The posters below were submitted to the South West London ICS Quality Improvement Conference 2023. All of the posters were reviewed by an expert panel of judges from outside of South West London ICS, with a selection being presented at the conference.
Patient safety QI posters
Find out more about some of the quality improvement work happening in patient safety across South West London ICS.
Patient safety
Dr Michael Masucci, Dr Ana Florea, Grace Konadu and Dr Muhammad Amaran – Epsom and St Helier University Hospitals NHS Trust
Background
AMS aims to improve efficacy and reduce adverse effects of antibiotic use by reducing inappropriate prescribing. Overuse of broad-spectrum IV antibiotics and failure to de-escalate leads to antimicrobial resistance (AMR) and longer hospital admissions. Antimicrobial resistance (AMR) is of growing concern to public health. Previous studies have shown AMS associated with reduction in length of stay (LOS) and costs of care.
Dr Melissa Truman, Dr Iyunade Ajibola, Dr Wallace Tan, Dr Rechard Rawoo – Croydon Health Services NHS Trust
Background
We aimed to assess antibiotic prescriptions on Wandle 1 Ward and compare these to trust guidelines to determine the number how many differed from these recommendations.
GP partners, Practice Management, Clinical Pharmacist, GPs, Nurse, Health Care Assistant, Senior Administrator, Reception Team – Sutton Medical Centre
Background
Problem – Unmet need for Osteoporosis management at Sutton Medical Centre
- Lack of medication reviews
- Patient is affected
- Compliance issues adverse GI effects
- Drug interactions drug bioavailability
- MHRA (June 2011) long-term risks of Osteocronosis of jaw and atypical fractures
Jessica Bishop, Alice Stroud – South London and Maudsley NHS Foundation Trust
Background
Young people presenting to mental health services often have unmet holistic care needs. Through the research and rationale, it has been identified that young people benefit from having a community care plan in place to support their direction of care.
Rebecca E. Christian, Dementia and Delirium Clinical Nurse Specialist – Epsom and St Helier University Hospitals NHS Trust
Background
Dementia and delirium are some of the main factors contributing to patient falls
It is also a trigger factor in “behavior that challenges”. Early identification helps in provision of person-centered care; reducing risks and improving quality of care delivery for older persons in hospital.
Dr Monika Nawrocka, Clinical Lead for Acute Home Visiting Service Team – Sutton Primary Care Networks
Background
The Acute Home Visiting Service was established in 2018 and was led by GPs until 2021 and is now led by paramedics. Since then we have continuously worked to improve the service, increase capacity and ensure patient safety. Since 2021, we have increased staff capacity by 200%.
Reena Barai, Community Pharmacist, S G Barai Pharmacy
Background
Valproate is a treatment for epilepsy and bipolar disorder. Children born to women who take valproate during pregnancy are at significant risk of birth defects and persistent developmental disorders. Therefore, MHRA set guidance in 2018 that valproate medicines must not be used in women or girls of childbearing potential unless a Pregnancy Prevention Programme (PPP) is in place. Despite awareness of this issue, according to a safety report issued in 2020, three babies per month are still being born after exposure to valproate. The devastating issue of sodium valproate has been described by Henrietta Hughes, the patient safety commissioner, as “a far bigger scandal than thalidomide.”
Susan Kitaka – Epsom and St Helier University Hospitals NHS Trust
Background
Venous thromboembolism (VTE) is a leading cause of potentially preventable harm. Randomized controlled trials have demonstrated that VTE prophylaxis, when administered completely, significantly reduces the risk for deep vein thrombosis, pulmonary embolism (PE), and fatal PE (Streiff and Lau, 2012). Non-administration of VTE prophylaxis medication is a pervasive problem in both academic and community hospitals, where 10–15% of doses are not administered. Nearly half of hospitalized patients missed ≥1 dose (Lau et al., 2018).
Florence Ilegbusi, Lead Nurse for Continence Service, Clinical Nurse Specialist – Epsom and St Helier University Hospitals NHS Trust
Background
The process on Frank Deas Ward is that any patient admitted with urinary catheter or requiring a urinary catheter inserted in hospital should have their catheter checked using the parameters in the catheter care bundle to ensure good quality catheter care for the patient. In the course of continence round it was discovered on Frank Deas Ward that catheter bundle was not being followed.
Project team
- Annabelle Keegan, Deputy Director of Midwifery
- Holly Hill, Practice Development Midwife and Lead for Maternity Helpline
- Sarah Paramasivam, Midwife Lead for Maternity Helpline
- Lisa Massey, Specialist Senior Midwife and Maternity Governance Lead
- Angela Gallon, Obstetrics Administrative Assistant
- Ed Jebson, Improvement Programme Manager
- St George’s University Hospitals NHS Foundation Trust
Background
During the Covid lockdowns where we had to limit patient attendance at the hospital, the Maternity team used telephone & virtual appointments to successfully maintain contact with patients. The use of telephone contact enabled patients to continue to receive timely advice and guidance and supported collaboration between hospital and community-based staff. The trust successfully bid and received funding from the Health Foundation Q Community enabling the design and set-up of a new dedicated maternity helpline service for patients and external partners.
Background
80 patients identified to be on iron supplements with inadequate monitoring. Some patients were on dual iron supplements. Several patients showed normal Hb and raised Ferritin levels. Queried clinical need to be on iron supplements which led to a QI project.
South-West Division Community Nurses Indigo Team, Gemma Allen, Anita Owusu and Karleen Huggins – Central London Community Healthcare NHS Trust
Background
Personalised care was part of a much bigger project across community nursing in Southwest Division. Self-care was a primary driver looking to improve independence. The Indigo team covers a complex caseload with various challenges.
Dr J Martin, Miss A Nanda, Mr R Booth, Miss S Ceraldi, Mr P Dent – Croydon Health Services NHS Trust
Background
The aims of this project were to reduce the need to re-prescribe medications from patients admitted under surgery, and to reduce delays to medications being given.
Project by Ana Weithers, Sepsis Clinical Specialist Nurse – Epsom and St Helier University Hospitals NHS Trust
Background
Sepsis remains the hidden killer in the NHS until now; 52,000 lives are lost to sepsis every year in the UK. Early identification and treatment are the key elements of improving outcome in sepsis. Under the NHS Long Term Plan all hospitals are required to deliver the best possible practices for identifying and treating sepsis.
The sepsis screening tool provides healthcare professionals with a method of supporting the decision-making process to identify sepsis and those patients likely to require escalation and urgent treatment in both primary and secondary care settings (Edwards et al, 2019). Unwarranted variation was identified as a result of ongoing Sepsis quality standard audit (NICE – QS 161), identifying the opportunity for improvement in the compliance and use of sepsis screening throughout the Trust.
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