Learning To Make a Difference
Documentation of lumbar punctures Neurology DIU
Dr Michal Rolinski
Dr Hannah Rowe
Supervised by Dr M Turner
ORH NHS Trust
Learning To Make a Difference
Background
•
First lumbar puncture (LP) performed in 1891
•
Although common an LP is an invasive procedure
•
Previous audits (1-3) have shown LP documentation to be poor
•
Raised concerns over consent and technical aspects
ORH NHS Trust
Learning To Make a Difference
Project Aims
•
To improve the quality of LP documentation on the Neurology DIU
•
To improve technical aspects of the procedure, specifically the sending of
paired serum glucose
ORH NHS Trust
Learning To Make a Difference
Action Planning
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make
that will result in
improvement?
•Increase in LP documentation
meeting required standard
•Increase in samples sent with
paired serum glucose to 100%
•Good documentation is
essential for patient safety.
•Sending paired serum glucose
enables accurate interpretation
of results and diagnosis
•Formal education session
•Information leaflet
ORH NHS Trust
Act
Plan
Study
Do
Learning To Make a Difference
Lumbar puncture process
Indication
for LP
Documentation of
results and actions
Patient consented
Results chased and
acted upon
LP
performed
Documentation
of procedure
Samples sent
ORH NHS Trust
Learning To Make a Difference
Methods
Lumbar puncture indicators
Indication
Contraindications
Consent documented
Position in which the LP was performed
Use of aseptic technique
Type of anaesthetic used
Dose of anaesthetic used
Site of spinal needle insertion
Size of spinal needle used
Number of attempts at needle insertion
Opening pressure
Any peri-procedure complication?
Post-procedure advice given
LP results documented
•
14 important indicators in
LP documentation identified pre data collection (box 1)
Fig1
ORH NHS Trust
14 January, 2011
QIP timeline
Month 0
Month 1
Month 2
Month 3
Learning To Make a Difference
Data collection
•
26 patient notes reviewed
•
LP’s performed by 7 SHO’s ( 2 FY2’s, 3 CT1’s, 2 CT2’s)
•
No formal LP training undertaken prior to QIP
ORH NHS Trust
Learning To Make a Difference
What difference has been made?
ORH NHS Trust
Learning To Make a Difference
LP documentation
 Pre-intervention median indicators documented =
8/14 fig3
 Consent documented in 8/9
 Less than half had 




indication (22%)
contraindications (33%)
position LP performed (22%)
site of spinal needle insertion (33%)
spinal needle size (44%) fig4
Fig 3
ORH NHS Trust
Learning To Make a Difference
LP documentation
Indicators
Indication
Before interventions
After both interventions
p value
22%
33%
89%
22%
57%
86%
86%
100%
0.3024
0.0601
1.0000
0.0032
Type of anaesthetic used
78%
78%
100%
100%
0.4750
0.4750
Dose of anaesthetic used
67%
100%
0.2125
Site of spinal needle insertion
33%
100%
0.0114
Size of spinal needle used
44%
86%
0.1451
Number of attempts at needle
insertion
89%
100%
1.0000
Opening pressure
89%
100%
1.0000
Any peri-procedure
complication?
55%
100%
0.0885
Post-procedure advice given
55%
100%
0.0885
LP results documented
0%
43%
0.0625
Contraindications
Consent documented
Position in which the LP was
performed
Use of aseptic technique
Fig 4
ORH NHS Trust
•Majority of indices improved after
interventions
•Position LP performed p=0.0032
•Site needle inserted p=0.0114
•Documentation indication (57%) and LP
results (43%) remained poor
•After both interventions 100%
documentation of 9/14 indices
•
Fig4
Learning To Make a Difference
Paired serum glucose
• Paired serum glucose samples sent
increased to 100%
• p=0.0885
Fig 5
ORH NHS Trust
fig5
Learning To Make a Difference
Discussion
• Interventions led to a significant improvement in the documentation of LP’s and
doubling of the number of paired serum glucose samples being sent to 100% fig5
•Disappointingly, pre-intervention no notes had LP results documented this only
increased to 43% fig4
•Likely due to DIU closing and notes being sent to secretaries/coding (most LP’s
performed in the afternoon)
ORH NHS Trust
Learning To Make a Difference
Next Steps
 LP leaflet currently going through departmental approval process
 Aim to provide LP education session and information leaflet as part of
induction process to all SHO’s starting Neurology rotation
 Create a file on DIU to hold records with outstanding LP results
 We have learnt that simple interventions can make a difference!
ORH NHS Trust
Learning To Make a Difference
References
1) Baer Et. Post-dural puncture bacterial meningitis. Anaesthesiology, 2006; 105(2): 381-93
2) Dakka Y, Warra N, Albadareen RJ, Jankowski M, Silver B. Headache rate and cost of care
following lumbar puncture at a single tertiary care hospital. Neurology.2011; 77(1): 71-4
3) Vallejo MC, Mandell GL, Sabo DP, Ramanathan S. Postdural puncture headache: a randomised
comparison of five spinal needles in obstetric patients. Anesth Analg. 2000; 91(4) 916-20
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