Clinical Audit Annual Report
2013/14
Report by: Stuart Metcalfe, Clinical Audit & Effectiveness Manager.
Date: June 2014.
Introduction from the Chair of Clinical Audit Group ............................................................................ 3
1. Report from the Clinical Audit & Effectiveness Manager ................................................................. 4
1.1
Clinical Audit & Effectiveness Team ................................................................................................................................ 4
1.2
Clinical Audit Group ........................................................................................................................................................ 4
1.3
Forward Planning ........................................................................................................................................................... 4
1.4
Annual Quality Report .................................................................................................................................................... 5
1.5
National and Regional Involvement ............................................................................................................................... 5
2. Programme Key Performance Indicators ......................................................................................... 6
2.1
Introduction and explanation of statistics ...................................................................................................................... 6
2.2
Summary ‘dashboard’ of Key Performance Indicators ................................................................................................... 7
2.3
Comment on Key Performance Indicators ...................................................................................................................... 8
3. Divisional summaries and tables ..................................................................................................... 9
3.1
DIAGNOSTICS & THERAPIES ............................................................................................................................................ 9
3.2
MEDICINE ...................................................................................................................................................................... 16
3.3
SPECIALISED SERVICES .................................................................................................................................................. 24
3.4
SURGERY, HEAD AND NECK .......................................................................................................................................... 29
3.5
WOMEN’S AND CHILDREN'S ......................................................................................................................................... 38
3.6
NON-DIVISION SPECIFIC ................................................................................................................................................ 49
Appendix A - UH Bristol Clinical Audit Staff (as at April 2014) ............................................................. 50
Appendix B - Clinical Effectiveness & Outcomes Strategy Action Plan ................................................. 51
Appendix C - Progress against Clinical Audit Forward Programme 2013/14 ........................................ 53
Appendix D - University Hospitals Bristol Clinical Audit Forward Programme 2014/15 ........................ 55
Appendix E - National audit participation (extract from Quality Report 2013/14) ............................... 70
Clinical Audit Annual Report 2013/14
Page 2
Introduction from the Chair of Clinical Audit Group
Clinical Audit is an essential tool to assess and improve the standards of care that we deliver. Used skilfully it
brings together professionals from many disciplines to improve the quality of clinical services.
Over the last year we have been challenged to assure both the Board and the Non- Executive Directors that
the Trust’s clinical audit program is meeting the needs of UH Bristol. In response to this we have reviewed our
processes, tried to ensure that our activity aligns to corporate and board objectives and that there is greater
ownership and visibility of audit within the Divisions. I would like to thank Start Metcalfe for the extraordinary
amount of work he has done to provide Divisions with the information they require to support and develop
their audit activity.
This year’s report again shows a clinical audit programme with a balance of projects initiated in response to
guidance issued by the National Institute for Health and Care Excellence (NICE), the National Patient Safety
Agency (NPSA), the Medical Royal Colleges, and projects initiated in response to local priorities.
Scrutiny of outcomes and action reports at each meeting of the Clinical Audit Group has continued this year.
We hope that this adds value to the projects and helps facilitates the implementation of actions where
appropriate. I would like to thank the Clinical Audit & Effectiveness Team for all their work in producing these
reports and for their dedication to the successful running of the clinical audit programme. You will see many
examples in this annual report of positive outcomes of clinical audit projects and we will continue to build on
this in the future. I would also like to thank all the Clinical Audit Convenors for their role in leading the clinical
audit programme within their Divisions and specialties and for their involvement in the work of the Clinical
Audit Group on behalf of the Trust.
Finally we are embarking on a survey to understand better how clinical audit functions in comparable trusts.
This is a significant undertaking, but one we hope will be invaluable in informing how we should take our
service forward. The results of this should be available later in the year and will be reported to Clinical Audit
Group and the Trust Audit Committee.
Anne Frampton
Chair, Clinical Audit Group
Clinical Audit Annual Report 2013/14
Page 3
1. Report from the Clinical Audit & Effectiveness Manager
1.1 Clinical Audit & Effectiveness Team
During the financial year 2013/14, clinical audit at University Hospitals Bristol NHS Foundation Trust was
supported by a team of 3.8 whole time equivalent (WTE) Clinical Audit Facilitators (CAFs) and one 0.8 WTE
Clinical Audit Clerk, employed by the Trust Services Division. Additional support is provided by a number of
other staff employed by the Clinical Divisions with a specific remit for clinical audit; primarily data
management for individual national clinical audit projects. The Clinical Audit & Effectiveness Team (CAET) also
includes a designated NICE Manager with a remit for coordinating assurance information relating to the
implementation of NICE guidance in all its forms. Full details of the team and the Divisions/specialties they
support can be found at Appendix A of this report.
In March 2013, the CAET completed the final phase of a ‘lean’ exercise as part of the Trust’s Transformation
Programme; the centralisation of the Team, physically located within Trust Headquarters. Having previously
been located within clinical areas, this was a major change for the service and for the CAFs. I would like to
thank the team for their part in embracing this change with vigour and enthusiasm.
Outside the process of centralisation, a number of other workstreams were agreed as part of this lean
exercise. These workstreams, along with other actions relating to the function of clinical audit, were
incorporated into an overall Clinical Effectiveness and Outcomes Strategy agreed in May 2013. The progress of
actions relating to clinical audit has been monitored by the CAG and the position at the end of the year can be
found at Appendix B.
1.2 Clinical Audit Group
The Clinical Audit Group (CAG) is the Trust’s lead group in relation to all matters relating to the practice of
clinical audit, supporting both the ‘Clinical Effectiveness’ and ‘Patient Safety’ dimensions of the NHS model of
Quality. The Group met five times during the financial year 2013/14 to enable discussion of core business, i.e.
annual forward plans, quarterly key performance indicators and project progress reports on registered activity.
At each meeting, the CAG reviews summary outcomes and actions reports from completed clinical audit
projects to ensure that results are clear and that robust action plans have been produced. Where this is not
the case, the CAG will seek further clarity from the project lead or from within the CAET before accepting the
project as complete. There are also instances where the Group determines that the outcomes would be
relevant to the work of other corporate governance/risk groups or other areas of the Trust. In this case, the
Group will recommend wider dissemination of the results as necessary. The CAG reports into the Trust Clinical
Quality Group on a quarterly basis, highlighting any relevant risk issues.
1.3 Forward Planning
Each year, Clinical Divisions/specialties agree a programme of planned clinical audit activity for the
forthcoming financial year. This process is co-ordinated by the CAET and overseen by the CAG. Each year’s
plan reflects agreed priority projects, based on considerations such as anticipated Trust/Divisional quality
objectives, National Clinical Audits, Commissioning priorities, national guidance (NICE, Patient Safety Alerts,
Royal College) and local clinical priorities. Progress against this plan is closely monitored by the CAET and CAG
(as is all registered activity) and reported to the CAG and the Trust Audit Committee. Overall progress against
this plan can be found at Appendix C, with further Divisional/specialty detail found within Section 3 of this
report.
The past year of reporting to our the Audit Committee has prompted a number of challenges about how best
to use the information that we report and how best to provide the necessary assurances the committee
require. The team has worked hard over the year to try and meet these requirements, developing new
Clinical Audit Annual Report 2013/14
Page 4
reporting processes as the year has gone on. Standard reporting into Divisions/specialties is in the process of
being implemented to allow more visibility of activity and better help the Team highlight/manage exceptions
where the progress of projects is not as expected. The process has also highlighted further opportunities to
improve our Clinical Audit Project Management database. This work will continue throughout the next
financial year.
The annual clinical audit forward plan for 2014/15 has been put together after wide consultation with
clinical/nursing staff and Divisional Quality/Safety Groups. To improve compliance with the plan, progress will
be monitored not only by the Clinical Audit Group but through regular reports into these Quality/Safety
Groups.
Projects have been prioritised based on priority areas for clinical audit as outlined within the Healthcare
Quality Improvement Partnerships (HQIP) ‘Clinical Audit Programme Guidance’. The full plan can be found at
Appendix D
1.4 Annual Quality Report
A mandated statement about participation in national clinical audits has been included in the Trust’s Quality
Report for 2013/14. The relevant extract has been reproduced at Appendix D of this report. As outlined
within this statement, the Trust has a duty to provide information on the actions taken and improvement
made as a result of clinical audit activity. This information can be found within the changes and benefits
section of Divisional reports (Section 3 of this report)
1.5 National and Regional Involvement
The Clinical Audit & Effectiveness Manager is the current Chair of the South West Audit Network (SWANS); a
regional forum bringing clinical audit professionals together to share best practice through presentations,
discussion and networking. This work is supported by the Healthcare Quality Improvement Partnership
(HQIP). The Chair of SWANS also represents the network on the National Quality Improvement & Clinical Audit
Network (NQICAN – previously the National Audit Governance Group), a national peer group consisting of
representatives from regional clinical audit networks/forums, including representation from the Department of
Health and Royal Colleges. NQICAN works closely with the Department of Health, HQIP, NICE and other
relevant national bodies to further the development of clinical audit within the NHS.
Stuart Metcalfe, Clinical Audit & Effectiveness Manager
Clinical Audit Annual Report 2013/14
Page 5
2. Programme Key Performance Indicators
2.1
Introduction and explanation of statistics
All project information for this report is taken from the UH Bristol Clinical Audit Project Management
Database. The statistics presented are based on registered activity during the financial year 2013/14. This
includes projects started in previous years and not yet complete as well as projects newly registered in
2013/14.
The definition of terms used as KPIs is outlined below:
Project registered
before start
Ongoing monitoring
(continuous) audit
Re-audit
NICE guidance
National
Interface
Proposal form completed and approved before commencing a project.
The continuous collection of data in order to measure practice. Ongoing audit should
involve regular review of data and implementation of changes in practice (where
necessary) in order to improve performance.
The repetition of an audit project in order to measure whether practice has improved
since the initial audit.
Audits relating to standards/recommendations from the National Institute of Health
and Care Excellence.
Denotes national audits, e.g. those audits part of the National Clinical Audit & Patient
Outcome Programme (NCAPOP), audits required for the annual Quality Report and
other Royal College/other professional bodies’ national audits.
Audit of care across organisational boundaries in the patient pathway, e.g. patient
referrals in from primary care to UH Bristol.
Multi-specialty
Involving a specialty/specialties other than the specialty under which the project has
been registered.
Multi-professional
Involving more than one profession (e.g. nurses and doctors).
Projects with patient
Involvement
Patients/carers involved in one or more of the following: identification of audit topic;
developing audit idea/project design; carrying out audit project; receiving audit
results.
Clinical Audit Annual Report 2013/14
Page 6
2.2
Summary ‘dashboard’ of Key Performance Indicators
Project registered before start
On-going (continuous) monitoring
Re-audits
Abandoned
Deferred
NICE guidance
Projects with patient involvement
National
Interface
Multi-specialty
Multi-professional
Completed projects
Action Plan produced
Confirmed good/acceptable practice #
Report produced
41
93%
4%
25%
2
0
4%
3%
7%
0%
25%
41%
37
86%
14%
97%
Medicine
91
57
72%
3%
15%
2
0
25%
3%
14%
0%
16%
33%
46
96%
4%
93%
Non-division specific
3
0
0%
33%
0%
1
0
0%
0%
0%
0%
67%
33%
2
100%
0%
50%
Specialised Services
47
22
77%
13%
21%
6
0
28%
2%
13%
0%
19%
23%
14
86%
14%
71%
Surgery, Head and Neck
118
62
82%
10%
31%
13
5
8%
8%
12%
3%
22%
25%
42
76%
24%
71%
Women and Children's
173
72
79%
23%
29%
16
1
15%
3%
6%
0%
21%
49%
77
96%
3%
70%
TOTAL (2013/14)
507
254
80%
13%
26%
40
6
15%
4%
10%
1%
21%
37%
218
90%
9%
80%
TOTAL (2012/13)
513
N/A
N/A
13%
26%
58
15
16%
5%
10%
1%
28%
46%
194
90%
10%
78%
New in year
75
Total number of projects *
Diagnostic and Therapy
* In progress (including ongoing monitoring audits) or completed during the year, this includes projects started in previous years and not yet complete. All percentages are
based on this total, apart from those in the last four columns which are based only on clinical audits completed during the year.
# please note: this statistic applies only to projects where an action plan was not produced, i.e. there will also have been a number of projects which produced an action
plan, but where practice was nevertheless identified as being of an acceptable standard
Clinical Audit Annual Report 2013/14
Page 7
2.3
Comment on Key Performance Indicators
As one can see from the above table, the results of many of the indicators remain similar to the previous year,
as does the level of overall activity. It is encouraging that the number of abandoned and deferred projects
decreased since the previous report despite the changes in remits of the CA&ET.
Of notable acceptation to this overall trend in 2013/14, is the percentage of projects with multi-specialty and
multi-disciplinary input. Although not reported here, performance has remained fairly constant over the last
three years at around 27% and 45% respectively. There is no obvious reason for this decrease and further
investigation will be undertaken to try and determine why this is the case.
Although the number of new projects started/registered is monitored as part of bi-monthly CAG reporting, this
is the first time that the overall figures have been included in the annual report. Hence there is no
comparative figure shown. Also included this year but not previously, is an indicator outlining the proportion
of activity registered before starting. Given the change in the work and areas covered by the team as a result
of centralisation, it is encouraging to see that the majority of projects have been discussed and registered
appropriately before starting.
Where possible, CAFs will do their best to obtain a formal report at the end of each individual project but this
is not always possible for a number of reasons. What is of vital importance however, is obtaining information
on the outcomes of the work undertaken and the actions necessary to improve practice where the need is
identified. To this end, the fact that the Trust can demonstrate that an action plan was produced in all but 1%
of projects completed is a good achievement.
Clinical Audit Annual Report 2013/14
Page 8
3. Divisional summaries and tables
The following section aims to provides further details of Divisional clinical audit , including relevant key performance
indicators.
3.1
DIAGNOSTICS & THERAPIES
The following chart shows the status at year end of those projects identified as priorities for audit as part of the
forward planning process in 2013/14. Full details of the status of individual projects on this plan can be found within
table 1 of this section.
Progress of planned projects
Complete
In progress
Not started
100%
80%
60%
40%
20%
0%
1
2
3
4
2
3
Diagnostic Services
4
Therapy Services
Prioritisation category
The chart below shows the status at year end of all registered projects (excluding those classified as ongoing
monitoring). Some projects will have started and finished within the financial year, some will have been started but
have yet to complete and are therefore rolled over. The figures also include projects that commenced in previous
years but have now been abandoned, those that previously commenced but were completed in 2013/14 and those
previously commenced but not completed by the end of 2013/14.
Individual project status at year end
20
18
16
15
13
10
10
8
4
5
2
1
2
0
0
Diagnostic Services
New in year/Completed
Clinical Audit Annual Report 2013/14
New in Year/Roll-over
Therapy Services
Rolled-over/Abandoned
Rolled-over/Completed
Rolled-over/Roll-over
Page 9
Percentage of projects egistered before start
100%
Make up of project project team
1
5
100%
80%
80%
60%
60%
24
40%
40%
10
20%
20%
46
23
0%
17
14
Diagnostic Services
Therapy Services
0%
Diagnostic Services
TRUE
Therapy Services
FALSE
Multi-professional
Percentage National Audit
100%
80%
80%
60%
60%
40%
40%
0%
Multi-specialty
Neither
Percentage re-audit
100%
20%
8
2
17
39
20%
46
5
24
Diagnostic Services
Therapy Services
12
7
Diagnostic Services
Therapy Services
0%
TRUE
FALSE
TRUE
FALSE
Guidance/standards type audited
35
31
30
25
20
15
12
11
9
10
9
5
2
1
0
Diagnostic Services
Therapy Services
NICE
Other National
Local
Percentage report produced
100%
Unclassified
Percentage action plan produced
1
100%
5
80%
80%
60%
60%
40%
40%
20%
20%
30
6
0%
26
6
Diagnostic Services
Therapy Services
0%
Diagnostic Services
TRUE
Clinical Audit Annual Report 2013/14
Therapy Services
FALSE
Yes
No - Confirmed good practice
Page 10
Table 1
Title
Sub-Specialty
Lead
Priority Start date
Status Q4
Audit of the management of patients with haemoglobinopathies
Laboratory Haematology Tom Latham
(Blood and Transplant audit programme)
1
Q3
Not started
Audit of patient information and consent (Blood and Transplant
Laboratory Haematology Tom Latham
audit programme)
1
Q4
Not started
Compliance with transfusion procedures
Laboratory Haematology Tom Latham
2
Q1
In progress
Transfusion information availability
Laboratory Haematology Tom Latham
2
Q1
Not started
Audit of microbiology sampling in stillbirth post mortems
Histopathology
Craig Charles Platt
2
Q2
In progress
Audit of double-reporting protocol in colorectal cancer biopsies
Histopathology
Golda ShelleyFraser
2
Q2
In progress
Supplementary reports after MDT meetings
Histopathology
Rob Pitcher
2
Q2
Not started
Audit of reporting of Cutaneous Malignant Melanoma at
UHBristol
Histopathology
Nidhi Bhatt
2
Q2
In progress
Diagnosis of malignancy in endometrial curettage and
subsequent resection specimen
Histopathology
Joya Pawade
2
Q1
In progress
Lung frozen section and paraffin diagnosis
Histopathology
Nidhi Bhatt
2
Q2
Completed
Percentage of pre-treatment non-small cell carcinoma not
otherwise specified (NSCLC-NOS)
Histopathology
Nidhi Bhatt
2
Q1
Completed
Turnaround time for reporting of biopsies suspected
Inflammatory Bowel Disease
Histopathology
Pramila Ramani
2
Q4
In progress
Placenta request forms and macroscopic reporting
Histopathology
Corina Moldovan
2
Q3
In progress
Prophylaxis in orthopaedic surgery
Microbiology
Martin Williams
4
Q3
Not started
Diagnosis and Initial Management of Suspected Communityacquired Bacterial Meningitis in Adults
Microbiology
Ed Barton
4
Q2
In progress
An audit of the use and management of blood glucose point of
care testing results in UH Bristol
Clinical Biochemistry
Paul Thomas/
Graham Bayly
2
Q3
Not started
CT radiation dose audit
Medical Physics &
Bioengineering
Ian Negus
2
Q1
Completed
Nutritional screening of upper gastro-intestinal surgical patients
Nutrition & Dietetics
in pre-op clinic
Tom Lander/Clare
Evans
3
Q2
Not started
Nutritional Screening
Nutrition & Dietetics
Rachel Cooke
2
Q1
In progress
Parenteral Nutrition within Critical Care
Nutrition & Dietetics
Rebecca Pooley
3
Q2
In progress
Documentation Audit
Physiotherapy/
Occupational Therapy
Linda Clarke/Scott
Allan
2
Q4
Not started
South West Quality and Patient Safety Improvement Programme
Pharmacy
(Medicines Management)
Kevin Gibbs
2
Q1
In progress
Re-audit compliance with prescribing policy Medicines Codes
Chapter M2
Pharmacy
Anne Edwards
2
Q2
Completed
Audit of the prescribing and monitoring of sliding scale heparin
infusions
Pharmacy
Jacqueline Criper
2
Q3
In progress
Vancomycin prescribing audit
Pharmacy
Elizabeth Jonas
2
Q2
Not started
Audit of adherence to the pharmacy prescription endorsing
policy
Pharmacy
Elin Wallis
2
Q1
Completed
Audit of medicines reconciliation on transfer between adult
intensive care unit (ICU) and post-ICU wards.
