Quality Improvement Posters 1027 – 1033
1027 Improving care planning for care home residents
Care planning for acute illness and end of life is a vital part of looking after patients in Care Homes. It is often done or actioned poorly leading to inappropriate admissions of vulnerable patients in an already over stretched system. Experience suggested this was sometimes occurring in a 120 bed care home that the practice provides medical services to. We decided to investigate this problem and trial solutions taking a Quality Improvement approach.The content of care plans were examined retrospectively for all patients in the care home (n=166) between January 2014 and April 2016.
All hospital admissions were assessed to determine if plans were followed. Nurses were questioned to assess their understanding of the care plans. A prospective study of staff contacts with out of hours and emergency services was initiated.The retrospective data showed 91.5% of patients had a care plan recorded and coded in their notes. 38 (22.9%) patients were admitted to hospital. 13 (34.2%) of these admissions were contrary to the documented care plan including 8 who died in hospital.
The prospective data from the initial 2 months has shown that 1 out of 24 (4.2%) episodes of contact with out of hours and emergency services was contrary to the written care plan. A colour coded system has been implemented to provide clearer information to staff; the prospective study of emergency contacts is continuing to assess the impact of this intervention. The project has also identified wider systems issues that will require separate interventions.
1028 Optimising prescribing in vitamin D deficiency
Introduction: The National Diet and Nutrition Survey reports that up to a quarter of people in the UK have low Vitamin D (25-hydroxyvitamin D <25 nmol/L). 112 adults (1.6% of our 6896 practice population) were prescribed colecalciferol-containing products over a 6-month period. A practice meeting revealed that clinicians lacked confidence in prescribing either maintenance or high-dose replacement regimens. 46% (23/50) of patients were prescribed generic colecalciferol, despite local guidelines advising prescribing cost-effective brands. 10% (5/50) were prescribed non-UK licensed brands.
Whilst we were better at prescribing maintenance regimens that complied with local prescribing guidelines, there was little consistency in the prescribing of high-dose replacement (90% (18/20) of maintenance regimens adhered with local prescribing guidelines compared with only 20% (4/20) of high-dose regimens).
Aim: To improve clinicians’ confidence and concordance with best prescribing practices. Method: I introduced an Emis template that facilitated selection of the correct preparation (brand, strength and duration) based on the patient’s Vitamin D level. This included links to a concise summary of local guidelines and a patient information leaflet. One month later, the data was re-audited and clinician confidence was evaluated via questionnaires.
Results: 12 patients were prescribed colecalciferol-containing products in this month. 75% (9/12) received high-dose replacement and 25% (3/12) maintenance. 91.6% (11/12) adhered with local guidelines. Clinicians’ confidence increased from 3/10 to 9/10.
Evaluation: This study supports the adoption of the Vitamin D Emis template as it led to better prescribing practices and improved clinician confidence. [250 words] ReferenceData from years 1 and 2 of the National Diet and Nutrition Survey (NDNS) rolling programme.
1029 Improving the patient pathway and reducing GP workload by direct optometrist referral to ophthalmology
Background: The ongoing pressures in General Practice have been well documented. Areas of practice have been identified nationally that could be reworked to benefit both the patient and GP workload. The aim of this project was to look at the current local referral pathway to ophthalmology and identify ways, if any, in which it could be improved.
Methods: The local referral pathway was mapped and data was collected regarding the number of ophthalmology referrals made, those which were seen by the optometrist requesting referral and the time taken in practice to make the referral. This was aimed to quantify the time taken in practice (GP and administrative) to manage referrals.
Results: The data indicated that for each 1000 listed patients, 12 optometry referrals were made over a one year period. Taking into account the time taken, this could release up to three hours of GP time and similar amounts of secretarial time each month.
Conclusions: ‘Forwarding’ on referrals to other specialties places a significant burden on general practice. Enabling systems and processes that allow direct referral can reduce the burden on primary care, improve the patient pathway, and increase GP availability to see problems that require GP input. In addition it can reduce the secretarial burden to focus on other tasks. The poster will describe the changes/refinements that can be made to the referral process.
1030 Quality Improvement in Struggling practices through energising patient participation groups
Aim Making sense of the complexities of the clinical workplace is challenging for students. In addition to developing emergent clinical reasoning skills, the provision of a safe, peer-driven environment is essential to allow students to debrief and reflect on experiences. We aimed to achieve this through small group student-led sessions facilitated by GPs possessing the ideal skill set.
Method Within the context of programme revisions at our Medical School the opportunity arose to expand and refine existing teaching models. A focus group of students exploring the concept of Clinical Debrief identified the importance of evolving longitudinal content and providing structure to the session whilst remaining student led. These ideas were developed in light of a literature review resulting in a novel learning experience.
