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Quality Improvement case studies

QI Case Study 1: Increase the knowledge and confidence of Anaesthetists at managing dental trauma

Background

Dental injury is frequently encountered during anaesthesia and is the most common cause of medico-legal claims made against anaesthetists.

Dental trauma, and in particular avulsion, is even more likely when anaesthetising children as they often have immature root completion in addition to more elastic alveolar bone compared with adults. The prompt management of these cases is the most important factor in ensuring these teeth will have the best successful long-term prognosis. As a result, it is essential for all those involved with anaesthesia to have the knowledge to confidently deal with dental trauma, especially in a children’s hospital such as Great Ormond Street.

Aim

To assess and improve the level of knowledge anaesthetists had of dental trauma, enabling better patient outcomes should dental trauma arise.

Don’t forget an aim should be measurable and timely

Method

I produced a survey which was sent both electronically and in paper form to the

Anaesthetics Department at Great Ormond Street Children’s Hospital. This survey was kindly filled out by thirty-four members of the Anaesthetics Department ranging from Consultants to Anaesthetic ODPs. The following eleven questions were asked on the survey:

  • What is your current level of training?
  • Do you usually consent for dental trauma?
  • Have you encountered dental trauma during intubation?
  • If so, during what kind of procedure have you encountered dental trauma most frequently?
  • Are you aware of local guidelines in management of dental trauma?
  • Are you aware of national guidelines in management of dental trauma?
  • The final five questions involved different clinical scenarios which tested their knowledge on a range of situations involving dental trauma.

Results

  • Only 29% of anaesthetists always consent for dental trauma despite the fact that 65% had encountered it during their career.
  • 59% of anaesthetists incorrectly believed there were local guidelines for managing dental trauma and only 35% were aware there are national guidelines.
  • 59% of anaesthetists would not know how to manage an avulsed adult tooth from a fit and healthy ten-year-old boy
  • 26% of anaesthetists would incorrectly reimplant an avulsed baby tooth.
  • 24% of anaesthetists would incorrectly reimplant an avulsed adult tooth on a patient who suffered from infective endocarditis.
  • 48% of anaesthetists did not know milk was the best storage media for an avulsed adult tooth if not reimplanted straight away.

PDSA Changes

  • The creation of a presentation on ‘How to deal with Dental Trauma’ which has
  • been electronically sent to all Anaesthetists in the Hospital
  • The creation of local dental trauma guidelines based on the national guidelines for Anaesthetists.

Conclusion

The survey highlighted that the management of dental trauma was a weakness for many anaesthetists with a number of deficiencies relating to lack of dental knowledge and confidence. I believe that through the implanted changes of this quality improvement project many of these deficiencies will be addressed, and as a result patient care will be greatly improved.

QI Case Study 2: Paediatrics Sepsis

Context

The improvement work was undertaken as part of Reducing Sepsis Mortality at Basildon University Hospital NHS Foundation Trust. It is a clinical ward base programme involving Multi-disciplinary Teams

Problem

Paediatric Sepsis 6 was rolled out nationally in 2015. Prior to this time, we were not using any sepsis pathway and staff were unaware of sepsis bundle. The emergency department has the highest volume of attendances of un-well children but there is nothing in place to enable staff trigger sepsis alert on the system. There was no training on sepsis awareness and Sepsis cases were not identified on time.

Assessment of problem and analysis of its causes

Baseline data was collected and analysed, and the main problem was administering antibiotics within the 1st hour of booking in. A deep dive into the cause showed that target is not met due to the amount of time it takes to do Lumbar punction on suspected sepsis before Ceftriaxone infusion is given. Sepsis awareness was minimal.

Aim

100% compliance with Paediatric Sepsis pathway by 31st December 2016

Intervention

  • Weekly team meeting
  • Measurement for Improvement- Smart Aim, drivers, real time process measurement and cycles of PDSAs
  • Lean- we eliminated unnecessary time spent: the antibiotic given was an infusion, we changed this to a drug that could be administered by bolus and just as effective.
  • Project Management- We used our workbook to monitor our task completion.
  • Theory of constraint- We removed the bottle neck of not being able to flag suspected sepsis by adding the command to the system and that took off going through 100+ notes to measure adequate identification and treatment of sepsis.

 Strategy for change

  • Project Team was formed, and they meet weekly to analyse data collected and test their changes.
  • Consulted with pharmacist to change from Ceftriaxone infusion to Cefataxime as first line IVAB given a bolus rather than infusion.
  • System modified to include sepsis triggering
  • Sepsis awareness day in all paediatrics area
  • Training to Dr’s & Nurses
  • Sepsis trolley (Ordered May 2016)
  • Posters in clinical area
  • Sepsis included at Ward meetings, huddles and handover
  • Review in real time all proformas completed to measure compliance with 6 components

Measurement for improvement

Outcome measure – number of Sepsis Mortality.

Process measures were derived from 4 CQUIN measures.

Balancing measure – number of antibiotics is reviewed and discontinued to avoid unnecessary Antibiotic administration.

Method: 7 tests of changes (PDSA) were done.

Effects of changes: Sepsis awareness created

  • Children with suspected sepsis were identified in a timely manner.
  • Real time measurement of all sepsis cases for learning and sharing.
  • Enthusiasm among the project team members to carry on the improvement
  • Staff Morale has increased

Lessons learnt

  • Always have a pathway and proforma that people will follow
  • Recurrent teaching and real time measurement are key to improvement

Message for others

“It had worked, just get committed”