Pharmacy
John Warburton
3
Q2
In progress
Re-audit of insulin prescribing to agreed prescribing bundle
Pharmacy
Kevin Gibbs
3
Q4
Not started
Audit of medicines reconciliation on discharge
Pharmacy
Emily Marshall
2
Q2
In progress
Clinical Audit Annual Report 2013/14
Page 11
Audit of consultant names on in-patient prescription charts and
Pharmacy
out-patient prescription forms
Kevin Gibbs
2
Q1
In progress
Home visit for cystic fibrosis patients on home intravenous
antibiotics
Physiotherapy
Jo Bond-Kendall
4
Q1
In progress
Re-audit Glasgow Hearing Aid Benefit Profile
Audiology
Regina Smith
3
Q1
Completed
Standards for and outcomes of videofluoroscopy referral
Speech and Language
Therapy
Vicki Weekes
3
Q2
Not started
Radiological interpretation recording in notes
Radiology
Sally King
3
Q2
In progress
Appropriateness of radiographic markers
Radiology
Simon Brown
3
Q3
In progress
Vascular interventional radiology outcome data
Radiology
Amit Goyal
3
Q1
Completed
The following activity was also in progress during the financial year (either rolled over from previous year or not identified
through plan):
Ref
Provisional Title of Project
Status
Diagnostic Services - Audiology (Adult)
3347
Re-audit of Real Ear Measurements 2012
Completed
3472
The completion of Glasgow Hearing Aid Benefit Profile in 2012
Completed
Diagnostic Services - Laboratory Medicine/Histopathology
3138
Adherence to double reporting protocol in reporting lung pathology
Completed
3216
Quality of perinatal autopsy in the South-West of England
Completed
3325
Turnaround time for reporting of biopsies of suspected Inflammatory Bowel Disease
Completed
3435
Regional audit of percentage of pre-treatment non-small cell carcinoma not otherwise specified (NSCLC-NOS)
Completed
3436
Audit of placenta request forms and macroscopic reporting
In Progress
3534
Diagnosis of malignancy in endometrial curettage and resection specimen
In Progress
3596
HER2 testing for gastric cancer
Completed
3608
Re-auditing the reporting of Cutaneous Malignant Melanoma at UH Bristol
In Progress
3609
Microbiology sampling in stillbirth post mortems – Re-audit 2012
Completed
3627
Audit of frozen section practice in thoracic pathology
In Progress
3688
Re-audit turnaround time for reporting of biopsies of suspected Inflammatory Bowel Disease
In Progress
3689
Receptor Status in invasive breast cancer reported in UH Bristol in relation to national guidelines
In Progress
3707
Turnaround time in reporting of skin specimens 2012-2013
In Progress
Diagnostic Services - Laboratory Medicine/Infection Control
733
Infection Control Ward/Department audit
Ongoing Project
992
Are all Trust employees complying with the Infection Control Hand Hygiene Policy?
Ongoing Project
3013
Infection Control Environment and Equipment Audit 2011-2012
Ongoing Project
3495
Prospective audit of linen handling and management at ward level 2013
Completed
3540
Vascular Access Management in Intensive Care
Completed
3606
Hand Hygiene Environment: a trust-wide audit of clinical and non-clinical areas
In Progress
3633
Trust-wide Spot Check Sluice/Commode/Toilet Audit
In Progress
3662
Documentation Audit of the recording of Peripheral Venous Cannula in adult ward areas trust wide
In Progress
3709
Re-auditing management of discharge information for patients with an infection/colonisation
In Progress
Diagnostic Services - Laboratory Medicine/Laboratory Haematology
2912
Audit of medical patients with Hb>8g/dl receiving red cell transfusion
Clinical Audit Annual Report 2013/14
Completed
Page 12
3014
National Comparative Audit of the Medical Use of Blood
Completed
3172
National comparative audit of the labelling of blood samples for transfusion - NHS Blood and Transplant
Completed
3451
Audit of consent gained for transfusions as per SaBTO guidelines
In Progress
3452
Use of red blood cell transfusion in haematology patients – a prospective audit
Completed
3541
Re-audit of use of red blood cell transfusion in haematology patients – a prospective audit
Completed
Diagnostic Services - Laboratory Medicine/Microbiology
3308
Is the antimicrobial management of Hospital Acquired Pneumonia consistent with local antibiotic guidelines at UH
Bristol?
Completed
3326
Audit of clinical liaison for alert organism results in microbiology
Completed
3433
Audit of the blood culture contamination rate at UH Bristol
Completed
3434
Diagnosis and Initial Management of Suspected Community-acquired Bacterial Meningitis in Adults
In Progress
3648
Laboratory diagnosis, sample processing and clinical management of invasive candidaemia
In Progress
Diagnostic Services - Medical Physics & Bioengineering
2832
The handover of radiology equipment 2010 - 2011
Abandoned
2911
National Computed Tomography Radiation Dose Audit
Completed
3696
Computed Tomography Patient Radiation Dose Audit – Level 2, BRI
Completed
Therapy Services - Nutrition & Dietetics
3116
Nutrition paperwork audit: a trust wide audit of the key prompts of CQC outcome 5
Completed
3267
Audit of nasogastric feeding practice on Cardiac Intensive Care Unit
In Progress
3274
Dietetic Record Card Audit 2012
Completed
3533
Nutrition: key prompts of CQC outcome 5. A bi-annual audit.
In Progress
3637
Audit of Parenteral Nutrition within Critical Care
In Progress
Occupational Therapy
3290
Audit of the Early Supported Discharge Team for Stroke Professional Standards
In Progress
Therapy Services - Pharmacy
2975
Audit of discharge referrals received by the Postal Anticoagulant Monitoring Service
In Progress
3027
Re-auditing missed doses for critical medication in medical and surgical divisions of UH Bristol
Completed
3055
An Evaluation of Insulin Prescribing Safety in a Teaching Hospital
Completed
3107
Intravenous to oral antibiotic switch – audit of practise within University Hospitals Bristol NHS Foundation Trust
In Progress
3345
Audit on the use of the Potassium Supplementation Standing Order
In Progress
3466
An audit of adherence to the continuous vancomycin infusion guideline for ITU
Completed
3475
Reauditing compliance with prescribing policy – Medicines Codes Chapter M2
Completed
3483
Audit of the Pharmacy prescription endorsing procedure
In Progress
3615
Audit of consultant name on prescription charts
In Progress
3624
Audit of the prescribing and monitoring of intravenous unfractionated heparin infusions
In Progress
3625
Blood test screening prior to commencement of significant cardiovascular drugs
In Progress
3679
Audit of medicines reconciliation on transfer from adult ICU or HDU to post-ICU wards
In Progress
3699
Audit of inpatient prescription chart
In Progress
3706
Audit of Medicines Reconciliation at Discharge
In Progress
Therapy Services - Physiotherapy
3289
Are Anterior cruciate ligament reconstruction patients adhering to the UH Bristol rehabilitation protocol?
In Progress
3384
Acute Stroke Therapy Service against NICE Stroke Quality Standard 5
In Progress
3656
Home intravenous antibiotic standards for the Cystic Fibrosis multidisciplinary team
In Progress
Clinical Audit Annual Report 2013/14
Page 13
Therapy Services - Radiology
2957
Audit of reporting standards of MRI of sacroiliac joints in arthritis
Abandoned
3054
Minimising eye dose in paediatric CT head
Completed
3062
Movement artefact in MRI scans for rectal cancer staging
Completed
3156
A re-audit into the Cardiac Magnetic Resonance Imaging (MRI) Perfusion Service
Completed
3238
Re-auditing non-anaesthetist conscious sedation during interventional radiology procedures
Completed
3255
Abdominal ultrasound examinations performed and reported by Advanced Practitioner Sonographers with or without
discussion with Consultant Radiologist
Completed
3321
Audit of accuracy of CT staging of mesothelioma
Completed
3327
Audit of radiation dose delivered for routine high resolution CT in adults
Completed
3328
National Audit of Standards for the NPSA and RCR Safety Checklist for Radiological Interventions
In Progress
3348
National Audit of Appropriate Imaging
Completed
3437
Audit of GP neuroimaging requests
Completed
3482
Vascular interventional radiology outcome data
Completed
3686
Annual re‐audit of image guided lung biopsies
Completed
3708
Quality of MRI lumbar spine examinations at University Hospitals Bristol
In Progress
3725
Subarachnoid haemorrhage and the use of diagnostic lumbar puncture
In Progress
Therapy Services - Speech & Language Therapy
3401
Re-auditing management of adult dysphagia patients 2012
In Progress
The following section summarises the changes, benefits or actions introduced as a result of completed audits within the
Division/specialties.
3347
This audit demonstrated that the process of recording of real ear measurement was broadly in line with
recommendations. Audiologists have been reminded that all information must be recorded on the database especially
reasons for sounds not recorded.
3472
This audit demonstrated that the completion of Glasgow Hearing Aid Benefit Profile was properly completed. Staff have
been further educated to always document specific reasons of not completing the Profile.
3138
This audit showed good adherence to the double reporting protocol in the reporting of lung pathology.
3216
Clinicians have been advised of the importance of including clinical information in consent form for perinatal autopsy and
the value of examination of placenta together with the stillbirth baby in this regional audit.
3325
As a result of this audit, short codes for macroscopy and a short list of SNOMED codes for Inflammatory Bowel Disease
were developed in order to improve turnaround time for reporting of biopsies of suspected IBD.
3435
This audit demonstrated that the Trust is meeting national standards relating to histological classification of lung cancers
as non-small cell carcinoma not otherwise specified prior to treatment (< 20%).
3596
This audit determined that gastric cancer patients managed at UH Bristol received HER2 testing as recommended by best
international practice. Cases referred to UH Bristol were reported in a timely manner.
3609
The improvement of routine heart blood swab and lung sampling taken from stillbirths for microbiology and virology was
evident in this re-audit. The locally agreed guidelines (including collecting viral PCR samples from the lung) which are
informed in part by national standards, are being followed.
3495
This audit demonstrated that the general principles/processes for linen handling are being followed on most wards. A
poster has been developed to be displayed on the ward trolley/cupboard to show designated coloured bags to be used.
3540
This audit highlighted the importance of documenting central venous line insertions on the Innovian database and making
use of standardised infusion line labels. Current dressing practice has also been reviewed to establish how lines can be
secured more effectively.
2912
This audit led to the promotion/practice of single unit transfusion as established best practice by the Patient Blood
Management Group.
3014
Local transfusion guidelines were updated as a result of this national audit of the medical use of red cells. Data
monitoring based on laboratory records in order to provide continuous monitoring of improvement is being carried out.
3172
Junior doctors are now educated in the correct procedure of labelling of blood samples for transfusion via the Trust’s
induction programme as a result of this audit. A process for rejecting any samples not labelled correctly has been
Clinical Audit Annual Report 2013/14
Page 14
developed.
3452
The audit of red blood cell transfusion in haematology patients helped to promote single unit transfusions.
3541
As a result of this audit, the junior doctor induction programme has been modified to ensure communication of key
recommendations within the Trust’s blood transfusion guidelines (especially red cell transfusion in haematology patients).
A process for reinforcing these recommendations at the point of blood transfusion request has also been developed.
3308
The Hospital Acquired Pneumonia Management guidelines were revised as a result of this audit. Better patient MRSA
screening is also being addressed by the Trust’s MRSA Recovery Plan.
3326
As a result of this audit, the laboratory guideline for the liaison of alert organism results was updated to reflect agreed
changes in practice.
3433
The Trust’s blood culture policy is to be reviewed and modified (including closer links to Department of Health best
practice guidelines. Regular feedback on blood culture contamination rates will be provided to the Emergency
Department and Medical Assessment Unit.
2911
This audit demonstrated that doses from CT scans are within the range seen locally and nationally. Early indications are
that UHBristol’s doses are in line with the rest of the country.
3696
This audit demonstrated that mean radiation doses for standard size patients in Computed Tomography is within required
levels (less than both local and national diagnostic reference levels).
3116
A single audit tool for nutrition paperwork was created as a result of this audit. This will be completed across the Trust
wide to cross check ward based results and monitor progress in compliance with the key prompts of CQC Standards.
3027
The Administration of Medicine Operating Procedure and UH Bristol Medicine Code Chapter M9 were amended as a
result of this audit. The time frame for administration of critical medications and the management procedure of missed
doses have been clarified.
3055
As a result of this audit, a specific subcutaneous insulin prescribing chart has been designed and implemented throughout
the Trust. Guidance for all prescribers to cover the insulin prescribing bundle and the new insulin chart has also been
written and disseminated.
3466
The vancomycin infusion template in ITU is to be modified to include “First level after 15hrs” and a drop down box of
named prescribers has been added to Innovian system as a result of this audit. Vancomycin prescribing information will
also be included in Innovian induction training.
3475
A visual aid to the Trust’s prescribing policy has been developed and is to be given out at junior doctor induction to help
promote good prescribing practice.
3054
A single protocol for paediatric CT head scanning was agreed as a result of this audit into minimising eye dose in paediatric
CT head scans.
3062
As a result of this audit, a cost and logistical analysis of the introduction of hyoscine butylbromide in patients undergoing
MRI scans for staging of rectal cancer was carried out as part of a general review of standards and technique.
3156
This re-audit audit into the Cardiac Magnetic Resonance Imaging (MRI) Perfusion Service demonstrated acceptable
practice.
3238
This re‐audit of non‐anaesthetist conscious sedation during interventional radiology procedures demonstrated that
changes previously implemented had been effective and that procedures and process had improved.
3255
This audit has led to extra training for Advanced Practitioner Sonographers on abdominal ultrasound scanning and the use
of reporting protocols.
3321/
3327
Protocols for CT scanning of the chest in adults (including mesothelioma imaging) are being rewritten as a result of this
audit. This will help maintain improve image quality, standardise technique aim for minimal dosage.
3348
This national audit run by the Royal College of Radiologists demonstrated that imaging at UH Bristol was appropriate.
3437
As a result of this audit into the management of headache in young people and adults, GP requests for CT head will be
changed to MRI head as a way to reduce radiation dose for patients under 50 years old.
3482
The outcomes measured in this audit of vascular interventional radiology demonstrated acceptable practice. Further
audits will be extended to include all interventional radiologists which will improve the study population size and increase
complication accuracy.
3686
This annual re-audit of image guided lung biopsies demonstrated acceptable practice. CRIS codes have been condensed
for interventional chest procedures.
Clinical Audit Annual Report 2013/14
Page 15
3.2
MEDICINE
The following chart shows the status at year end of those projects identified as priorities for audit as part of the
forward planning process in 2013/14. Full details of the status of individual projects on this plan can be found within
table 1 of this section.
Progress of planned projects
Complete
100%
80%
60%
40%
20%
0%
1
In progress
Not started
1
1
1
2
5
3
13
3
2
2
2
3
2
1
1
1
5
2
3
1
Emergency Department
Medical Specialties
Prioritisation category
The chart below shows the status at year end of all registered projects (excluding those classified as ongoing
monitoring). Some projects will have started and finished within the financial year, some will have been started but
have yet to complete and are therefore rolled over. The figures also include projects that commenced in previous
years but have now been abandoned, those that previously commenced but were completed in 2013/14 and those
previously commenced but not completed by the end of 2013/14.
