete referrals. An antenatal risk assessment proforma was introduced at two local practices that included clear referral indications, risk assessment tools and a lifestyle advice checklist. The same proforma was also distributed to GP trainees for use in their practices, alongside a teaching session about its use and current guidelines/best practice.
Outcomes Re-audit of practice showed significant improvement in levels of risk assessment, lifestyle advice given and a reduction in referral rates to secondary care.
Discussion This simple change in practice led to significant and sustainable improvements in patient care, which will be presented. Challenges and further work are also explored.