Quality Improvement Posters 1021 – 1026
1021 Identifying frailty to prevent falls in the at risk population
Background: Frailty is a multifactorial health state in which patients have reduced resiliance to medical events and environmental changes, resulting in significant morbidity and mortality. Falls are a leading cause of disability and death in the elderly population.
Aim: This quality improvement project explores how frail patients can be identified using the electronic frailty index (eFI) and how this can enable preventive measures to be put in place to reduce falls in the frail population.
Method: 22 patients were identified with an eFI score of 0.25 (lower end moderate); their SystmOne records were analysed for patient demographics, falls, bloods pressure recordings, polypharmacy and medication reviews over a 12 month period. The patients then participated in telephone interviews.
Outcomes: The mean age for low-moderate frailty score was 70 (range 39-89). 32% had a documented fall on SystmOne, however 60% of the cohort reported a fall on the telephone, suggesting the true number of falls was much higher than recorded. 95% of the patients had had their blood pressure checked, however only 14% had had a postural blood pressure recorded. Polpharmacy was common and the mean number of repeat medications was 9 (range from 3-15), 91% of patients were on at least one ‘high falls risk’ medication, the most common being antihypertensive and analgesics.
Recommendations: The eFI on SystmOne can be could be used as a screening tool for those at risk of falls, and it can prompt focussed medication reviews, postural blood pressure checks and referrals to falls prevention services.
1022 Quality improvement for diabetes care
Aim: To pilot the use of quality improvement methods and tools at general practice level in diabetes care.
Relevance/impact: Over four million people in the UK live with diabetes mellitus and the prevalence is rising. Effective control and monitoring can reduce mortality and morbidity. Much of the management of diabetic patients especially type 2 is undertaken in general practice. The National Diabetes Audit (NDA) showed there was a variation in performance in process and control indicators and there was potential for general practices to improve their care.
Methods: Three CCGs and one Local Welsh Health Board were selected with their clinical leads for diabetes to be involved in this project. They were supported by two RCGP clinical QI leads through training and mentoring to enable them to work with up to six practices each. Practices were selected in most cases where there was seen to be room for improvement as demonstrated by their NDA data. Each practice was to choose at least one area for improvement and using quality improvement methods and tools introduce an intervention, plan its introduction and test its effectiveness.
Outcomes: The poster will illustrate how these practices have progressed, the improvements that have been achieved and the barriers they have encountered.
Discussion: Collecting and displaying the results from the NDA may be the first step in improving diabetes care and further action needs to be taken. QI tools in this project have been shown to be one way to achieve further improvement.
1023 ECG monitoring in patients on high-dose methadone in a community based substance-misuse service
Aims: Review current practice of electrocardiogram (ECG) monitoring in patients on high-dose methadone (≥100mg/day) against 2007 DoH guidelines. Identify scope for improvement. Recommend and implement changes.
Content: A quality improvement project was carried out at a substance-misuse service providing community-based opiate-substitute treatment (OST); a retrospective study of patients on high-dose methadone within the final quarter of 2015. Re-audit scheduled for the final quarter of 2016 after implementing recommendations.
Relevance: Prevalence of opiate use in the North East region is just under 10 per 1000 population; well above the national average of 7/1000. OST is a mainstay of maintenance and recovery provided by specialist substance-misuse services and General Practice alike. High-dose methadone has been associated with prolonged QTc and risk of Torsades-de-Pointes.
Outcomes: The service prescribed OST for 256 patients; Methadone–191, buprenorphine–65. Twenty-three patients were prescribed high-dose methadone (12% methadone patients). Nine of these (39%) had been requested to have an ECG within a year of audit date. Four patients had an ECG within a year (17% of all high-dose, 44% of those asked), 2 of which were abnormal.
Discussion: Compliance with national guidelines was disappointing both in terms of service provision and patient compliance. The multifactorial causes of this demanded a holistic approach to reviewing the system and making recommendations. Improvement strategies included raising prescriber awareness through education and computer prompts, increasing patient awareness through information leaflets distributed by pharmacists, recovery workers supporting patients in accessing ECGs, and improving the administration system for filing ECG reports.