Individual project status at year end
25
22
20
20
20
15
10
10
3
5
3
6
4
1
1
0
Emergency Department (Adult)
Medical Specialties
New in year/Abandonded
New in year/Completed
New in Year/Roll-over
Rolled-over/Abandoned
Rolled-over/Completed
Rolled-over/Roll-over
Percentage of projects registered before start
100%
100%
15
80%
60%
Make up of project team
9
80%
43
60%
40%
40%
20%
15
3
5
25
Emergency Department (Adult)
Medical Specialties
20%
11
56
0%
0%
Emergency Department (Adult)
TRUE
Clinical Audit Annual Report 2013/14
Medical Specialties
FALSE
Multi-professional
Multi-specialty
Neither
Page 16
Percentage National Audit
Percentage re-audit
100%
100%
80%
80%
60%
60%
40%
40%
15
63
8
20%
5
17
60
3
11
Emergency Department (Adult)
Medical Specialties
20%
0%
0%
Emergency Department (Adult)
TRUE
Medical Specialties
FALSE
TRUE
FALSE
Guidance/standards type audited
30
28
25
20
19
20
15
15
10
5
4
4
1
0
Emergency Department (Adult)
NICE
Medical Specialties
Other National
Local
Unclassified
Percentage report produced
Percentage action plan produced
1
100%
80%
2
100%
80%
2
60%
60%
40%
40%
20%
20%
4
39
0%
6
38
Emergency Department (Adult)
Medical Specialties
0%
Emergency Department (Adult)
TRUE
Medical Specialties
FALSE
Yes
No - Confirmed good practice
Table 1
Title
Sub-Specialty
Lead
Paracetamol Overdose (College of Emergency Medicine)
Emergency Department
Paul Reavely
1
Q3
In progress
Severe Sepsis (College of Emergency Medicine)
Emergency Department
Lisa Munro Davis
1
Q3
In progress
Radiology reporting
Emergency Department
Emma Redfern
2
Q3
In progress
Consultant Sign Off (College of Emergency Medicine)
Emergency Department
Anne Frampton
1
Q1
Completed
Community Acquired pneumonia
Acute Medicine/
Emergency Department
Richard Jeavons
3
Q3
Not started
Clinical Audit Annual Report 2013/14
Priority Start date
Status Q4
Page 17
Child protection/C4C
Emergency Department
Lead to be
confirmed
2
Q3
Not started
Chest Drain
Emergency Department
Phil Cowburn
3
Q3
In progress
Sedation
Emergency Department
Rob Stafford
2
Q3
In progress
Prescribing
Emergency Department
Becky Thorpe
2
Q2
In progress
Pancreatitis
Emergency Department
Paul Reavely
3
Q3
In progress
Severe sepsis
Acute Medicine/
Emergency Department
Jessica Triay
3
Q3
In progress
National Hip Fracture Database (NHFD)
Care of the Elderly
Rachel Bradley
1
Q1
In progress
National Audit of Dementia
Care of the Elderly
Julie Dovey
1
Q4
Not started
Stroke National Audit Programme (SSNAP)
Care of the Elderly
Sarah Caine
1
Q1
In progress
VTE prophlaxis management
Care of the Elderly
Peter Murphy/
Sarah Caine
2
Q2
Not started
Thrombolysis management
Care of the Elderly
Peter Murphy/
Sarah Caine
2
Q2
In progress
Management of genital herpes
Contraception and Sexual
Andrew Leung
Health
3
Q3
Not started
Management of early syphilis
Contraception and Sexual
Andrew Leung
Health
3
Q3
Not started
Management of late syphilis
Contraception and Sexual
Andrew Leung
Health
3
Q3
Not started
Management of lymphogranuloma venereum
Contraception and Sexual
Andrew Leung
Health
3
Q3
Not started
HIV testing in patients with lymphoma
Contraception and Sexual
Helen Wheeler
Health
3
Q3
Not started
HIV pepse audit of SARC patients
Contraception and Sexual
Rachel Westwick
Health
3
Q3
In progress
BASE – Sexual Health Outreach services
Contraception and Sexual
Nikki Jeal
Health
3
Q3
Completed
Integrated service at Bristol Sexual Health Centre
Contraception and Sexual
Judith Berry
Health
3
Q3
Not started
HIV Partner Notification
Contraception and Sexual
Andrew Leung
Health
3
Q3
Not started
Emergency IUD
Contraception and Sexual Leonor HerreraHealth
Vega
3
Q3
Not started
Emergency contraception
Contraception and Sexual Leonor HerreraHealth
Vega
3
Q3
Not started
Audit of NICE guidance on management of patients with
psoriasis
Dermatology
David de Berker
2
Q1
Completed
Audit of completeness of excision of non-melanoma skin cancer
Dermatology
in Bristol Dermatology
Adam Bray
2
Q1
In progress
Audit of notification of GPs of patient melanoma diagnosis
within 24 hours
Dermatology
Gemma Gregory
2
Q1
In progress
National Inpatient Diabetes Audit (NIDA)
Diabetes and
Endocrinology
Bushra Ahmed
1
Q2
In progress
Management of multiple endocrine neoplasia
Diabetes and
Endocrinology
Karin Bradley
3
Q2
Not started
Management of hypoglycaemic events
Diabetes and
Endocrinology
Karin Bradley
3
Q3
Not started
Prevalence and management of benign hypercalcaemia
Diabetes and
Endocrinology
Karin Bradley
3
Q3
Not started
Audit of Adult Outpatient Diabetes Care
Diabetes and
Endocrinology
Natasha
Thorogood
2
Q2
In progress
Clinical Audit Annual Report 2013/14
Page 18
TA64 Growth hormone deficiency (adults)
Diabetes and
Endocrinology
Karin Bradley
2
Q3
Completed
National Inflammatory Bowel Disease audit
Gastroenterology
Tom Creed
1
Q1
In progress
National COPD audit
Respiratory
Nabil Jarad
1
Q4
In progress
British Thoracic Society audit programme
Respiratory
Lead to be
confirmed
1
Q3
Complete
Bronchoscopic lung volume reduction with airway valves for
Respiratory/Thoracic
Surgery
Nabil Jarad/Tim
Batchelor
2
Q3
In progress
Oxygen prescription
Respiratory
Liz Gamble
3
Q2
Completed
Suspected lymph node tuberculosis audit
Respiratory
Sarah Mungall
3
Q1
Not started
Rheumatoid arthritis
Rheumatology
Robert Marshall
2
Q1
Completed
The following activity was also in progress during the financial year (either rolled over from previous year or not identified
through plan):
Ref
Provisional Title of Project
Status
Emergency Department (Adult)
3040
Chest drain procedure carried out in the Emergency Department
In Progress
3068
Observation unit prescribing audit
Completed
3111
re-audit of patient vital signs in the adult Emergency Department (ED)
In Progress
3130
Consultant sign off (College of Emergency Medicine)
Completed
3300
Renal Colic (College of Emergency Medicine)
Completed
3363
Fractured Neck of Femur (College of Emergency Medicine)
In Progress
3412
Re-audit of the initial management of sepsis
In Progress
3440
Audit of quality of GP letters from patients discharged from the Emergency Department
Completed
3468
Management of out of hospital cardiac arrest
Completed
3488
Management of primary spontaneous pneumothorax in emergency medicine.
In Progress
3516
An audit of palliative care practices in the BRI ED
In Progress
3543
National Audit of Seizure Management (NASH)
Completed
3544
Paracetamol Overdose (College of Emergency Medicine)
In Progress
3558
Audit of the Emergency Departments' Pancreatitis Management
In Progress
3559
Missed Doses in ED
In Progress
3591
Ensuring time critical radiological findings ordered from the ED are reviewed in a timely manner
In Progress
3592
To audit the results of radiology imaging requested in the Emergency Department
In Progress
3593
Management of head injuries presented to the BRI Emergency Department
In Progress
3597
Chest Drain re-audit (initial audit ID 3040)
In Progress
3660
Procedural sedation in the Emergency Department
In Progress
Medical Specialties/Acute Medicine
2738
Clotting and D dimer use in the Medical Assessment Unit
Abandoned
3411
Defining the diagnosis of subarachnoid haemorrhage (SAH)
Completed
3453
Review of the medical response to acutely ill patients determined by Early Warning Scores (EWS)
Completed
3563
Prescription and documentation of Non-invasive Ventilation (NIV) therapy
Completed
Clinical Audit Annual Report 2013/14
Page 19
Medical Specialties/Care of the Elderly
2968
Audit of Appropriateness of Blood Transfusions
Completed
3104
Timely brain imaging for stroke patients
Completed
3177
The Acute Management of Hyponatraemia
Completed
3353
Post-operative care of over 80 year olds after elective surgery (NCEPOD recommendations)
Completed
3487
Audit of Parkinson Medication Prescribing and Administration
Completed
3489
Audit of Stroke Re-admissions September 2012 - February 2013
Abandoned
3524
An audit of appropriate thrombolysis for stroke patients
In Progress
3526
OLP001 - National Audit of Dementia (NAD)
Completed
3550
Stroke Thrombolysis Audit
In Progress
3564
An audit of the diagnosis and treatment of Urinary Tract and catheter associated infections in patients over 65 years in
the Bristol Royal Infirmary
In Progress
3651
Audit on the accuracy of respiratory rate and its effects on EWS
In Progress
3652
Assessment of the management of anaemia perioperatively in patients undergoing total hip replacements for fractured
In Progress
neck of femur
3677
Management of patients with a fracture neck of femur who take novel oral anticoagulation medication (NOAC)
In Progress
3678
Management of patients with a fractured neck of femur who take warfarin anticoagulation medication
In Progress
3720
Use of Abbey pain scale in patients with dementia and delirium over the age of 75 years
In Progress
Medical Specialties/Contraceptive & Sexual Health Services (CASH)
2990
Quick Starting Contraception following the administration of progestogen-only emergency contraception
Completed
2995
An audit of Long Acting Reversible Contraceptives (LARC) Problem Management at Bristol Sexual Health
Completed
3167
Audit of HIV testing among patients with Hepatitis B and/or Hepatitis C infection attending the Hepatology clinic
Completed
3205
Sexual Health Outreach services – occupational health needs of women selling sex on the street in Bristol
Completed
3251
Audit of the Management of Epididymo-orchitis at Bristol Sexual Health Centre
In Progress
3344
The use of the Patient Group Direction for the Progestogen-Only Sub-Dermal Contraceptive Implant (Nexplanon®) at
Bristol Sexual Health Service
Completed
3525
Audit of the management of gonorrhoea infection in patients who attend Bristol sexual health services
Completed
3551
Audit of HSA1 form for CQC standard compliance and early medical abortion protocol UK
In Progress
3629
HIV PEPSE proforma audit
In Progress
3641
Re-audit of quick starting contraception following implementation of a 'Quick starting Contraception' check list into the
emergency contraception form
In Progress
3650
Re-audit of patient records for under 18s in Sexual Health Services in Bristol
In Progress
Medical Specialties/Dermatology
3360
Regional audit of TL01 therapy for chronic or guttate plaque psoriasis
Completed
3367
NICE technology appraisal TA180 Ustekinumab for the treatment of adults with moderate to severe psoriasis
Completed
3467
Implementing NICE guidance for the assessment and management of psoriasis
Completed
3486
Audit on legibility of patient dermatology notes
Completed
3518
An audit on informed consent in Dermatological Surgery
Completed
3519
Management of recurrent and incompletely excised Basal Cell Carcinoma
Completed
3521
Dermatology Outpatient Waiting Times
Completed
3522
Methotrexate monitoring in psoriasis patients
Completed
3536
Re-audit of the quality indicators in a teledermatology service
Completed
3569
Skin Cancer Complete Excision Rates Audit
Ongoing Project
3601
Retrospective audit of patients on anticoagulants undergoing dermatological procedures
Completed
3649
Melanoma Pathway Audit
In Progress
Clinical Audit Annual Report 2013/14
Page 20
Medical Specialties/Diabetes & Endocrinology
3263
Audit of inpatient management of diabetic foot problems
Completed
3266
NICE technology appraisal TA203 Liraglutide for the treatment of type 2 diabetes
Completed
3336
National Diabetes Inpatient Audit
In Progress
3478
Audit of the management of hyperglycaemia in acute coronary syndromes
Completed
3485
Audit of Adult Outpatient Diabetes Care at the UH Bristol General Diabetes clinics
In Progress
3698
Re-audit of the management of hyperglycaemia in acute coronary syndromes
In Progress
3723
Audit of Growth Hormone replacement in adults with Growth Hormone Deficiency
In Progress
Medical Specialties/Gastroenterology & Hepatology
2603
LTC004 - National Adult Inflammatory Bowel Disease Audit
In Progress
3122
NICE technology appraisal TA187 Infliximab and adalimumab for the treatment of Crohn’s disease
Completed
3306
Audit of missed doses of medication on ward 11
Completed
3600
Re-Audit of when antibiotics prescribed and when given on ward 11
Completed
3670
Adherence of Hepatitis B screening in patients with Inflammatory Bowel Disease (IBD) starting Immunosuppressive
Therapy
In Progress
Medical Specialties/General Medicine
3118
Duplication of drug prescription / Inappropriate rapid re-dosing in ED and MAU
Completed
3198
Audit of the management of cellulitis
Completed
3598
An Audit of patients admitted with Acute Alcohol Withdrawal
In Progress
3355
Audit of DVT Diagnosis through the Thrombosis Clinic
Completed
Medical Specialties/Liaison Psychiatry
3197
Re-auditing depression with a chronic physical health problem
Completed
3528
Improving DNA rates in Liaison Psychiatry Outpatient Clinics
In Progress
3589
Audit of frequent attenders with self-harm to the Emergency department
Completed
Medical Specialties/Respiratory
3291
Blood glucose monitoring in Cystic Fibrosis patients during first 48 hours of admission to cystic fibrosis unit
In Progress
3354
Bronchectasis audit (British Thoracic Society)
In Progress
3462
Isolation in Patients with Possible Pulmonary Tuberculosis
Completed
3520
Non-Invasive Ventilation (British Thoracic Society)
In Progress
3523
An audit of smoking cessation advice given to current smokers
Completed
3599
British Thoracic Society (BTS) Emergency Oxygen Audit 2013
Completed
3722
National Chronic Obstructive Pulmonary Disease (COPD) audit
In Progress
Medical Specialties/Rheumatology
3406
NICE technology appraisal TA161 Secondary prevention of osteoporotic fragility fractures in postmenopausal women
In Progress
3447
NICE TA130 Rheumatoid arthritis - adalimumab, etanercept and infliximab
Completed
3697
Does current blood test monitoring lead to treatment change in Ankylosing Spondylitis patients on TNFi
In Progress
The following section summarises the changes, benefits or actions introduced as a result of completed audits within the
Division/specialties.
3440
This audit demonstrated that the quality of GP letters from patients discharged from the Emergency Departed exceeded
those reported nationally. To improve the quality further, education sessions were conducted for staff highlighting the
requirements of a good letter and the need to accurately record key information on Medway.
3468
A post cardiac care bundle document was written to aid the management of post cardiac arrest patients presenting to the
emergency department as a result of this audit.
Clinical Audit Annual Report 2013/14
Page 21
3601
This audit demonstrated good compliance standards for not stopping anticoagulants prior to surgery. The need to
develop clear guidelines with nursing staff on post-operative management of patients on agents that alter blood
coagulation was recognised and implemented.
3462
Education sessions were conducted for all Medical Assessment Unit nursing teams regarding a new protocol and which
patients should be considered for isolation for possible pulmonary TB as a result of this audit. Consultants have been
reminded to review chest x-rays on post take ward rounds.
3104
This audit led to the introduction to ‘Direct to CT’ for all pre-alerted patients as part of the ‘Stroke 90’ project to help
improve compliance with timings of brain imagining within 1 hour and 24 hours of arrival.
3453
Awareness of the importance of the timely and appropriate escalation of patients to clinical staff for patients with a
EWS>=4 was highlighted to all medical staff at presentations as a result of this audit. Further improvements on the
documentation of ceiling of care, critical care consideration and discussions with the next of kin were highlighted.
3167
This audit demonstrated that the documentation of whether patients who are Hep B surface antigen positive are offered
a HIV test within 6 months of attendance needed to improve. Educational presentations were made to all doctors in the
department to ensure this test is offered to appropriate patients and documented if declined.
3118
This audit led to an amendment to the drug chart section of the Emergency Department notes to make it clearer when
drugs have already been given in the ED.
3667
Excellent results against standards except for the provision of written information about psoriasis and the treatment and
care were demonstrated through this audit. A new assessment proforma detailing information giving was implemented
was implemented to improve standards further.
3263
As a result of this audit, a single inpatient diabetes foot pathway is to be introduced along with a CQUIN for an inpatient
Diabetes Specialist Nurse for Specialised Services.
3563
This audit highlighted the need for improvement in the documentation of Non-Invasive Ventilation (NIV) therapy.
Education of junior doctors regarding areas for improvement was conducted. A NIV prescription chart has been designed
and implemented.
3122
In addition to confirming our compliance with relevant NICE guidance on the use of two drugs in Crohn's disease, this
audit has led to improvements in the way that we document such treatment, which better informs a patient's annual
review.
2968
This audit led to teaching sessions on appropriate blood transfusion to new doctors following clarification and agreement
as to which guidelines to follow.
3411
The need to develop a lumbar puncture proforma to aid documentation was identified through this audit.
Recommendations to keep a lumbar puncture trolley (containing all required equipment) in the MAU and Ambulatory
Acer Units are in the process of being implemented.
3447
This audit demonstrated good compliance against standards for the treatment of patients with Rheumatoid Arthritis. A
nurse referral form (for completion by the doctor who refers the patient for biological therapy) to ensure 2 DMARDs have
already been tried was implemented. Patient review dates will be recorded in the Cellma database.
3177
A local clinical guideline for the management of hyponatraemia is in the process of being developed as a result of this
audit.
3344
As a result of this audit areas of poor documentation of key information were identified, highlighting the need to amend
the progesterone only sub dermal contraceptive implant proforma. The service is moving towards an electronic patient
record which will improve the recording of this clinical information.
3205
Poor compliance regarding documentation of care offered and patient information taken resulted in the development of a
clinical guideline for the ‘One25’ sexual health clinic and an agreement amongst clinical staff on the development of
history taking/testing frequency guidelines.
3600/
3306
This re-audit showed an increase in compliance for antibiotics given within 1 hour of prescribed time on ward 11.
Teaching sessions were given following first audit (ID 3306) to all clinical staff. Stock levels on wards were also reviewed.
3355
This audit led to the implementation of a protocol for the management of upper limb DVT.
3360
This multi-centre audit identified a delay in patients starting treatment across both centres as the 90% target was not met
for starting treatment within 6 weeks. Results were fedback to both teams and re-audit recommended. The audit
demonstrated that all pre-phototherapy checks are completed and all patients referred urgently are seen within the three
week recommended timeframe.
3197
This complex audit highlighted areas of inappropriate prescribing which lead to teaching sessions and dissemination of
information across both secondary and primary care.
3198
The Trust Cellulitis guidelines were updated as a result of this audit.
Clinical Audit Annual Report 2013/14
Page 22
3589
Care plans for the treatment of self-harm patients presenting to the Emergency Department have been reviewed and
amended as a result of this audit. More defined criteria regarding review dates, patient and relevant others participation
in the implementation of the plans and whether it was shared with the GP have been included.
3522
This audit demonstrated good compliance with standards for baseline blood measurements but also highlighted areas of
improvement in baseline chest X-Rays and conducting weekly bloods until dose is stabilised. A nurse led nutrition and
monitoring clinic for methotrexate with scope for consultant referrals for drug monitoring with blood tests/BP/urinalysis
was introduced. Education sessions for all staff on documenting contraceptive advice given and the need to order chest
X-rays and to weigh the patient are being introduced.
3523
This rapid cycle audit was conducted three times with continuous improvements against standards for smoking cessation
advice given at each cycle. An education programme including presentations, posters and leaflets was delivered to all
doctors involved in the medical take,
3519
Audit identified that discussions of incompletely excised Basal Cell Carcinomas (BCCs) are not always discussed at the
Multidisciplinary Team meetings (MDT). The need to use one system for requesting histology reports of skin biopsies was
identified and is being researched. Recommendations made for the use of the UK national minimum dataset for pathology
reporting of BCCs.
3478
A proforma for the diabetes management of patients with hyperglycaemia after acute coronary syndrome was
implemented as a result of this audit.
3525
This audit demonstrated generally very good compliance against standards for the management of gonorrhoea. The
service is moving towards an electronic patient record (EPR) therefore additional tick boxes for ‘test offered’ and ‘written
information offered’ will be included in the EPR as a prompt.
2995
A mail merge letter template outlining possible treatment regimes for LARC bleeding problems has been designed as a
result of this audit. A BSH pathway for identifying gynaecological pathology and when to refer is in development.
3487
An alert sticker for the drug charts of people with Parkinson’s Disease (PD) was developed and introduced as a result of
this audit. Staff education on the importance of correct prescribing and administration of PD drugs was conducted.
Pharmacy will ensure that medications are always available, including out of hours, with back up supplies in emergency
drug store.
3266
This audit led to the development of a local policy (in agreement with the local NICE Commissioning College) for patients
who can have liraglutide in combination with insulin.
3486
This audit has led to the development of an electronic proforma on Medway to improve documentation of information for
dermatology patients
2990
As a result of this audit, Patient Group Directives updated to include guidance on quick starting contraception. The
emergency contraception proforma has also been updated to include check boxes for key discussion points with patients.
Staff training has been undertaken on guidelines at both central and community sites.
3518
This audit demonstrated that information relating to consent was generally documented for dermatological surgery.
Booking letters have been amended to include ‘top tips’ to help improve practice further.
3521
This audit of outpatient waiting times demonstrated that approximately 80% of patients are seen within 30 minutes of
arrival in clinics. A number of modifications to the waiting room have been made to improve patient comfort and
appointment letters updated to include warning of potential long waits.
3536
Improved compliance of quality indicators in teledermatology was demonstrated by this re-audit. Web links have been
included in feedback to GPs with tips on photographic techniques along with the use of GP reflective learning templates
to aid further improvements.
3467
Lead dermatology nurse and consultant provided Psoriasis Area and Severity Index (PASI) and Psoriasis Epidemiological
Screening Tool (PEST) workshops for rheumatology and dermatology teams as a result of this audit. PEST, PASI and
Dermatology Quality Life Index (DQLI) packages have been designed and are available in clinic.
Clinical Audit Annual Report 2013/14
Page 23
3.3
SPECIALISED SERVICES
The following chart shows the status at year end of those projects identified as priorities for audit as part of the
forward planning process in 2013/14. Full details of the status of individual projects on this plan can be found within
table 1 of this section.