Outcome Details of clinical debrief will be presented. There is considerable emphasis on continuity of tutors and groups supporting effective clinical supervision. Content is primarily student generated from real cases supplemented by additional themes of increasing complexity across the year, using trigger materials such as longitudinal case studies. This provides a framework for tutors to explore competencies for practice whilst remaining responsive to student needs.
Discussion Medicine is more than knowledge; students need to learn to think and behave like doctors. Although this may be ‘caught’ we believe it should also be ‘taught’. Clinical Debrief provides this opportunity, and through role-modelling, we hope tutors will promote GP as a positive and potentially academic career choice.
1031 Perception of quality improvement in general practitioner trainees in the East Midlands
N K Gill-Banning
Aims To understand the perceptions of quality improvement in general practitioner trainees and challenges faced by their trainers.
Contents An anonymous survey with multiple choice questions was distributed across 277 trainees between 1st and 14th October, 2015. 310 Educational supervisors who consented were interviewed between February and May 2016.
Relevance This provides some evidence around quality improvement culture in the East Midlands as opposed to none. It evolves the possibility of investing in key areas that come out of this work to bridge the gap between trainees, trainers and service providers.
Outcomes 26.2% trainees and 20% trainers responded. This is a limitation and is likely to reflect those that are interested in the topic or educational matters in general on the background of current work pressures in NHS.72% and 78% had never heard of Pareto and Statistical process chart respectively. 2% trainees with lean six sigma knowledge received external training outside NHS.100% trainers did not know QI tools despite using PDSA technique. They relied on significant event analysis for quality improvement. 75% of them understood evidence based QI and the remaining cohort found QI to be error-reactive and specific to a person’s willingness to improve.
Discussion There is low knowledge of QI amongst GP trainees in the East Midlands but it is better than other regions. Major impetus is required to train willing trainers about the tools, techniques to redesign services. Providing trainees protected time to do QI along with mentoring would help. A cultural shift is required to bridge the educational gap.
1032 Improving Healthcare in a 24 Hour Care Setting: an Outcome Audit
Background: Care home residents often have multiple morbidities and complex social needs, and are therefore prone to episodes of illness requiring emergency medical interventions. Practical and organisational factors causing delays in access to primary care services can result in more frequent hospital admissions and poorer health outcomes.
Aims: To reduce the number of illness episodes requiring unplanned medical intervention in a nursing home, through fixed enhanced primary care services. These included regular GP visits and improved anticipatory care planning.
Methods: Setting: 24 Hour care nursing home. Population: 18 residents of a nursing home during two inclusion periods: 17.07.15 – 17.01.16 and 15.02.16 – 15.08.16. Design: Mirror image outcome audit.
Results: Changes to primary care provision significantly reduced the average number of illness episodes suffered per resident. A reduction in the time taken for illness episodes to be correctly identified trended towards significance. Non-significant changes observed were the proportion of episodes caused by chronic disease, and the likelihood of episodes resulting in admission.
Discussion: This study shows that simple changes to primary care provision in care homes can improve the standard of health care received, and reduce the use of acute services. These findings are consistent with a growing body of evidence supporting the use of enhanced primary care services in care homes. This has implications for residential care providers, clinical commissioning groups and primary care providers.
1033 Managing hyperpolypharmacy through medication reviews in the population aged 75 or above
Hyperpolypharmacy is a growing problem in the population aged 75 or above, both in terms of costs for the NHS, and side effects for patients. Patients taking ten or more medications are 300% more likely to be admitted to hospital, more likely to suffer drug side-effects and adverse reactions, and are a growing burden on NHS resources. Medication reviews are a key way to help practices address this problem.
This clinical programme, conducted in a GP practice, aimed to clinically assess and implement medicines related interventions within this population currently being prescribed ten or more medicines. This involved: The risk stratification of population aged 75 or above; Extracting a wealth of data, considering the number of QOF registers the person is registered on, the number of GP consultations in the previous 12 months and the number of hospital/A&E admissions; The development of an electronic template for medications reviews; Conducting Level 2 and Level 3 medications reviews; Documenting and analysing outcomes to facilitate any prospective follow up with patients.
In total, 608 Level 2 medication reviews were completed, with 365 progressing to Level 3 medications reviews. These resulted in interventions including, 640 medications stopped, 121 GP reviews, and 89 dose reductions. The saving from medication interventions was £18,113, with an assessment additionally identifying 49 avoided hospital admissions, which saved the NHS £107,800. Thus the total saving made from this programme was £125,913.61. This clinical programme is sustainable, scalable, and replicable in other practices and CCGs.