1024 Quality Improvement in a Primary Care Vasectomy Service
Quality Improvement in a Primary Care Vasectomy ServiceIntroduction: Our Practice has offered vasectomies to patients registered in GP practices across our region for the past decade. As a result, this has shifted the provision of this service locally to Primary care.
Aims: The aim was identify areas for development in the productivity and efficiency of the service, applying ‘lean’ thinking to streamline and improve patient flow. This intended to provide the opportunity to embrace technological innovation, maximise utilisation of resources and improve patient experience.
Content: Data was compiled from January 2015 to March 2016, comprising the number of cases performed each session and the time taken to perform each procedure. Patient satisfaction survey results were also analysed. Baseline data preceded an improvement programme, which was developed using quality improvement methodology.
The interventions included: The implementation of a pre-recorded video explaining the procedure, played during the patient’s pre-operative ‘check-in’ to aid the consent process. Reduction in the number of days when procedure is performed to create one list, one day per week at one site.Full use of three adjoining rooms to the procedureIncreased utilisation of Healthcare Assistants.
Results: The post-intervention data revealed an increase in productivity of up to 40% each month, with an increase of cases per session, reduced DNA rates and a reduction in the number of sessions held. Patient experience increased after the improvement measures. Discussion: The implementation of service improvement methodology has not only improved productivity, but the patient experience of the service. We feel that this improvement programme has the potential to be replicated in other day-case community settings.
1025 Creating dementia friendly GP surgeries: A systematic approach
Aims and Objectives Creating Dementia Friendly Communities was a key commitment of the Prime Ministers Challenge on Dementia, 2012. This programme has been championed across the UK and all sectors of the community have been encouraged to get involved. In response to this, Wessex Academic Health Science Network established a systematic approach for GP surgeries to become ‘Dementia Friendly’: the iSPACE model.
Summary of Work iSPACE stands for Identify a Dementia Champion within the GP surgery; Staff training; Partnership with patients, carers and the voluntary sector; Assessment and oversight of use of medication (e.g. antipsychotics); Care planning and use of tools such as ‘This is Me’; Ensuring the environment supports people with dementia. We will outline the set of actions within each of these categories.
Outcomes There are currently 120 GP surgeries across Wessex involved in the process of becoming Dementia Friendly, and adopting the iSPACE approach. Approximately 80 practices have received training from the iSPACE team. Quantitative data indicate that in-house training is improving clinicians’ confidence in managing dementia. Qualitative feedback from practices indicates they highly value this systematic approach. “There are a lot of quick wins that make a real difference to staff and patient”. “We found we were already doing a lot of it – it was about bringing it all together to help raise awareness”.
Discussion and relevance This model provides a systematic way of checking that all aspects of care is patient-centred and ‘Dementia Friendly’ within GP surgeries.
1026 Can a trigger tool approach engage busy clinicians in work around safety?
The Problem Working in general practice can feel like you’re running on a hamster wheel that is spinning faster and faster. The way we work, high risk and high volume, and the pressures we are under set us up to make mistakes.The challenge for busy GPs is knowing where to look to understand more about how safe their practice is.
The approach Trigger tools are not new. However, the design has drawbacks that are likely to limit uptake by busy GPs – they are reliant on random case reviews which are labour intensive and generate a lot of ‘noise’ and not enough ‘signal’ when it comes to flagging-up patient safety incidents. We developed and alternative approach using Emis-based searches to identify patients at higher risk of harm. Searches covered a range of clinical activity: prescribing, critical diagnoses and results handling. Searches were complemented by smart worksheets which guide clinicians through a reflective process in a way that is straightforward and can be completed in minutes. Completed worksheets can be exported in one click, with patient identifiers removed, to your appraisal folder. So it can be used as evidence of reflective practice for revalidation.
Findings We have undertaken over 200 casenote reviews. Trigger tool searches identified actions that need to be taken to remedy potential patient safety problems in 45-90% of cases reviewed. GPs value the trigger tool approach.
Discussion It is possible to engage busy GPs in reflective work around patient safety when their activity is focused in a meaningful way. The ‘plug and play’ design of the trigger tool searches and worksheets mean that they can be easily used by other practices.