Progress of planned projects
Complete
100%
80%
60%
40%
20%
0%
In progress
Not started
1
2
5
2
4
1
1
2
1
Cardiac Services
2
Oncology, Heamatology & Palliative Medicine
Prioritisation category
The chart below shows the status at year end of all registered projects (excluding those classified as ongoing
monitoring). Some projects will have started and finished within the financial year, some will have been started but
have yet to complete and are therefore rolled over. The figures also include projects that commenced in previous
years but have now been abandoned, those that previously commenced but were completed in 2013/14 and those
previously commenced but not completed by the end of 2013/14.
Individual project status at year end
9
10
9
7
8
6
6
3
4
3
2
2
1
2
1
1
1
0
Cardiac Services
Oncology & Clinical Haematology & Palliative Medicine
New in year/Abandonded
New in year/Completed
New in Year/Roll-over
Rolled-over/Abandoned
Rolled-over/Completed
Rolled-over/Roll-over
Percentage of projects registered before start
100%
80%
5
Make up of project team
100%
80%
7
60%
60%
40%
40%
20%
14
19
20%
16
13
3
2
5
6
Cardiac Services
Oncology & Clinical
Haematology & Palliative
Medicine
0%
0%
Cardiac Services
TRUE
Clinical Audit Annual Report 2013/14
Oncology & Clinical
Haematology & Palliative
Medicine
FALSE
Multi-professional
Multi-specialty
Neither
Page 24
Percentage National Audit
Percentage re-audit
100%
100%
80%
80%
60%
60%
40%
20%
16
23
5
1
40%
18
17
20%
4
6
Cardiac Services
Oncology & Clinical
Haematology & Palliative
Medicine
0%
0%
Cardiac Services
Oncology & Clinical
Haematology & Palliative
Medicine
TRUE
TRUE
FALSE
FALSE
Guidance/standards type audited
10
8
8
8
8
8
6
4
4
4
4
2
1
0
Cardiac Services
Oncology & Clinical Haematology & Palliative Medicine
NICE
Other National
Local
Percentage report produced
Percentage action plan produced
100%
1
100%
80%
80%
4
60%
60%
40%
40%
20%
Unclassified
3
1
20%
7
0%
2
10
Cardiac Services
Oncology & Clinical
Haematology & Palliative
Medicine
0%
Cardiac Services
TRUE
Oncology & Clinical
Haematology & Palliative
Medicine
FALSE
Yes
No - Confirmed good practice
Table 1
Title
Sub-Specialty
Lead
Adult Cardiac Surgery (ACS)
Cardiac Surgery
Alan Bryan
1
Q1
In progress
Acute Coronary Syndrome/Acute Myocardial Infarction (MINAP) Cardiology
Julian Strange
1
Q1
In progress
National Cardiac Arrhythmia Audit (HRM)
Cardiology
Tom Johnson
1
Q1
In progress
National Heart Failure Audit (HF)
Cardiology
Angus Nightingale
1
Q1
In progress
Adult Coronary Angioplasty
Cardiology
Tom Johnson
1
Q1
In progress
TA230 Myocardial infarction (persistent ST-segment elevation)
bivalirudin
Cardiology
Julian Strange
2
Q3
Not started
Clinical Audit Annual Report 2013/14
Priority Start date
Status Q4
Page 25
Sutureless Aortic Valve Replacement
Cardiac Surgery
George
Asimakopoulos
2
Q3
Not started
National Lung Cancer Audit (NLCA)
Oncology/Respiratory
Adam Dangoor
1
Q1
In progress
VTE Prophylaxis/risk assessment
Haematology
Amanda Clarke
1
Q2
In progress
NICE TA193 Leukaemia (chronic lymphocytic, relapsed) rituximab
Haematology
Jenny Bird
1
Q2
Completed
An audit of Identification of patients in the last year of life and
advance care planning in respiratory disease
Palliative Medicine/
Respiratory
Colette Reid
2
Q1
Completed
An audit of Identification of patients in the last year of life and
advance care planning in patients with dementia
Palliative Medicine
Colette Reid
2
Q1
Completed
An audit of Identification of patients in the last year of life and
advance care planning in patients with advanced cancer
Palliative Medicine
Colette Reid
2
Q1
Completed
An audit of Identification of patients in the last year of life and
advance care planning in frail elderly patients
Palliative Medicine
Colette Reid
2
Q1
Not started
An audit of interventions and investigations in the last week of
life
Palliative Medicine
Colette Reid
2
Q1
Completed
The following activity was also in progress during the financial year (either rolled over from previous year or not identified
through plan):
Ref
Provisional Title of Project
Status
Cardiac Services/Cardiac Surgery
3304 Early and long-term outcome of mitral valve surgical procedures in adult patients
In Progress
3305 Audit of transaortic sutureless aortic valve implantation outcomes - a Bristol Heart Institute experience
Abandoned
3307 The effect of arterial cannulation strategy (axillary vs. femoral vs. ascending aortic) on outcomes following aortic surgery Abandoned
3471 Clinical outcomes after second time cardiac re-operations and complex aortic procedures
Abandoned
3505 Anticoagulation management for patients with new onset atrial fibrillation after Coronary Artery Bypass Graft surgery
Completed
Cardiac Services/Cardiology
2910 Audit of Echocardiographic follow-up after Aortic Valve Replacement (AVR)
Abandoned
2933 Management of Pregnant Patients with Aortopathy
Completed
2960 Should we still be screening patients with Coarctation of the Aorta for Intracranial Aneurysms? A re-audit.
In Progress
3262 NICE technology appraisal TA95 Implantable Cardioverter Debfibrillators (ICDs) for the treatment of arrhythmias
In Progress
3301 Poor nutrition links to higher incidence of pressure ulcers for inpatients. Are patients being educated?
In Progress
3374 Audit of implantable devices used in cardiac rhythm management at University Hospitals Bristol
In Progress
3375 Outcomes following VT ablation
In Progress
3465 Audit of Percutaneous Balloon Mitral Valvuloplasty
In Progress
3480 Effectiveness of paroxysmal and persistent atrial fibrillation ablation
In Progress
3557 Ambulatory blood pressure monitoring audit
Completed
3654 Simvastatin and calcium channel blocker prescription
In Progress
3655 Renin-Angiotensin-Aldosterone System (RAAS) medication prescription
In Progress
3665 Documentation of TR Band removal and radial artery occlusion rate post coronary intervention via the radial route
In Progress
3700 Audit of Non ST segment elevation myocardial infarction (NSTEMI) pathway
In Progress
3701 Conscious Sedation for Transoesophageal Echocardiography
In Progress
Oncology & Clinical Haematology/Clinical Haematology
3639 Audit of the new Trust guidelines for the management of febril neutropaenia
In Progress
3695 Consent for chemotherapy for patients diagnosed with Acute Myeloid Leukaemia (AML)
In Progress
Clinical Audit Annual Report 2013/14
Page 26
Oncology & Clinical Haematology/Oncology
2999 Keyworkers for Teenagers and Young Adults with cancer
Completed
3057 Trastuzumab in advanced breast cancer NICE TAG 34/CG 81
Completed
3119 Use of Sunitinib in advanced/metastatic renal cell carcinoma - re-audit of NICE TA169.
Completed
3285 An audit of weekly checks documentation undertaken within the Radiotherapy Department at the BHOC
Completed
3297 Adjuvant use of Docetaxel in Breast cancer - NICE TA 109/CG 80/ASWCS
Completed
3322 Intravenous contrast during radiotherapy planning
Completed
3351 Completeness of chemotherapy pre assessment and administration charts
In Progress
3352 GCSF (Neulasta) and treatment of febrile neutropenia (FN) post TAC chemotherapy in breast cancer patients - re-audit
Completed
3378 Management of Metastatic Spinal Cord Compression - re-audit NICE CG75/92/29
In Progress
3389 Neutropaenia Sepsis - re-audit
Abandoned
3490 Neo-adjuvant treatment in breast cancer
Abandoned
3553 An audit to assess the prevention of corticosteroid-induced osteoporosis in patients with CNS tumours
In Progress
3554 Referral of 15-24 year old patients with cancer to the TYA MDT
In Progress
3613 A re-audit of weekly checks documentation undertaken within the radiotherapy department at the BHOC
In Progress
3621 An audit of Post Radio-iodine Ablation follow-up for differentiated thyroid cancer
In Progress
3630
Audit of patient monitoring practice in patients receiving Abiraterone acetate and prednisolone for metastatic
castration resistant prostate cancer
In Progress
Oncology & Clinical Haematology/Palliative Medicine
3399 Audit of end of life discussions in patients with COPD
Completed
3416 Audit of ‘Do not attempt resuscitation’ documentation (part of a BNSSG-wide audit)
In Progress
3727 National Care of the Dying Audit – UH Bristol version 2014
In Progress
The following section summarises the changes, benefits or actions introduced as a result of completed audits within the
Division/specialties.
3505
This audit has led to increased awareness of anticoagulaton management for patients with new onset atrial fibrillation
after coronary artery bypass graft surgery. Staff have been advised to calculate patients’ CHADS-2 score and base their
anticoagulation strategy on this.
2933
New regional referral guidelines were sent out to district general hospitals in South West that the risk of aortopathy in
pregnancy should be discussed with patients with Marfan’s Syndrome. Early to the regional centre for assessment or
advice was agreed to be a good approach.
3557
This audit demonstrated acceptable compliance with recommendations outlined in NICE guidance for the treatment of
hypertension. The number of daytime blood pressure readings used to calculate average daytime ambulatory blood
pressure was found to be undertaken as required.
3352
This audit demonstrated that all patients were treated as per local neutropenic sepsis guidelines. The TAC protocol has
been amended as per cancer network guidelines.
3057
The addition of a chemocare on-screen prompt to check and record HER2 status has been implemented as a result of this
audit. A Trastuzumab prescribing checklist has also been designed and implemented for doctors to act as an aide memoire.
3297
Excellent compliance with standards for breat cancer treatment was demonstrated by this audit. The need for a future
prospective audit has been identified for patients who are node positive/high risk who did not receive a taxane.
3119
As a result of this audit, a proforma has been developed and implemented for patients starting Sunitinib to improve future
compliance with NICE guidelines.
3285
This audit has led to the establishment of a working sub group to improve compliance of the completion with weekly
radiotherapy checks. This multidisciplinary group will review the current protocol and form. A re-audit following
implementation of an updated protocol and form will be undertaken.
3322
This audit has led to further staff education to emphasise to all medical staff that IV contrast is available for CT scans and
should be used for planning tumour sites as recommended by Royal College of Radiologists (2004) guidance.
2999
The need to improve documentation of a named key worker for patients in the Teenage and Young Person Service was
identified through this audit. This service is in the process of being developed and the results of this audit will be
Clinical Audit Annual Report 2013/14
Page 27
incorporated into the new service.
2997
Areas for improvement in prescribing documentation were identified as a result of this audit. Results have been widely
circulated and presentations made to help raise awareness of the issues and to improve practice.
3399
This audit identified areas for improvement regarding discussion with patients about End of Life care (EOL) and
communication with the GP. Amendments have been made to the ICE system to make ‘Discussions around end of life care’
a mandatory field. The Palliative Care Team now attends respiratory board rounds to help with the management of these
patients and a process for sending letters to GPs regarding EOL discussion has been implemented.
3644
This audit identified areas for improvement regarding documentation of communication with GP and the offer to patients
and relatives to participate in advance care planning for patients with dementia. Education and awareness to all
appropriate staff to improve these areas of care has been undertaken. Ward board rounds are now used to identify those
patients with dementia thought to be in the last year of life.
3491
This audit identified areas for improvement regarding standards to manage patients with advanced cancer. Results have
been widely circulated and presentations made to help raise awareness of the issues and to improve practice.
Clinical Audit Annual Report 2013/14
Page 28
3.4
SURGERY, HEAD AND NECK
The following chart shows the status at year end of those projects identified as priorities for audit as part of the
forward planning process in 2013/14. Full details of the status of individual projects on this plan can be found within
table 1 of this section.
Progress of planned projects
Complete
In progress
Not started
100%
80%
3
60%
3
3
40%
3
1
1
2
2
3
1
3
Anaesthesia, Critical Care & Theatres
6
1
1
2
1
1
1
2
4
2
3
4
0%
1
3
2
4
20%
1
3
Dental Services
6
2
2
Ophthalmology
2
4
Surgical Specialties
Prioritisation category
The chart below shows the status at year end of all registered projects (excluding those classified as ongoing
monitoring). Some projects will have started and finished within the financial year, some will have been started but
have yet to complete and are therefore rolled over. The figures also include projects that commenced in previous
years but have now been abandoned, those that previously commenced but were completed in 2013/14 and those
previously commenced but not completed by the end of 2013/14.
Individual project status at year end
14
12
10
8
6
4
2
0
12
11
9
8
8
7
6
8
8
5
2
1
1
3
2
1
Anaesthesia, Critical Care & Theatres
1
1
1
Adult Surgical Specialties
1
1
2
1
Ophthalmology
1
Dental & Maxillofacial Surgery (inc.
ENT)
New in year/Abandonded
New in year/Completed
New in year/Deferred
New in Year/Roll-over
Rolled-over/Abandoned
Rolled-over/Completed
Rolled-over/Deferred
Rolled-over/Roll-over
Percentage of projects registered before start
3
100%
80%
12
11
4
6
Make up of project team
100%
80%
8
60%
60%
40%
40%
20%
20%
14
26
23
34
0%
15
2
5
14
5
14
2
10
11
0%
Anaesthesia, Adult Surgical Ophthalmology
Dental &
Critical Care &
Specialties
Maxillofacial
Theatres
Surgery (inc.
ENT)
TRUE
Clinical Audit Annual Report 2013/14
FALSE
31
5
4
Anaesthesia, Adult Surgical Ophthalmology
Dental &
Critical Care &
Specialties
Maxillofacial
Theatres
Surgery (inc.
ENT)
Multi-professional
Multi-specialty
Neither
Page 29
Percentage National Audit
Percentage re-audit
100%
100%
80%
80%
60%
60%
40%
16
20%
40%
23
6
13
39
1
26
1
6
20%
0%
17
23
5
6
28
14
12
0%
Anaesthesia, Adult Surgical Ophthalmology
Dental &
Critical Care &
Specialties
Maxillofacial
Theatres
Surgery (inc.
ENT)
TRUE
Anaesthesia, Adult Surgical Ophthalmology
Dental &
Critical Care &
Specialties
Maxillofacial
Theatres
Surgery (inc.
ENT)
FALSE
TRUE
FALSE
Guidance/standards type audit
25
22
20
16
14
15
8
10
12
10
5
5
5
11
7
3
3
2
0
Anaesthesia, Critical Care & Theatres
Adult Surgical Specialties
NICE
Other National
Ophthalmology
Local
Unclassified
Percentage report produced
Percentage action plan produced
100%
100%
1
80%
5
60%
Dental & Maxillofacial Surgery (inc.
ENT)
6
1
3
1
80%
5
60%
40%
40%
20%
7
2
7
20%
14
0%
6
2
7
17
0%
Anaesthesia, Adult Surgical Ophthalmology
Dental &
Critical Care &
Specialties
Maxillofacial
Theatres
Surgery (inc.
ENT)
TRUE
Anaesthesia, Adult Surgical Ophthalmology
Dental &
Critical Care &
Specialties
Maxillofacial
Theatres
Surgery (inc.
ENT)
FALSE
Yes
No - Confirmed good practice
Table 1
Title
Sub-Specialty
Lead
Emergency Laparotomy
Anaesthesia/Surgery
Rachel Craven/
Jane Blazeby
1
Q3
In progress
SPINT/ASAP audit
Anaesthesia
Frances Forrest/
Rachel Bradley
2
Q1
In progress
Abbey pain chart for patients with dementia/cognitive
impairment
Anaesthesia/Acute Pain
Team
Lead to be
confirmed
2
Q3
Not started
Presence of essential emergency information in theatres
Anaesthesia
Diana Terry
3
Q3
Not started
Safe prescribing and completion of drug charts
Anaesthesia
Diana Terry
2
Q3
Not started
Clinical Audit Annual Report 2013/14
Priority Start date
Status Q4
Page 30
South West Quality and Patient Safety Improvement Programme
Theatres
(Critical Care)
Sanjoy Shah
2
Q1
In progress
Adult critical care case mix programme (ICNARC CMP)
Critical Care
Tim Gould
1
Q1
In progress
Potential Donor Audit
Critical Care
Fran O’Higgins
1
Q1
In progress
ALung Hemolung Respiratory Assist System
Critical Care
Tim Gould
2
Q1
Not started
Audit of medication errors on ICU
Critical Care
John Warburton
2
Q1
In progress
Audit of blood transfusion practice
Critical Care
Dan FreshwaterTurner
3
Q1
Not started
Audit of appropriate PPI prescribing
Critical Care
Tim Gould
3
Q1
Not started
Liz Varian
2
Q1
In progress
South West Quality and Patient Safety Improvement Programme
Theatres
(Perioperative Care)
National Head & Neck Cancer (DAHNO)
Oral and Maxillofacial
Surgery
Ceri Hughes
1
Q1
In progress
Pre-formed metal crown failure rates
Primary Care Dental
Service
Katherine Walls
4
Q4
In progress
Dental undergraduate treatment plans (re-audit)
Restorative Dentistry
Rob Jagger
4
Q2
Completed
Extraction of first permanent molars (re-audit)
Child Dental Health
Sarah Dewhurst
4
Q1
Completed
Salivary gland imaging (re-audit)
Dental Radiology
Jane Luker/
Rebecca Davies
4
Q3
In progress
Condition of surgical margins in resections for cancer of the oral Oral and Maxillofacial
cavity and oropharynx
Surgery
Ceri Hughes
4
Q4
Not started
Primary Care Unit protocols for patients with suspected
coagulation defects
Oral Medicine / Oral
Surgery
Sarah Ellison/Tony
Brooke
4
Q4
Not started
Primary Care Unit patient satisfaction (re-audit)
Oral Medicine
Tony Brooke
4
Q3
Not started
Mental Capacity Act
Hospital wide
Sarah Foy/Tony
Brooke
3
Q3
Not started
Endoscopic sinus surgery outcomes (re-audit)
Adult ENT
Claire LangtonHewer
4
Q3
Not started
Turbinate surgery
Adult ENT
Claire LangtonHewer
4
Q3
Not started
Implantation of multifocal intraocular lenses during
cataractsurgery
Cornea and Cataract
Phil Jaycock
2
Q4
Not started
Boston Type 1 Keratoprosthesis
Cornea and Cataract
Derek Tole
2
Q1
Completed
Intraocular lens insertion for correction of refractive error with
preservation of the natural lens guidance
Cornea and Cataract
Phil Jaycock
2
Q4
Not started
TA229 Macular oedema (retinal vein occlusion) –
dexamethasone
Medical & Surgical Retina Claire Bailey
2
Q1
In progress
Deep Sclerectomy (non-penetrating glaucoma filtration surgery) Glaucoma
Rani Sebastian
2
Q1
In progress
Selective Laser Trabeculoplasty (SLT)
Glaucoma
Rani Sebastian
2
Q4
Not started
Trabeculectomy outcomes
Glaucoma
John Sparrow/
Peter Tsangaris
4
Q1
Not started
Microbial Keratitis re-audit
Cornea and Cataract
Derek Tole/Stuart
Cook
4
Q2
In progress
Cataract Outcomes
Cornea and Cataract
Derek Tole
3
Q1
Completed
A&E 4 hour breaches and follow-ups
A&E & Primary Care
Derek Tole/Rafik
Girgis
3
Q3
Not started
Lucentis outcomes
Medical & Surgical Retina Adam Ross (Cons)
3
Q2
Not started
Clinical Audit Annual Report 2013/14
Page 31
Referral and treatment times for Diabetic retinopathy and
maculopathy
Medical & Surgical Retina
Outcomes of nasolacrimal duct probing (re-audit)
Abosede Cole/
Kate Powell
3
Q4
Not started
Paediatrics, Oculoplastics
Amanda Churchill
and Squint
4
Q1
Not started
Documenting Non-Accidental Injury
Paediatrics, Oculoplastics
Cathy Williams
and Squint
4
Q2
Completed
Paediatric Eye Service Satisfaction Survey
Paediatrics, Oculoplastics
Amanda Churchill
and Squint
4
Q2
Completed
Discharge of paediatric patients from orthoptic department
Orthoptics and
Optometry
Ann Starbuck/
Estelle Bishop
4
Q1
Not started
Assessment of orbital trauma patients (re-audit)
Orthoptics and
Optometry
Ann Starbuck/
Estelle Bishop
4
Q2
Not started
Instilling of dilating drops in children for refraction and fundus
and media examination
Orthoptics and
Optometry
Ann Starbuck/
Estelle Bishop
4
Q3
Not started
Visual outcomes in Congenital cataract patients
Orthoptics and
Optometry
Sarah Smith
4
Q2
Not started
National Bowel Cancer Audit (NBOCAP)
Colorectal
Rob Longman
1
Q1
In progress
SECCA (Radiofrequency Ablation for Feacal Incontinence)
Colorectal
Paul Sylvester
2
Q3
In progress
CT-guided guidewire localisation of impalpable lung lesions
before minimal access surgical excision
Thoracic
Tim Bachelor
2
Q3
In progress
National Joint Registry (NJR)
Trauma & Orthopaedics
Sanchit
Mehendale
1
Q1
In progress
Trauma (TARN)
Trauma & Orthopaedics
Matt Thomas
1
Q1
In progress
National Oesophago-Gastric Cancer Audit (NAOGC)
Upper GI
Paul Barham
1
Q1
In progress
VSGBI Vascular Surgery Database
Vascular
Peter Lamont
1
Q1
In progress
NICE TA167 Abdominal aortic aneurysm - endovascular stent
grafts
Vascular
Marcus Brooks
1
Q1
Completed
Carotid interventions (CIA)
Vascular
Peter Lamont
1
Q1
In progress
Fenestrated endovascular aortic stent graft for juxta-renal
abdominal aortic aneurysm repair (F-EVAR)
Vascular
Marcus Brooks
2
Q3
Not started
The following activity was also in progress during the financial year (either rolled over from previous year or not identified
through plan):
Ref
Provisional Title of Project
Status
Adult Ear, Nose and Throat (ENT)
3079
ENT urgent clinic letters
Abandoned
3080
Accuracy of MRI scans in the detection of primary and recurrent cholesteatoma
Abandoned
3125
Coding by Theatre staff
Completed
3270
Tympanomastoid Surgery
Abandoned
3278
Current practice in septoplasty
Completed
3469
Antibiotic prescribing - re-audit
Completed
3474
ENT Outpatient procedures coding
Completed
3646
Provision of patient information in ENT: informed consent
In Progress
3657
Infectious mononucleosis screening in tonsillitis
Completed
3685
ENT Hot clinic referrals
In Progress
3079
ENT urgent clinic letters
Abandoned
Clinical Audit Annual Report 2013/14
Page 32
Anaesthesia & Critical Care & Theatres – Anaesthesia
2959
Fasting times in trauma surgery
Abandoned
3449
Completion of pre-operative anaesthetic review documentation.
Completed
3517
An audit of the alarm settings on anaesthetic machines in Bristol Royal Infirmary
Completed
3658
Obstetric Anaesthesia Documentation Audit
In Progress
3666
An audit of analgesia prescribing in acute medical and surgical admissions with renal impairment
Completed
3687
Lung protective ventilation in theatres
In Progress
3422
Appropriateness of referrals to pain management programme (PMP)
Completed
3494
Management of patients undergoing major lower limb amputation - Severn deanery project
In Progress
3530
Chronic pain- Audit of record keeping standards during epidural injections for the management of spinal origin pain
In Progress
3669
Frequency and Severity of Complications of Ophthalmic anaesthesia in Cataract surgery
In Progress
3705
Safety of epidural catheter removal as part of the acute pain management
In Progress
1704
Dural Puncture
Ongoing Project
2906
Obesity in Obstetric Anaesthesia [re-audit of 1966]
Abandoned
3457
Caesarean section anaesthesia: technique and failure rate [re-audit of 1703]
Completed
3643
Adequacy of Post Caesarean Section Pain Relief [re-audit of 1170]
Completed
3719
Hyperglycaemia in theatre recovery
In Progress
Anaesthesia & Critical Care & Theatres – Critical Care Services
537
Potential Donor Audit (PDA)
Ongoing Project
3365
Stress ulcer prophylaxis on discharge from ITU, appropriate or inappropriate?
Completed
3400
Delayed and out of hours discharges from ITU
In Progress
3445
Are packed red cell transfusions on intensive care compliant with BCSH guidelines in non-bleeding patients
Abandoned
Anaesthesia & Critical Care & Theatres – Theatres
3719
Hyperglycaemia in theatre recovery
In Progress
Dental Services
3313
Are Cone Beam Computerised Tomography (CBCT) scans using the smallest volume necessary to answer the clinical
question?
Completed
3424
Local anaesthetic written prescriptions referred to the school of hygiene
Completed
Dental Services/Oral & Maxillofacial
2879
Identification and management of bisphosphonate therapy patients presenting to the oral and maxillofacial surgery
department [related to 2750]
Abandoned
3077
Maxillofacial trauma referrals
Deferred
3330
Quality of radiographs received with Oral Surgery referrals
Completed
3366
Incidence of inferior dental/ lingual nerve sensory damage post mandibular third molar extractions
In Progress
3387
Information given to patients taking Bisphosphonates about Bisphosphonate Related Osteonecrosis of the Jaw
(BRONJ)
Completed
3675
An audit to assess the success rate of surgical endodontics (apicectomy) within the oral surgery department
In Progress
3713
Quality of clinical coding in oral and maxillofacial surgery
In Progress
3717
Oral & Maxillofacial Trauma - audit of timescales for emergency treatment
In Progress
Dental Services/Oral Medicine
2850
How effective are our glycerol blocks in achieving pain control in trigeminal neuralgia?
Abandoned
3317
Histopathological Diagnosis in Oral Medicine [re-audit]
In Progress
3595
Quality of Clinical Information on Biopsy Request Forms
In Progress
Clinical Audit Annual Report 2013/14
Page 33
Dental Services/Orthodontics
3157
Management of orthodontic patients with a history of dental trauma to incisor teeth
In Progress
3226
Lost orthodontic appliances [re-audit]
Completed
3248
New patient referrals to the orthodontic department.
Completed
3607
Undiagnosed caries in patients referred for Orthodontic treatment
Completed
3623
Photography consent and photographic quality in the orthodontic department
Completed
Dental Services/Paediatric Dentistry
3155
Quality of record-keeping for paediatric dental trauma patients
Completed
3331
Extraction of first permanent molars of poor prognosis in children [re-audit of 2545]
Completed
3357
Fluoride: are we following the national guidelines? [re-audit of 2430]
In Progress
3386
Users’ views of the paediatric dental clinic [re-audit of 2263]
Completed
3481
Patient satisfaction with paediatric general anaesthetic services for dental treatment
Deferred
Dental Services / Restorative Dentistry
2773
Endodontic referrals received at Bristol Dental Hospital
Completed
3082
Quality of life of patients with total prostheses before and after treatment with conventional dentures in Bristol
Dental Hospital
In Progress
3163
Patient satisfaction of Dental GA care pathway for Special Care patients
In Progress
3224
Dental implant treatment at Bristol Dental Hospital
In Progress
3292
Are radiographs utilised on new patient periodontal clinics appropriate to aid periodontal diagnosis?
In Progress
3341
Prescriptions, special trays and wax rims for complete denture construction [re-audit of 3147]
Completed
3420
Head and Neck Cancer: Is radiotherapy being delayed by dental screening and subsequent extractions?
In Progress
3430
Restorative undergraduate treatment plans
In Progress
3431
Implant-retained over-denture complications at Bristol Dental Hospital
Completed
3459
Quality of dental screening and DPT fluoride prescriptions in the management of head and neck oncology patients
In Progress
3529
Caries prevention regimes given to head and neck oncology patients following oncological therapy
Deferred
3555
Radiographs taken by Undergraduates carrying out Endodontics
Completed
3661
The quality of Endodontic referral radiographs received at the Bristol Dental Hospital
In Progress
3680
Denture care for inpatients
In Progress
Ophthalmology / General
2893
Post-cataract endophthalmitis rate at Bristol Eye Hospital 2005 to 2010 [re-audit of 1125]
Completed
3364
Clinical coding of oculoplastic and vitreoretinal procedures
In Progress
Ophthalmology / A&E and Primary Care
3165
Record-keeping for child casualty patients at BEH [re-audit of 2836]
In Progress
Ophthalmology / Cornea & Cataracts
2872
Ocular biometry [re-audit of 2362]
In Progress
3072
Incidence and causes for 2 lines of Snellen Visual Acuity loss following phacoemulsification and intraocular lens
implantation [re-audit of 2001]
Abandoned
3181
Descemet’s Stripping Automated Endothelial Keratoplasty (DSAEK): Visual Acuity outcomes and Complications
In Progress
3388
Boston Type 1 Keratoprosthesis - initial outcomes report to Clinical Effectiveness Group
Completed
3423
Cataract outcomes 2012 [re-audit of 3195]
Completed
3703
Re-audit of microbial keratitis at Bristol Eye Hospital
In Progress
3718
Cataract outcomes audit 2013 [re-audit of 3423]
In Progress
Clinical Audit Annual Report 2013/14
Page 34
Ophthalmology / Glaucoma & Shared Care
3011
Blindness in glaucoma patients
Completed
3302
Glaucoma outpatient follow up appointments at Bristol Eye Hospital [re-audit 2012]
In Progress
3390
Deep Sclerectomy (non-penetrating glaucoma filtration surgery)
Completed
Ophthalmology / Medical & Surgical Retina
2829
Management of non-ischaemic Central Retinal Vein Occlusion (CRVO) at Bristol Eye Hospital [re-audit of 1917]
Completed
3160
Time frame of patients’ journey in Age Related Macular Degeneration (AMD) service
Completed
3418
Maculopathy Referrals from Bristol and Weston Diabetic Eye Screening Programme
In Progress
3417
Referral and Treatment Times for patients with suspected Proliferative Retinopathy
In Progress
Ophthalmology / Orthoptics & Optometry
3235
Orthoptic new case referrals
Completed
3287
Reception vision screening
In Progress
Ophthalmology / Paediatrics, Oculoplastics & Squint
2313
Adult Squint Surgery Outcomes
In Progress
2925
Referrals from Paediatric Rheumatology of children diagnosed with Juvenile Idiopathic Arthritis to the Eye Hospital for
Completed
uveitis screening
Impact of neuro-ophthalmic disorders on the Bristol Eye Hospital paediatric service
Completed
3010
Paediatric Eye surgery service: parental and patient satisfaction.
Deferred
3161
Basal Cell Carcinoma patient consultation and treatment times in the oculoplastics department
In Progress
3179
External dacryocystorhinostomy audit [re-audit of 2312]
Deferred
3229
Surgical Outcome of Correction of Exotropia in Children
In Progress
3288
Nurse-Led Botox treatment for Blepharospasm, Hemi facial spasm and entropion at Bristol Eye Hospital.
Completed
2838
Adult Surgical Specialties
3236
Streamlining discharge in Elective Surgery: An Audit of Criteria Led Discharge
In Progress
3343
Is Foundation doctors’ understanding of IV fluid prescribing adequate?
In Progress
3371
Surgical Ward Rounds in the BRI: When, who and how often?
In Progress
3415
Are we following UH Bristol guidelines for gentamicin prescribing in adults?
In Progress
Adult Surgical Specialties / Lower GI Surgery
3227
Reversal of ileostomies
Completed
3342
Are we following the NCEPOD recommendations for emergency surgery in Octogenarians?
In Progress
3383
Re-admission to hospital of patients waiting for surgery on "hot gall bladder" laparascopic cholycystectomy waiting list In Progress
Adult Surgical Specialties / Orthopaedics (T&O)
2592
Health Protection Agency - Surgical Site Infection Surveillance
Ongoing
2908
Audit of acute pain management for hip fracture patients
Completed
3397
Daycase Hand Surgery at South Bristol Community Hospital: cancellations and patient experience
In Progress
Adult Surgical Specialties / Thoracic Surgery
3280
Thoracic Surgery lobectomy patients – why are patients staying longer than 5 days in hospital?
In Progress
Adult Surgical Specialties / Upper GI Surgery
2817
Audit on the Management of Acute Pancreatitis
Completed
2852
Pre-Operative Emergency Patient Audit (PEPA)
Completed
2904
Evaluating the use of PET/CT (Positron Emission Tomography/Computed Tomography) in the staging of Oesophageal
Cancer
In Progress
Adult Surgical Specialties / Vascular Surgery
2680
Can pre-operative Carotid Duplex screening reduce the risk of stroke following cardiac bypass?
Clinical Audit Annual Report 2013/14
In progress
Page 35
The following section summarises the changes, benefits or actions introduced as a result of completed audits within the
Division/specialties.
3125
This audit demonstrated high accuracy of procedure coding by Clinical Coding staff for patients undergoing ENT surgical
procedures.
3278
Following this audit of sepoplasty it was decided that an increased number of day case operations was needed to reach
target. This will be done by changing to morning operations and providing more open appointments. It was also agreed
that further work was needed to better understand reasoning behind post op bleed/unwell patients after surgery
3469
This re-audit demonstrated significant improvement in antibiotic prescribing within ENT practice.
3474
This audit of ENT Outpatient procedures coding resulted in the re-design of the outpatient outcome form to make this
clearer for staff to complete and to assist correct charging for outpatient procedures
3657
This audit led to the creation of a new departmental policy for infectious mononucleosis screening for tonsillitis. This
should result in a cost saving from targeting infectious mononucleosis screening more effectively.
3449
A new chart with an expanded pre-operative section has been introduced throughout clinical areas as a result of this
audit.
3517
Following this audit of anaesthetic machine checks it was decided to update the Trust’s guidance on levels for machine
alarms (as advised by the Association of Anaesthetists of Great Britain and Ireland). The Medical Equipment Management
Organisation service now checks with the Department of Anaesthesia to ensure that individual levels are set rather than
the manufacturer defaults.
3666
Guidelines have been revised as a result of this audit into analgesia prescribing in acute medical and surgical admissions
with renal impairment.
3422
The audit has led to updated referral criteria being developed for the Pain Management Programme, more in line with
Pain Society guidance. These have been widely cascaded and are expected to lead to more efficient use of clinical
resources.
3457
This audit demonstrated good compliance with recommendations for the use of regional anaesthesia (RA) during
caesarean section and rates of conversion from regional to general anaesthetic during the procedure, indicating that pain
was well controlled by RA for the majority of patients.
3643
This audit demonstrated high patient satisfaction with pain-relief provided following a caesarean section, as well as
clinical best practice in prescription of non-steroidal anti-Inflammatory drugs.
3313
This audit was used as evidence to support a business proposal for purchasing a small volume Cone Beam CT machines for
Bristol Dental Hospital.
3424
This audit of local anaesthetic written prescriptions referred to the school of hygiene led to the development of a local
policy to help standardise practice.
3330
The referral proformas for oral surgery patients have been redesigned as a result of this audit to help improve the quality
of radiographs received.
3387
Following this audit of information given to patients taking Bisphosphonates about Bisphosphonate Related Osteonecrosis
of the Jaw (BRONJ), it was agreed that a revised patient leaflet should be implemented. Posters have been developed for
use in the oral surgery department detailing the key points of information about BRONJ that must be relayed to the
appropriate patients.
3226
To improve the service, the laboratory work card has been re-designed to include a check box to determine whether new
or remake orthodontic appliances are required.
3248
New orthodontic department guidelines outlining referral criteria have been introduced as a result of this audit. It was
also agreed with the oncology department to produce a similar patient information leaflet to hand out to relevant
patients in new patient oncology clinics.
3607
This audit confirmed good practice in treatment of undiagnosed caries in patients referred for orthodontic treatment.
General Dental Practitioners have been further educated in the form of helpful reply letters with feedback and referral
guidelines with re-referrals.
3623
Following this audit of photography consent and photographic quality in the orthodontic department, it was agreed that a
single universal site should be available to store start and end photographs.
3155
As a result of this audit, the trauma form has been re-designed to help improve the quality of record-keeping for
paediatric dental trauma patients. A re-audit is currently underway.
3331
This re-audit demonstrated improvements in practice for children having tooth extractions of first permanent molars of
poor prognosis. Further awareness of standards was highlighted through presentations.
3386
As a result of this audit into the user views of paediatric dental clinics, a new clinic flow sheet has been introduced to
provide more information to patients.
Clinical Audit Annual Report 2013/14
Page 36
2773
This audit of endodontic referrals received at Bristol Dental Hospital demonstrated good adherence to standards.
3341
This re-audit of prescriptions, special trays and wax rims for complete denture construction has led to the agreement of
criteria for the production of special trays and wax rims. Results have been disseminated and the prosthetics laboratory
management will hold training session in order to encourage good practice.
3431
This audit demonstrated that implant-retained over-denture complications at Bristol Dental Hospital were within agreed
rates.
3365
This audit has led to the creation of new local guidelines for the management of patients prescribed stress ulcer
prophylaxis on ITU.
3364
This audit demonstrated good practice in the clinical coding of oculoplastic and vitreoretinal procedures.
3388
The results of this audit of a new interventional procedure agreed by the Trust (Boston Type 1 Keratoprosthesis)
demonstrated that outcomes were within published guidance.
3423
This annual audit of cataract outcomes demonstrated good practice against nationally benchmarked outcome data.
3011
This audit demonstrated that the management of blindness in glaucoma patients was being treated appropriately.
3390
This audit confirmed that patients undergoing Deep Sclerectomy (non-penetrating glaucoma filtration surgery) were being
treated appropriately.
3417
This audit identified the need for improvements in referral and treatment times for patients with suspected Proliferative
Retinopathy. Local retinopathy guidelines have been re-written and re-audit planned.
3418
This audit identified the need for improvements in referral and treatment times for patients with suspected Proliferative
Retinopathy. Local retinopathy guidelines have been re-written and re-audit planned
3287
The Trust has changed from the use of the Snellen to logMAR vision test as a result of this his audit of reception vision
screening.
3010
This audit of the paediatric eye surgery service demonstrated good levels of parental and patient satisfaction.
3391
As a result of this audit into non-accidental Head Injury in children (ophthalmological review), guidelines were created for
the referral to a Paediatric Ophthalmologist where concern exists. It was also agreed that the proforma available from the
Royal College of Paediatrics and Child Health and The Royal College of Ophthalmologists for accurate description and
documentation of clinical history and findings should be adopted.
3626
This audit of compliance with hand hygiene guidance on Ward 2 led to the design a more up to date poster as a visual
prompt to hand hygiene on entry to and exit from the ward. Posters will be more strategically placed near the swipe card
access points and the dispensers themselves. It was also decided to re-locate the shelf much nearer the hand gel
dispenser so that it may fulfil its initial purpose.
3415
This audit of gentamicin prescribing led to the re-design of the current drug chart and the identification and implantation
of further nurse training.
Clinical Audit Annual Report 2013/14
Page 37
WOMEN’S AND CHILDREN'S
3.5
The following chart shows the status at year end of those projects identified as priorities for audit as part of the
forward planning process in 2013/14. Full details of the status of individual projects on this plan can be found within
table 1 of this section.
Progress of planned projects
Complete
100%
80%
60%
40%
20%
0%
In progress
Not started
4
4
7
4
7
19
1
1
3
2
3
2
2
9
2
1
2
3
Children's Services
Women's Services
Prioritisation category
The chart below shows the status at year end of all registered projects (excluding those classified as ongoing
monitoring). Some projects will have started and finished within the financial year, some will have been started but
have yet to complete and are therefore rolled over. The figures also include projects that commenced in previous
years but have now been abandoned, those that previously commenced but were completed in 2013/14 and those
previously commenced but not completed by the end of 2013/14.
Individual project status at year end
40
35
32
30
17
20
12
11
10
13
11
6
10
2
1
0
Children's Services
Women's Services
New in year/Completed
New in Year/Roll-over
Rolled-over/Abandoned
Rolled-over/Completed
Rolled-over/Deferred
Rolled-over/Roll-over
Percentage of projects registered before start
100%
80%
Make up of project team
100%
24
80%
24
3
28
60%
60%
40%
40%
20%
55
7
20%
80
41
0%
42
42
Children's Services
Women's Services
0%
Children's Services
TRUE
Clinical Audit Annual Report 2013/14
Women's Services
FALSE
Multi-professional
Multi-specialty
Neither
Page 38
Percentage National Audit
Percentage re-audit
100%
100%
80%
80%
60%
60%
40%
36
40%
95
65
9
4
Children's Services
Women's Services
20%
0%
86
20%
TRUE
18
33
Children's Services
Women's Services
0%
FALSE
TRUE
FALSE
Guidance/stand type audited
60
49
50
40
30
20
24
25
20
19
11
15
10
10
0
Children's Services
Women's Services
NICE
Other National
Local
Percentage report produced
Unclassified
Percentage action plan produced
100%
100%
15
80%
1
1
1
80%
8
60%
60%
40%
40%
20%
20%
37
17
0%
50
24
Children's Services
Women's Services
0%
Children's Services
TRUE
Women's Services
FALSE
Yes
No - Confirmed good practice
No
Table 1
Title
Sub-Specialty
Lead
Congenital heart disease (CHD)
Cardiac Surgery
Andrew Parry
National Diabetes Audit (NDA)
Priority Start date
Status Q4
1
Q1
In progress
Diabetes & Endocrinology Christine Burren
1
Q2
In progress
National Inflammatory Bowel Disease audit
Gastroenterology
Christine Spray
1
Q1
In progress
Paediatric Intensive Care (PICANet)
Intensive Care
Peter Davis
1
Q1
In progress
Renal Registry (UKRR)
Nephrology
Carol Inward
1
Q2
In progress
Epilepsy 12 (Childhood Epilepsy)
Neurology
Phil Jardine
1
Q1
In progress
Clinical Audit Annual Report 2013/14
Page 39
National Neonatal Audit Project
Neonatal Intensive Care
Pam Cairns
1
Q1
In progress
Vermont-Oxford Benchmarking Project
Neonatal Intensive Care
David Harding
2
Q1
In progress
Audit of Anaesthetic Record Keeping (to include detailed audit
of documentation of consent process)
Anaesthesia
Gail Lawes
3
Q2
In progress
Audit of the provision of Anaesthetic Preoperative Information
Anaesthesia
Steve Sale
3
Q2
In progress
Re-audit of Antibiotic Policy Compliance Audit
Anaesthesia
Bev Guard
3
Q2
Completed
Cochlear Implants
Audiology
Liz Midgley
1
Q1
In progress
Hospital passport
Cross Hospital
Sara Palmer
2
Q3
Not started
Audit of growth monitoring practice
Endocrinology
Liz Crowne
1
Q1
Complete
An audit of the physical and psychological management of selfharm in the emergency department
Emergency Department
Lisa Goldsworthy
3
Q1
In progress
Audit of paediatric asthma management
Emergency Department
Nick Sargant
1
Q1
Completed
Consultant sign off for febrile children < 1 year old in the ED
Emergency Department
Mark Lyttle
1
Q1
In progress
An audit of the Management of Head Injury in the Children’s
Emergency Department
Emergency Department
Mark Lyttle
3
Q1
In progress
An audit of the Management of Children in the Children’s
Emergency Department with Suspected Urinary Tract Infection
Emergency Department
Will Christian
3
Q2
In progress
Neonatal resuscitation
Neonatology
Ward Managers
2
Q3
Not started
Immediate Care of the Newborn (Joint project with Obstetrics
and Midwifery)
Neonatology
Jackie Moxham/
Anoo Jain
2
Q1
Not started
Newborn feeding (Joint project with NICU)
Neonatology
Joan Beales
2
Q1
In progress
Examination of the Newborn (joint project with Obstetrics and
Midwifery)
Neonatology
Wendy Ring/Anoo
Jain
2
Q3
In progress
Support for Parents (Joint project with Obstetrics and Midwifery) Neonatology
Jackie Moxham/
Anoo Jain
2
Q2
Completed
Anaemia in Chronic Kidney Disease 3b to 5
Nephrology
Moin Saleem
3
Q2
Not started
Dialysis Access Complications
Nephrology
Jane Tizzard
3
Q2
In progress
Care of patients on Dialysis
Nephrology
Jan Dudley
3
Q2
In progress
Management of Renal Bone Disease
Nephrology
Martin Mraz
3
Q2
Not started
Prescription of Dialysis Line Locks
Nephrology
Rebekah Rogers
3
Q2
Not started
Vancomycin – monitoring and dose adjustment
Pharmacy
Jenny Haylor
2
Q3
In progress
Patient administration and compliance issues when prescribed
Proton Pump Inhibitors
Pharmacy
Nicola Singh
2
Q3
Not started
Accurate CRIS documentation of consultant checks
Radiology
David Grier
3
Q3
Not started
Genetic Haemoglobinopathy screening (re-audit)
Clinical Genetics
Jessica Bailey
3
Q3
In progress
Key identifiers in dictation
Clinical Genetics
Ingrid Scurr
3
Q1
In progress
Case note peer review
Clinical Genetics
Alan Donaldson
3
Q3
Not started
West of Britain Group joint audit – probably Lynch syndrome
screening
Clinical Genetics
Alan Donaldson
3
Q3
Not started
Total Laparoscopic Hysterectomy (TLH)
Gynaecology
Caroline Overton
2
Q3
In progress
Clinical Audit Annual Report 2013/14
Page 40
Swab management on CDS / Handover to Theatres
Obstetrics/Midwifery
Bryony Strachan/
Emma Treloar
2
Q3
In progress
Care of Women in Labour
Obstetrics
Emma Treloar/
Belinda Cox
2
Q1
In progress
Intermittent Auscultation
Obstetrics/Midwifery
Emma Treloar/
Belinda Cox
2
Q1
In progress
Continuous Electronic Fetal Monitoring
Obstetrics/Midwifery
Emma Treloar/
Belinda Cox
2
Q1
In progress
Fetal Blood Sampling
Obstetrics/Midwifery
Emma Treloar/
Belinda Cox
2
Q1
In progress
Use of Oxytocin
Obstetrics/Midwifery
Emma Treloar/
Belinda Cox
2
Q1
In progress
Caesarean Section
Obstetrics/Midwifery
Emma Treloar/
Belinda Cox
2
Q1
In progress
Induction of Labour
Obstetrics/Midwifery
Emma Treloar/
Belinda Cox
2
Q2
Complete
Severely Ill Women
Obstetrics/Midwifery
Emma Treloar/
Belinda Cox
2
Q1
Complete
High Dependency Care
Obstetrics/Midwifery
Emma Treloar/
Belinda Cox
2
Q1
In progress
Vaginal Birth after Caesarean Section
Obstetrics/Midwifery
Emma Treloar/
Belinda Cox
2
Q1
In progress
Operative Vaginal Delivery
Obstetrics/Midwifery
Rachna Bahl/Lisa
Damsell
2
Q1
In progress
Multiple Pregnancy and Birth
Obstetrics/Midwifery
Rachna Bahl/Lisa
Damsell
2
Q4
In progress
Perineal Trauma
Obstetrics/Midwifery
Rachna Bahl/Lisa
Damsell
2
Q3
In progress
Shoulder Dystocia
Obstetrics/Midwifery
Rachna Bahl/Lisa
Damsell
2
Q1
In progress
Obstetric Haemorrhage
Obstetrics/Midwifery
Rachna Bahl/Lisa
Damsell
2
Q1
In progress
Pre-existing Diabetes
Obstetrics/Midwifery
Rachna Bahl/Lisa
Damsell
2
Q3
Not started
Obesity
Obstetrics/Midwifery
Rachna Bahl/ SJ
Sheldon
2
Q1
Not started
Mental Health
Obstetrics/Midwifery
SJ Sheldon/
Rachel Liebling
2
Q3
In progress
Handover of Care (Onsite)
Obstetrics/Midwifery
Sarah-Jane
Sheldon
2
Q1
In progress
Non-Obstetric Emergency Care
Obstetrics/Midwifery
Rachna Bahl/Lisa
Damsell
2
Q3
Not started
Neonatal resuscitation
Obstetrics/Midwifery
Ward Managers/
CDS WP
2
Q3
Not started
Immediate Care of the Newborn (Joint project with NICU)
Obstetrics/Midwifery
Jackie Moxham/
Anoo Jain
2
Q1
Not started
Newborn feeding (Joint project with NICU)
Obstetrics/Midwifery
Joan Beales
2
Q3
In progress
Examination of the Newborn (Joint project with NICU)
Obstetrics/Midwifery
Wendy Ring/Anoo
Jain
2
Q3
Not started
Bladder Care
Obstetrics/Midwifery
Jackie Moxham
2
Q3
In progress
Support for Parents (Joint project with NICU)
Obstetrics/Midwifery
Jackie Moxham/
Anoo Jain
2
Q2
Complete
Recovery
Obstetrics/Midwifery
Claire Dowse
2
Q1
Not started
Clinical Audit Annual Report 2013/14
Page 41
The following activity was also in progress during the financial year (either rolled over from previous year or not identified
through plan):
Ref
Title of Project
Status
Children’s Services/Anaesthesia
2746
Audit of compliance with antibiotic guidelines for surgery
Completed
2822
Administration of sedative premedication to children
Completed
3098
BRCH PONV and Pain Management up to 6 hours post day surgery with next day Telephone follow up
In Progress
3250
Pre op fasting in children undergoing surgery in the BRHC
In Progress
3409
Re-audit of compliance with antibiotic guidelines for surgery with particular reference to antibiotic prophylaxis in
theatre
In Progress
3410
Audit of Anaesthetic Record Keeping
In Progress
Children’s Services/Cardiac Services
3202
Re-audit of anti-coagulation therapy for children in Cardiac Services
In Progress
3208
Quality and interprebility of faxed ECGs
In Progress
3246
Perioperative management of Blalock-Tausig Shunt audit
In Progress
3380
3408
Follow up and complications associated with aortic valvuloplasty via axillary cut-down for critical aortic stenosis in
neonates
An audit of the management of children with respiratory synctial virus who are undergoing cardiopulmonary bypass
surgery for Chronic Heart Disease
In Progress
In Progress
Children’s Services/Dietetics
2966
Meeting nutritional needs, standards and quality of care in paediatrics: Outcome 5 compliance
In Progress
3105
Paediatric Dietetic input for Paediatric Diabetes
Completed
Children’s Services/Emergency Department
3029
The College of Emergency Medicine Consultant Sign Off Audit
Completed
3106
Audit of antimicrobial prescribing practice on the children's ward following presentation to the Children's Emergency
Department
Completed
3117
Management of non-blanching rashes presenting to the Children's Emergency Department
Completed
3221
Observations in the paediatric Emergency Department
Completed
3222
Improving adolescent care in the paediatric Emergency Department
Completed
3243
Nasal ciliary brushings in the management of primary ciliary dyskinesia
In Progress
3320
Handover from the paediatric Emergency Department to BRHC wards
In Progress
3376
Management of non-bleaching rash in the paediatric Emergency Department
In Progress
3379
Paediatric sedation in the ED
In Progress
3393
College of Emergency Medicine - consultant sign off
In Progress
Children’s Services/Paediatric Endocrinology
2818
Audit of insulin tolerance tests performed on the clinical investigation unit at Bristol Royal Hospital for Children
Completed
3296
Diabetic Ketoacidosis in accordance with the Southwest Paediatric Diabetes Regional Network Integrated Care Pathway
guidelines from 2007-2012.
In Progress
Children’s Services/Gastroenterology
2490
United Kingdom National Inflammatory Bowel Disease Audit
In Progress
3377
Infliximab and Adalimumab use in children with crohns disease
In Progress
Children’s Services/Paediatric Intensive Care
72
Regional Audit of Critical Care Outcomes (Audit of Critically Ill Children)
Ongoing
2548
PICU Discharge delay audit 2010
In Progress
2639
Audit of the Documentation of Information & Clinical Observations on the Bristol Paediatric Observation Chart
Completed
3392
Audit of resuscitation documentation at BRHC
In Progress
Clinical Audit Annual Report 2013/14
Page 42
Children’s Services/Paediatric Nephrology
2285
Retrospective audit of anaemia in paedatric patients with CKD stage 5 disease 2003- 7
In Progress
2745
Audit of dialysis access service and complications (01/01/09 - 30/06/10)
In Progress
2924
Pre-Renal Transplantation immunization and investigations
In Progress
2970
Urinary Tract Infection Audit of NICE guidance - Healthcare Quality Improvement Partnership (HQIP)
In Progress
2988
Compliance with current guidelines for MRSA screening on the paediatric nephrology ward
Completed
3002
Audit of patients with Stage 4 Chronic Kidney Disease (2010-11)
In Progress
3385
Gentamicin prescribing in paediatrics
In Progress
3402
Audit of Management of Hyperlipidaemia in Children with CKD Stage 4 & 5
In Progress
3403
Renal replacement therapy (dialysis) in children at the BRCH (2011/12)
In Progress
Children’s Services/Neurology
3398
Epilepsy12 - UK Collaborative audit of healthcare for children and young people with suspected epileptic seizures
In Progress
Children’s Services/Paediatric Oncology
2687
Audit of bone marrow transplant febrile neutropenia guidelines
In Progress
3069
An audit of prescribing against NHSLA standards for BMT inpatients and outpatients
In Progress
3359
Audit of paediatric sickle cell management
In Progress
3370
Aseptic Non Touch Technique (ANTT) in IV practice 2012-13
In Progress
Children’s Services/Paediatric Respiratory
2106
British Paediatric Respiratory Society / British Thoracic Society Asthma Audit
In Progress
2434
Parental satisfaction in a nurse led paediatric clinic
Completed
2769
Inpatient nebuliser adherence
Completed
Children’s Services/Paediatric Rheumatology
3045
3170
Management of community acquired pneumonia (CAP) in Bristol Royal Hospital for Children British Thoracic Society
Guidelines
Waiting times for patients listed for intra - articular joint injections for Juvenile Idiopathic Arthritis using BSPAR
standards of care
In Progress
In Progress
Children’s Services/Paediatric Surgery
3194
Audit of patients undergoing oesophagogastric dissociation surgery
In Progress
3200
International, multicentre audit of outcomes following appendicectomy
Completed
3318
Children who ‘did not attend’ (DNA) Paediatric General Surgery and Paediatric Urology outpatient clinic appointments
In Progress
Women’s Services/Gynaecology
3413
Key identifiers in dictation
In Progress
231
The collection of regional gynaecological cancer for the purposes of audit and improvement of management
Ongoing
1945
National audit of invasive cervical cancers
Ongoing
2740
Documentation and information given following insertion of the Levonorgestrel Releasing Intrauterine System (Mirena
IUS)
Completed
3016
Continuous audit of laparoscopic hysterectomy
Ongoing
3063
Management of ovarian cancer
In Progress
3228
Management of patients at joint Gynaecology-Haematology Clinic
Completed
3271
Hysteroscopy - mode of anaesthesia
Completed
3272
Timing of misoprostol prior to transcervical surgical procedures in Gynaecology
In Progress
3311
Colposcopy - treating to cure
Completed
3316
Treatment standards in colposcopy for high grade disease
Completed
3338
Senior house officer pre-operative ward round checks
In Progress
Clinical Audit Annual Report 2013/14
Page 43
Women’s Services/Obstetrics & Midwifery
633
Audit of blood usage on Central Delivery Suite
Ongoing
1638
A series of audits of UNICEF UK Baby Friendly Initiative best practice standards
Ongoing
2321
2730
National Screening Committee Audit Haemoglobinopathies, Infectious Diseases, Downs Screening and Newborn Blood
spot - NICE CG 62
Re-audit of the implementation of Modified Obstetric Early Warning Score (MEOWS) charts at St Michael’s Hospital
Delivery Suite (CNST 3.2.8)
Ongoing
Ongoing
2762
Pleuro-amniotic shunt for fetal pleural effusion (NICE IPG190)
In Progress
2795
Perineal tear audit (CNST 3.3.5a)
Ongoing
2801
Pregnancies in Women with Prosthetic Heart Valves and Therapeutic Anticoagulation 2007 – 2010
Completed
2802
Antenatal and Intrapartum management of very preterm labour
Completed
2803
Bristol Stillbirth audit - continuous
Ongoing
2833
HIV testing in Pregnancy (re-audit)
Ongoing
2841
Management of Cardiac problems in pregnancy
In Progress
2853
Compliance with procedures for swab, needle and instrument counts
Ongoing
2927
Beta-blocker use in Cardiac Antenatal Patients
Completed
2929
Re-audit of diagnosis and management of obstetric cholestasis
Completed
2956
Emergency department admissions of pregnant women (CNST 3.4.10)
Completed
2964
Induction of labour (CNST 3.2.7)
Completed
3015
Management of operative vaginal delivery: including multiple instrument use and failed operative vaginal delivery
(CNST 3.3.3)
In Progress
3026
Re-audit of management of pre-existing diabetes – local standards
Completed
3041
Re-audit of clinical risk assessment – Labour (CNST 3.4.7)
In Progress
3064
Re-audit of prophylaxis in women with venous thromboembolism (CNST 3.3.8b)
Completed
3090
Enhanced recovery in gynaecological surgery
In Progress
3133
Complex twins seen in fetal medicine department
In Progress
3134
TORCH screening at St Michael's Hospital
Completed
3142
Management of women who deliver preterm
In Progress
3149
Height of fundus measurement
Completed
3212
Post natal bladder care
Completed
3239
Intrapartum care for women with cardiac disease
In Progress
3240
Midwife Examination of the Newborn re-audit
Completed
3244
Compliance with Mulitple Pregnancy Guideline – NICE CG129
In Progress
3298
Induction of labour process - going beyond CNST
In Progress
3299
Management of placenta accreta
In Progress
3315
Maternity outlier alert for 'maternal non-elective readmissions'
In Progress
3334
Appropriate use of fast bleep system for Caesarean section
In Progress
3335
Labour ward staffing (CNST 3.1.6)
Completed
3337
Gestational diabetes follow up fasting blood sugar- Re-audit
In Progress
3350
Management of thrombocytopenia in pregnancy
In Progress
3362
Management of newborn where group B streptococcus present in mother or baby – re-audit (CNST 3.5.4)
Completed
3405
Post-caesarean section infection
In Progress
Clinical Audit Annual Report 2013/14
Page 44
The following section summarises the changes, benefits or actions introduced as a result of completed audits within the
Division/specialties.
3203
Following this audit of management of croup at Bristol Royal Hospital for Children, the availability of patient information
leaflets has been increased and further training to staff provided highlighting assessment of severity and acting
appropriately. There has also been communication with GPs regarding the use of ambulances for moderate / severe
croup.
3346
Following this audit of azathioprine prescribing in paediatric dermatology patients, the British Society of Paediatric
Rheumatology patient information and advice regarding sun protection was introduced.
3368
Following this audit of smoking advice to parents of wheezy children, parent smoking status and advice fields are to be
included on the wheeze proforma.
3549
Following this audit of compliance of intravenous fluid administration with local guidelines it was confirmed that the
prescription guideline has been incorporated into the general paediatric induction programme. It was also agreed that
nurses should be consulted on future re-audit, which should take into account amount of time patient is continuously on
iv fluids.
3340
This audit resulted in a clarification of local guidelines for the treatment of neonates with heart murmur and
improvements to referral proforma.
3570
This audit of charts - fluid and infusion prescription and recording in NICU highlighted the need for further
training/teaching sessions. These are in the process of being arranged.
3604
This audit demonstrated good compliance in Neonatal Intensive Care with standards relating to prescription of
gentamicin, independent checks of preparation and administration, and timeliness of administration.
3098
The results of this audit of management of pain and post-operative nausea and vomiting were very positive with the
majority of audit standards met and overall satisfaction on the care, pain and post-operative nausea/vomiting
management being reported as good to excellent. Parents frequently praised both medical and nursing staff for their
care and diligence during their hospital experience.
3250
Following this audit of pre op fasting in children undergoing surgery, clear fluid intake is being encouraged in the period
greater than two hours before operation start time.
3409
Following this re-audit of compliance with local antibiotic guidelines for surgery it was agreed that induction information
for new juniors should include the need to document antibiotics on drug chart. The need to document "knife to skin"
time and antibiotic prescribing is to be considered when re-designing anaesthetic charts.
3461
This audit determined that LMX is to remain 1st line topical local anaesthetic for cannulation in children’s theatres. The
scope should be explored for keeping Ametop in stock for when cannulation / bloods are needed in < 1 hour.
3638
It was agreed that a local guideline should be introduced as a result of this audit of temperature control of paediatric
patients in the peri-operative period. It was agreed that active warming should always be used from induction when
anaesthetic time is prolonged, or if patient is high risk.
3208
Following this audit of quality and interprebility of faxed ECGs it was agreed to switch from faxed to scanned ECGs.
3246
Following this audit of perioperative management of Blalock-Tausig Shunt surgery it was agreed that a proforma checklist
be introduced and a consensus view on use of pre-operative aspirin be pursued.
3247
Following this re-audit of anti-coagulation therapy for children in Cardiac Services, healthcare staff have been educated
regarding warfarin guidelines and a warfarin handbook has been produced.
3408
Following this audit of the management of children with respiratory synctial virus undergoing cardiopulmonary bypass
surgery for CHD it was agreed guidelines should be reviewed.
3506
Following this audit of Fetal Cardiology Screening and Diagnostic Service it was agreed trainees should be encouraged to
record outcomes of neonatal echo and link them with maternal records for future audit purposes. This should be done
for both normal and abnormal scans. Ways of linking outcome data of children with normal scans into HeartSuite (a local
clinical database) should be explored.
3320
Following the audit of handover from the Children's Emergency Department to inpatient wards, a new "handover sheet"
was introduced.
3379
Following this audit of paediatric sedation in the Emergency Department, a patient information leaflet for sedation has
been produced. This includes a form for parents to sign, indicating that they have read the leaflet and understood it.
3428
Following this audit of compliance of management of severe asthma in children with national and local guidelines, local
guidelines are being reviewed. Awareness of the Acute Asthma Management Guideline is being promoted in the
Emergency Department and in General Paediatric teaching.
3460
Following this audit of the GP Phone Advice Service, information about the GP advice line has been added to the
induction checklist in the Children's Emergency Department introductory handbook. Reminders and extra column have
Clinical Audit Annual Report 2013/14
Page 45
been incorporated in the Telephone Log template.
3500
Following this audit of assessment and management of paediatric burns before referral to South West Children’s Burns
Service, it was agreed a checklist should be developed with involvement of "Burns” team.
3501
Following this audit of time taken to reach decision to admit (and subsequent time to admission) in the Children's
Emergency Department, it was recommended that a non-clinical nurse (or a nursing co-ordinator) role be introduced and
that the scope for criteria led discharges be reviewed.
3182
Following this audit of vitamin D deficiency and management in children with type 1 Diabetes Mellitus, local guidelines
were amended to include specific details of blood samples and quantities needed at point of diagnosis of type 1 diabetes.
There was also liaison with biochemistry department to improve blood sampling practice.
3296
Following this audit of diabetic ketoacidosis versus the Southwest Paediatric Diabetes Regional Network guidelines, it was
agreed patients admitted with Diabetic Ketoacidosis be managed in a designated HDU bed. Training is to be provided for
HDU nurses in using the SW Integrated Care Pathway. This audit is to be presented at South-West Paediatric Diabetes
Network meeting.
3373
This audit has led to the redesign of local records to allow for easier and more consistent recording of treatment and
monitoring details, accessible to the wider clinical team.
3502
Following this audit of the transition between paediatric and adult endocrine services, a summary sheet has been
developed to be used for each transitioning patient. A patient information booklet on the transition process is being
developed and work is in progress with the special needs team to create a specific pathway for identified patients
3507
Following this audit of auxology screening carried out on the paediatric wards it was recommended that a working group
be established to cascade auxology training. This training should outline that all children whose height is below the third
percentile should be highlighted to medical staff (regardless of their weight) and that there should be clear guidelines to
inform medical staff of further action if abnormal growth is identified.
3377
Following this audit of Infliximab and Adalimumab use in children with crohns disease it was agreed to introduce a
checklist at end of the infliximab guideline to help record whether consent has been obtained, risks have been discussed
and whether a history of TB has been taken.
3207
Following this audit of peritoneal dialysis in post-operative cardiac patients, a Peritoneal Dialysis Prescription and
observation booklet which contains all the information necessary for a child receiving Peritoneal Dialysis has been
introduced.
3394
Following this audit of red cell transfusion practice in paediatric intensive care it was recommended that education be
provided to both medical and nursing staff as to guidelines for blood product transfusion. The guidelines are to be
amended to include new units for measurement of Haemoglobin, from g/dl to g/l.
2745
The results of this audit of dialysis access service and complications were shared with the aim of stimulating good
practice
2970
Following this audit of urinary tract infection, the local guideline has been amended to include questions regarding risk
factors, and re-audit of one of criteria has been initiated.
3382
This audit of recombinant human growth hormone use in children with chronic kidney disease demonstrated high
compliance with the majority of the standards. It was agreed attempts should continue to optimise nutritional and
metabolic status prior to treatment.
3402
Following this audit of management of hyperlipidaemia in children with chronic kidney disease, it was agreed the
possibility of programming the Proton System for reminders to check lipids should be investigated. Clinicians have been
encouraged to monitor lipids regularly and it has been agreed that patients with low density lipoprotein levels above
specified cut off be referred to a dietician for advice.
3527
Following this audit of care of patients undergoing renal transplantation at Bristol Royal Hospital for Children, feedback
was provided to theatres that the 18 hour cold ischaemia times must not be exceeded. Information regarding the
possible consequences of intraoperative hypotension was disseminated
2687
Following this audit of bone marrow transplant febrile neutropenia guidelines, it was recommended that teaching
registrars regarding vancomycin and antibiotic use should be introduced. The audit results will be considered further
when reviewing neutropenia guidelines.
3359
This audit of compliance of paediatric sickle cell management with national standards recommendations led to the
creation of a standard immunisation letter to be sent to GP surgeries with the clinic letter. A copy will be given to the
parent in clinic.
3441
This re-audit of non-operative reduction of intussusception showed good compliance with relevant standards and the
best success rate in 20 years of audit.
3463
This audit of imaging the renal tract in children with urinary tract infection demonstrated good compliance with relevant
standards. Results were presented to clinicians, highlighting NICE guidance and availability of Trust guidelines.
Clinical Audit Annual Report 2013/14
Page 46
3479
This audit of radiology reporting times for paediatric inpatient and A+E plain films demonstrated good compliance of with
Royal College of Radiologist’s guidance, increasing during the course of 2012/2013.
3603
Following this audit of cranial ultrasound scans performed on PICU for patients with congenital heart disease, it was
agreed that arterial and venous doppler should be performed on cranial ultrasounds as a routine measure. The current
PICU guidelines for cranial and renal ultrasound in congenital heart disease are to be reviewed.
3045
Following this audit of the management of community acquired pneumonia for children admitted to Bristol Royal
Hospital for Children, further work was initiated to assess management in Paediatric Emergency Department
3243
Following this audit of nasal ciliary brushings in the management of primary ciliary dyskinesia it has been agreed that
referral form data be copied into patient notes.
3395
This national audit of asthma management resulted in further education for ward staff regarding discharge planning,
written information, inhaler technique and the need for asthma action plans & follow up.
3170
Following this audit of waiting times for patients listed for intra-articular joint injections for Juvenile Idiopathic Arthritis,
more dates have been made available for general anaesthesia. A pathway is being formulated to establish any delays in
listing patients for joint injections.
3150
Following this audit of management and outcomes of isolated preputial reconstruction in distal hypospadias, local
consensus has been reached regarding the prescription of prophylactic antibiotics.
3201
Following this audit of antibiotic prescribing in appendicectomy at the Bristol Royal Hospital for Children, it was decided
to continue with the changed antibiotic policy for children with perforated and/or gangrenous appendicitis. Results of
this audit were presented at the British Association of Paediatric Surgeons 2013 conference.
3358
Following this audit of consent to examination or treatment in Children's Services, it was agreed and emphasised that
abbreviations should not be used on consent forms.
3496
Following this audit of VTE prophylaxis (follow up of non-compliant cases), posters have been designed and put up
around the department to promote awareness of prescribing appropriately.
3511
This rapid cycle audit demonstrated improvement over three audit cycles in the use of the agreed format for key
identifiers when dictating letters in Clinical Genetics.
3338
This audit demonstrated considerable improvement in the documentation of pre-operative ward round checks by junior
doctors in gynaecology patients.
3426
This audit led to the implementation of a standardised proforma to improve documentation and increased access to
support from a psychologist for gynaecology patients with Vaginal Agenesis.
3429
This audit has led to further work to improve the treatment pathway for patients with vulval abscess, reducing the need
for overnight stays and long waits prior to operations.
3438
This audit demonstrated good compliance with waiting time standards for suspected gynaecological cancers.
3531
This audit demonstrated substantial improvement in meeting National Screening Committee standards for timeliness of
treatment for high grade disease in the Colposcopy department.
2762
Following this audit of pleuroamniotic shunt for fetal pleural effusion, it was decided that a dataset should be agreed to
record key information for babies requiring pleuroamniotic shunts.
3142
This audit demonstrated good levels of compliance with appropriate use of the actim partus test and the prescribing of
steroids for threatened pre-term labour.
3244
As a result of this audit, local guidelines were amended to follow NICE recommendations for multiple pregnancy and a
patient information leaflet was developed as a result of this audit.
3299
As a result of this audit, a local guideline for cases of placenta accreta was produced. This guideline is based on
recommendations from the Royal College of Obstetrics and Gynaecology.
3312
This audit led to the development and approval of a specific consent form for caesarean section, designed to include all
aspects recommended in Royal College of Obstetrics and Gynaecology guidelines. The form also includes a list of preprinted risks and checks to help ensure that patients are aware these risks and have the opportunity to ask further
questions.
3315
A range of changes were implemented to improve data quality as a result of this audit. Guidelines and patient
information have been revised and patient pathways for maternal non-elective readmissions at St Michael's Hospital
have been reviewed.
3334
This re-audit demonstrated that, where the new ‘Fast Bleep’ system was used, it was effective at helping staff to meet
the 30 minute target from decision for Category 1 caesarean section to delivery.
3337
This audit demonstrated some improvement in proportion of women with gestational diabetes having some kind of
diabetes test postnatally. Further work is underway to incorporate further testing information for GPs in electronic
discharge summaries.
3405
This audit led to a wide-ranging campaign to improve clinical management of mild pyrexia during and after labour and to
Clinical Audit Annual Report 2013/14
Page 47
cut sepsis including the production and audit of clear guidance on diagnosis and use of antibiotics in urinary tract
infection
3464
As a result of this audit, changes have been made to the documentation for antenatal HIV screening of women to
improve compliance with UK National Screening Committee standards.
3509
This audit has led to further service improvement work to increase capacity to manage patients with hyperemesis
gravidarum as daycase patients rather than inpatients where appropriate. This will reduce pressures on beds on Ward 78
and improving patient experience.
3510
This audit demonstrated that women who attended the Day Assessment Unit (DAU) for their appointment at Term +10
days and who had a concerning finding were offered induction within one day, in accordance with NICE
recommendations. Revisions were made to the DAU profoma to help improve documentation at these appointments in
future.
3547
This audit demonstrated good support from midwives for parents of children with an unexpected poor outcome at birth.
3635
This audit demonstrated that referrals for medical review are being made where appropriate.
3275/ This audit/re-audit led to improvements in documentation of key information required to comply with Human
3477 Fertilisation and Embryology Act in the Reproductive Medicine department at St Michael's Hospital.
Clinical Audit Annual Report 2013/14
Page 48
3.6
NON-DIVISION SPECIFIC
Title
Area
Lead
Priority Start date
Status Q4
Audit of Staff Support and Being Open Policy (Duty of Candour)
and follow up re-audit 6/12 later
Trust Services
Anne Reader
1
Q1
Completed
Audit of Serious Incident Policy and Policy for the Management
of Incidents and follow up re-audit 6/12 later
Trust Services
Anne Reader
1
Q1
In progress
Audit of Policy for the Management of Incidents and follow up
re-audit 6/12 later
Trust Services
Simon Harrison
Boyle/Mel Fewkes
1
Q1
In progress
Audit of VTE Policy and follow up re-audit 6/12 later
Haematology
Anne Reader/
Amanda Clarke
1
Q2
In progress
Medicines Storage
Pharmacy
Steve Brown
2
Q4
Not started
Inpatient prescribing audit
Pharmacy
Helen Badham
3
Q2
In progress
South West Quality and Patient Safety Improvement Programme
Nursing
(General Ward)
Anne Reader/
Catherine Hughes
2
Q1
In progress
National Cardiac Arrest Audit (NCAA)
Resuscitation Services
Jo Bruce Jones
1
Q1
In progress
Inpatient documentation audit
Record Keeping
Jane Luker
2
Q3
Completed
Dementia Screening
Nursing
Natalie Godfrey
1
Q1
In progress
Ward transfers for patients with cognitive impairment
Nursing
Natalie Godfrey
1
Q3
In progress
Learning disabilities risk assessment/reasonable adjustments
Nursing
Lorna Hayes
2
Q3
In progress
Patient Safety Thermometer
Nursing
Helen Morgan
1
Q1
In progress
Ward based monthly monitoring work (EWS scores and other
measures)
Nursing
Helen Morgan
2
Q2
In progress
The following activity was also in progress during the financial year (either rolled over from previous year or not identified
through plan):
Status
2369
Provisional Title of Project
Specialty
Saving Lives – a programme to reduce healthcare associated infections
Sub-Specialty
The Prevention of Hospital Acquired Thrombosis [CQUIN target]
3323
Dementia screening (CQUIN)
Completed
Ref
1510
Ongoing project
Abandoned
The following section summarises the changes, benefits or actions introduced as a result of completed audits within the
Division/specialties.
3724
This audit/re-audit of the Trust staff support and being open policy (duty of candour) led to changes to the Trust’s Root
Cause Analysis template to better record whether staff are informing patients/families when incidents occur.
Improvement in practice was demonstrated and further amendments to the template will be made.
2945
This Trust wide audit of medical record keeping showed that practice needs to be improved. A programme of ‘spot’ audits
has been implemented. It was agreed that the audit methodology and the standards measured should be completely
revised to focus on the key issues. These revisions are in line with standards outlined by the Royal College of Physicians
‘Generic Record Keeping’ guidance.
3095
As a result of this audit of dementia screening, guidelines have been developed to reflect the screening required to
identify known dementia, delirium and possible dementia. Assessment labels for the confusion assessment method
(CAM) to assess for delirium, Abbreviated Mental Test Score (AMTS) to provide baseline of cognitive function, and
dementia case finding question to screen for a possible dementia have been developed and added to the Trusts EROS
system. Work is underway to include the above assessments in clerking proformas and also to adapt e-discharge
summary to capture / record dementia screening status at discharge.
Clinical Audit Annual Report 2013/14
Page 49
Appendix A - UH Bristol Clinical Audit Staff (as at April 2014)
Division
Specialty
Clinical Audit Facilitator
Laboratory Medicine
Dr Joya Pawade
Medical Physics & Bioengineering
agnostics & Therapy
Isabella To
Pharmacy
Adult Therapies
Isabella To
Medical Specialties
Trudy Gale
Emergency Services
Specialised Services
Surgery & Head &
Neck
Mr Phil Quirk
Mr Kevin Gibbs
Usual contact is Head of Service
Radiology
Medicine
Clinical Audit Convenor
Dr John Hughes
Dr Rachel Bradley
Dr Anne Frampton
Cardiac Services
Isabella To
Dr Richard Bateman
Oncology & Haematology
Trudy Gale
Dr Charlie Comins
Anaesthesia
Dr Frances Forrest
Critical Care
Dr Dan Freshwater-Turner
General Surgery
Chrissie Gardner
Trauma & Orthopaedics
Mr Doug West
Mr Steve Mitchell
Dental Services & Maxillo-facial Surgery
Mr Tony Brooke
Ophthalmology
Mr Derek Tole
Adult ENT
Ms Claire Langton-Hewer
Obstetrics & Gynaecology
Jonathan Penny
Women & Children’s Neonatology
Children’s Services
Other staff
Richard Hancock
Ms Naomi Crouch
Dr Will Christian
Stuart Metcalfe
Clinical Audit & Effectiveness Manager (1.0)
James Osborne
Michael Aldridge
NICE Manager (1.0)
Clinical Audit Clerk (0.8)
Membership of the Clinical Audit Group
Dr Anne Frampton (Chair)
Stuart Metcalfe (Clinical Audit and Effectiveness Manager)
Chris Swonnell (Head of Quality - Patient Experience and Clinical Effectiveness)
James Osborne (NICE Manager)
Clinical Audit Convenors - see above
Clinical Audit Annual Report 2013/14
Page 50
Appendix B - Clinical Effectiveness & Outcomes Strategy Action Plan
Objective
Action
Lead
Timescale
Measure of success
Status
1.1 Relocate Clinical Audit Facilitators to Trust
Headquarters and commence new remits as
outlined/agreed through consultation
Stuart Metcalfe, Clinical
Audit & Effectiveness
Manager
May 2013
Positive feedback from CAET and
Divisions (review due in December
2013)
Completed
Stuart Metcalfe, Clinical
Audit & Effectiveness
Manager
May 2013
Appointment of new Clinical Audit
Facilitator
Completed
Jon Penny, Clinical Audit
Facilitator
July 2013
Demonstrated reduction of
database fields and time taken to
register projects
Completed
Richard Hancock, Clinical
Audit Facilitator
August 2013
Re-issue of project documentation
Completed
Jon Penny, Clinical Audit
Facilitator
August 2013
Website updated/testing of links to
documents
Completed
2.4 Explore further options for database design with
the Trust IM&T department
Jon Penny, Clinical Audit
Facilitator
April 2014
Decision will be reached on whether
to continue to use an MS access
Completed
database or alternative
3.1 Re-design/create an appropriate dashboard or
register to provide a clear summary of participation in
national clinical audit
Stuart Metcalfe, Clinical
Audit & Effectiveness
Manager
September 2013
Evidence of regular receipt of
(previously revised revised dashboard/register at
to February 2013) Clinical Audit Group (CAG)
1. To re-structure the
Clinical Audit &
Effectiveness Team
1.2 Appoint to vacant Clinical Audit Facilitator post
(CAET)
(Medicine/Oncology)
2.1 Rationalise content of clinical audit database to
eliminate unnecessary data fields and expedite speed
of project registration
2. To improve the
efficiency of the
2.2 Re-design clinical audit project documentation
registration/
reporting process of 2.3 Update website (external/internal) with new
clinical audit
documentation links
projects
3. To ensure that the
results from
national clinical
audits are reported
and acted upon
appropriately
Completed
Comment: Project database re-designed and national audit register report created. Ongoing development will continue as necessary.
3.2 Improve the process of cascading national clinical
audit reports to clinical leads upon publication,
requesting that summary outcomes and actions are
developed
Stuart Metcalfe, Clinical
Audit & Effectiveness
Manager
April 2014
(revised
completion date
June 2014)
Responses to national clinical
reports will be received by CAG
within six months of publication,
with exceptions reported to Clinical
Quality Group
In progress
Comment: The paper based summary form has been re-designed. There has been an improvement in the number of national audit summaries received
reviewed by CAG (six over the last two meetings). A KPI as outlined above will be added to the register for June CAG meeting and reported thereafter.
Clinical Audit Annual Report 2013/14
Page 51
4.1 Consult as to how to improve process and
relevance of annual forward programme
Stuart Metcalfe, Clinical
Audit & Effectiveness
Manager
September 2013
Process reviewed and agreed by
Clinical Audit Group, introduced to
coincide with timetable for
development of Divisional quality
objectives and Operating Plans
Completed
4. To review system
Comment: Amended process for agreeing the annual forward plan agreed with CAG and CQG. Consultation period extended until May 2014 to better ensure
for planning annual that Divisional/Corporate clinical audit objectives are included
clinical audit
Process reviewed and agreed by
programme
Stuart Metcalfe, Clinical
November 2013 Clinical Audit Group, introduced to
4.2 Introduce updated forward planning process
Audit & Effectiveness
(previously revised coincide with timetable for
Completed
Manager
to January 2014)
development of Divisional quality
objectives and Operating Plans
Comment: Final plan to go to CAG in June, then CQG in July
5.1 Agree participation in the Foundation Doctor and
core medical trainee training programmes and agree
delivery with CAET
5.2 Review and update current training materials
where required and re-launch clinical audit workshop
5. To review, refresh
and re-launch
clinical audit
training
Stuart Metcalfe, Clinical
Audit & Effectiveness
Manager
September 2013
Jon Penny, Clinical Audit
Facilitator
November 2013
(revised
completion date
September 2014)
Participation in programme
Completed
Re-launch of workshop
In progress
Comment: Workshop slides partially reviewed. Member of the CA&E Team attending a ‘Train the Trainer’ workshop in June 2014 provided by HQIP to further
review local content against this training.
5.3 Explore alternative options for training delivery
(including eLearning and condensed delivery)
Chrissie Gardner, Clinical
Audit Facilitator
January 2014
(revised
completion date
January 2015)
Clarification of options and decision
made as to alternative training
options
In progress
Comment: Member of the CA&E Team attending a ‘Train the Trainer’ workshop provided by HQIP to further review. We will use the re-introduction of the
workshops to help determine other delivery options. Links to HQIP elearning and other training guides will be available via nternal and external websites by
the end of June 2015
6. To ensure divisional
scrutiny of
‘outcomes and
actions’ reports
following
completion of
clinical audit
projects
6.1 Clarify current lines of reporting and enhance
arrangements if and where required
Stuart Metcalfe, Clinical
Audit & Effectiveness
Manager / Divisions
July 2013
(revised
completion date
August 2014)
Documented evidence of
appropriate divisional scrutiny of
outcomes and actions reports
In progress
Comment: Standard Divisional/specialty reports created (status of projects in progress/outcome and actions and outstanding actions from completed
projects). Reports well received in Divisions of Medicine and Surgery. Outcomes and actions already reviewed by Children’s Governance Group.
Clinical Audit Annual Report 2013/14
Page 52
Appendix C - Progress against Clinical Audit Forward Programme 2013/14
226 projects on the plan were due to have commenced by the end of the financial year. The Table below shows that
overall, 152 (67%) of these projects commenced as planned. Critically, 47 out of 50 (94%) Priority 1 projects had
either commenced or been completed. Two national audits identified as part of the 2013/14 planning process had
been due to commence during the year but have subsequently been withdrawn at national level. The Trust did not
participate in one project, an audit of patient information and consent (Blood and Transplant audit programme) due
to organisation issues at NHSBT. It should be noted that although this project was listed as P1, it is not part of the
mandatory National Clinical Audit & Patient Outcome Programme (NCAPOP) and no penalty applies for nonparticipation.
Division
Priority
P1
Status (Q4)
Complete
In progress
Not started
P1 Total
P2
P2 Total
P3
3 Total
4
Complete
In progress
Not started
Complete
In progress
Not started
Complete
In progress
Not started
4 Total
Total
D&T
Spec
1
7
SHN
1
10
W&C
2
9
NDS
1
7
2
2
5
12
5
22
2
4
3
9
Med
2
7
1
10
3
8
2
13
2
4
14
20
8
4
11
1
8
7
16
1
11
4
23
11
38
1
9
6
16
8
1
3
1
5
2
1
3
36
43
15
65
14
% projects commenced to planned timescale
3
7
P1
94%
7
8
4
3
11
18
53
P2
71%
P3
44%
Total
7
40
3
50
18
54
29
101
6
18
30
54
4
5
12
21
226
1
1
P4
42%
All
67%
The graph below shows the overall percentage of projects commenced to timescale. Figures for the previous year’s
plan have been included as a comparator.
Priority
P1
P2
P3
P4
Overall
% commenced to timescale
 11% (83% in 2012/13 to 94% in 2013/14)
 10% (61% in 2012/13 to 71% in 2013/14)
No change (44% in 2012/13 and 44% in 2013/14)
 25% (17% in 2012/13 to 42% in 2013/14)
 7% (60% in 2012/13 to 67% in 2013/14)
Clinical Audit Annual Report 2013/14
Page 53
The graphs below show planned activity (i.e. the number of projects due to have started) against actual activity (the
number of projects in progress or complete) per quarter over the full year. Planned and actual trajectories for all
activity and for those projects categorised as priority 1 and 2 are also plotted.
Clinical Audit Annual Report 2013/14
Page 54
Appendix D - University Hospitals Bristol Clinical Audit Forward Programme 2014/15
All the projects within the programme have been identified through consultation as priorities for the Trust. This is not an exhaustive list of clinical audit activity that will take place
throughout 2014/15; other projects may be facilitated by the Clinical Audit & Effectiveness Team over the year according to on-going priorities and available resources.
Each of the audits in the programme has been listed according to the categories below. These are based on priority areas for clinical audit as outlined within the Healthcare Quality
Improvement Partnerships (HQIP) ‘Clinical Audit Programme Guidance’.
Priority 1
Priority 2
Failure to deliver on these externally driven audits may carry a penalty for the Trust (either
financial or in the form of a failed target or non-compliance with standards). Audits within
this section relate to or support the following priorities:
Many of these audit projects emanate from Trust governance issues or high profile local
initiatives although no penalties exist for non-participation. Audits within this section
relate to or support the following priorities:










New national targets and existing commitments (e.g., participation in heart disease
audits, stroke, Myocardial Ischaemia).
Participation in the National Clinical Audit & Patient Outcome Programme (NCAPOP)
or Quality Accounts
DoH statutory requirements, e.g. infection control monitoring.
CQUINS or other commissioner priorities.
Board assurance requirements
External accreditation schemes, e.g. NHS Litigation Authority, cancer peer review.
Clinical Effectiveness activity (e.g. following the introduction of new procedures).
Patient Safety issues (including NPSA/safety alerts).
National Confidential Enquiries (NCEs).
Clinical Risk issues e.g. serious untoward incidents/adverse incidents.
Priority 3
Priority 4
These projects have been identified within Divisions/specialties/services as important
pieces of work. Audits within this section relate to or support the following priorities:
It is important that to maintain a degree of locally initiated projects by clinical staff; these
projects can lead to real improvements in patient care as well as providing valuable
education for junior staff but do not necessarily fall into any of the other categories.







Participation in national audits not part of NCAPOP (e.g. Royal College initiated)
Demonstrating compliance with CQC outcomes.
Guidance from professional bodies (e.g. Royal College)
Audits of NICE guidance.
Local guidelines/policies
Identified through consultation with Trust members
Other/Clinician Interest (based on criteria such as high cost, high risk, potential for
change, patient involvement etc).
Please note that the contact in the ‘Lead’ column may not be the person who will carry out this audit, but the senior clinician proposing and supervising a project which they plan to
delegate to a junior member of staff to carry out (who would then become the project lead).
Clinical Audit Annual Report 2013/14
Page 55
Division of Diagnostics & Therapies
Sub-Specialty
Lead
Rationale/comment
Priority
Q Start
Use of blood in patients with Sickle Cell Disease
Laboratory Haematology
Tom Latham
National Audit (Quality Accounts)
1
Q2
Supplementary reports to identify discrepancies in paediatric
tumours
Histopathology
Pramila Ramani
Link to Board Assurance Framework/Corporate
Objectives
2
Q2
Placentas microscopy in 2013
Histopathology
Craig Charles Platt
National guidance (RCPath Tissue Pathway 2011)
3
Q3
Re-auditing the quality of perinatal autopsy in South-West of
England
Histopathology
Corina Moldovan
National guidance (RCPath guidelines for autopsy
practice 2002 and 2006)
3
Q3
Assessment of clinical information of the specimen request forms
Histopathology
Alica Torres
National guidance (RCPath)
3
Q1
Turnaround time for urgent biopsies
Histopathology
Joya Pawade
Departmental/service objective
2
Q1
Supplementary report for gynaecology pathology
Histopathology
Joya Pawade
Departmental/service objective
2
Q2
Re-auditing frozen section practice in thoracic pathology
Histopathology
Nidhi Bhatt
Departmental/service objective
Re-audit ID 3627
2
Q4
Timing of antibiotic prophylaxis in cardiac surgery
Microbiology
Mbiye Mpenge
Local guidance (antibiotic guidelines)
3
Q1
Procalcitonin testing in acute medical admissions
Microbiology
Richard Brindle
Link to Board Assurance Framework/Corporate
Objectives
2
Q3
Prophylaxis in orthopaedic surgery
Microbiology
Martin Williams
To ensure patients are getting the correct prophylaxis
4
Q4
Audit of management of hyponatraemia
Clinical Biochemistry
Paul Thomas
Patient Safety
Trust guideline
2
Q2
Audit of Hand hygiene facilities
Infection Control
Joanna Hamilton-Davies
External accreditation/regulation (links to CQC Outcome
work)
2
Q1
Audit of Environment
Infection Control
Joanna Hamilton-Davies
National guidance (DoH)
2
Q1
Medical Physics &
Bioengineering
Ian Negus
National guidance (Requirement of IRMER)
2
Q3
Title
Laboratory Medicine
Medical Physics & Bioengineering
CT radiation dose audit of L3 scanner
Nutrition & Dietetics
Clinical Audit Annual Report 2013/14
Page 56
Adherence to Enteral Tube Feeding Clinical Guideline in Critical
Care
Nutrition & Dietetics
Rebecca Pooley
Local guidance
3
Q2
‘Nutrition Deep Dive audit’ an audit into the key observational
prompts of the Nutritional Care Policy’
Nutrition & Dietetics
Rachel Liston
External accreditation/regulation (links to CQC Outcome
work)
3
Q3
Occupational Therapy &
Physiotherapy Outpatients
Julie Packman
National guidance (NHS Constitution – Improving
waiting times for outpatient services)
3
Q2
Safer Care South West (Medicines Management)
Pharmacy
Kevin Gibbs
Clinical audit/monitoring arising from individual
workstreams
2
Q1
Re-audit of insulin prescribing to agreed prescribing bundle
Pharmacy
Kevin Gibbs
Re-audit after implementation of new drug chart and
guidance in 2013.
3
Q4
Vancomycin prescribing audit
Pharmacy
Emily Marshall
Identified through patient safety/risk/incident reporting
2
Q2
Oral methotrexate treatment on adult patients (except oncology) in
Pharmacy
UHBristol
Helen Badham
National guidance (NPSA alert 3+13)
2
Q1
Physiotherapy
Sarah Brown
National guidance (Core standards for Intensive care
units)
3
Q2
Audiology
Regina Smith
Outcomes monitoring - to assess the primary outcome
measures as part of a quality assurance programme
2
Q1
Speech and Language
Therapy
Vicki Weekes
National guidance (RCSLT)
3
Q3
An audit of radiation dose of 128-MDCT coronary CT angiography
Radiology
Stephen Lyon
National guidance (Ionising Radiation Medical Exposures
Regulations 2000)
2
Q1
Radiographers protocolling of CT scan
Radiology
Will Loughborough
Identified through patient safety/risk/incident reporting
2
Q2
Radiological interpretation recording
Radiology
Sally King
Rollover from 2013-14.
3
Q2
Sub-Specialty
Lead
Rationale
Priority
Q Start
Emergency Department
Lead to be confirmed
National Audit (Quality Accounts)
1
Q2
Occupational Therapy
‘Patient pending’ process – Waiting list initiative
Pharmacy
Physiotherapy
Physiotherapy standards in Intensive care unit
Audiology
Re-audit Real Hearing Measurement
Speech & Language Therapy
Standards for and outcomes of videofluoroscopy referral
Radiology
Division of Medicine
Title
Emergency Department
Mental Health (College of Emergency Medicine)
Clinical Audit Annual Report 2013/14
Page 57
Older People (College of Emergency Medicine)
Emergency Department
Lead to be confirmed
National Audit (Quality Accounts)
1
Q2
National Audit of Seizure Management
Emergency Department
Lead to be confirmed
National Audit (Quality Accounts)
1
Q2
Discharge Summary - observation ward
Emergency Department
Lead to be confirmed
Commissioning requirement (CQUIN)
Link to Board Assurance Framework/Corporate Objectives
1
Q2
Subarachnoid Haemorrhage
Emergency Department
Lead to be confirmed
National guidance (National Confidential Enquiry)
3
Q2
Electronic sign off of results
Emergency Department
Lead to be confirmed
Identified through patient safety/risk/incident reporting
2
Q2
Central Lines
Emergency Department
Lead to be confirmed
Identified through patient safety/risk/incident reporting
2
Q2
Head injury
Emergency Department
Lead to be confirmed
Local guidance
3
Q2
Fluid prescribing
Emergency Department
Lead to be confirmed
National guidance (NICE)
2
Q2
Lower limb prophylaxsis for DVT in lower limb POP
Emergency Department
Lead to be confirmed
National guidance
2
Q2
National Hip Fracture Database (NHFD)
Care of the Elderly
Rachel Bradley
National audit (NCAPOP)
1
Q1
National Falls Prevention Audit (FFFAP)
Care of the Elderly
Rachel Bradley
National audit (NCAPOP)
1
Q1
Enhanced Recovery Programme and Hip Fracture
Care of the Elderly
Rachel Bradley
Link to Board Assurance Framework/Corporate Objectives
2
Q2
Male osteoporotic hip fractures at the BRI
Care of the Elderly
Theresa Allain
Local concern/practice improvement
3
Q1
Notes Audit
Care of the Elderly
Margaret MacMahon
External accreditation/regulation (links to CQC Outcome
21)
2
Q1
National Audit of Dementia
Care of the Elderly
Julie Dovey
National audit (NCAPOP)
1
Q4
Stroke National Audit Programme (SSNAP)
Stroke care
Sarah Caine
National audit (NCAPOP)
1
Q1
Management of syphilis
Contraception and Sexual
Health
Andrew Leung
National guidance (BASHH and local guidelines)
3
Q3
Integrated service at Bristol Sexual Health Centre
Contraception and Sexual
Health
Judy Berry
Local concern/service provision issue
3
Q1
Management of PID
Contraception and Sexual
Health
Karla Blee
National guidance (BASHH and local guidelines)
3
Q1
Medical Specialties
Clinical Audit Annual Report 2013/14
Page 58
Epididymo-orchitis
Contraception and Sexual
Health
Andrew Leung
National guidance (BASHH and local guidelines)
3
Q1
Re-audit of long-acting reversible contraception (LARC)
Contraception and Sexual
Health
Leonor Herrera-Vega
National guidance (BASHH and local guidelines)
3
Q3
Re-audit of emergency contraception
Contraception and Sexual
Health
Leonor Herrera-Vega
National guidance (BASHH and local guidelines)
3
Q3
Audit of completeness of excision of non-melanoma skin cancer in
Bristol Dermatology
Dermatology
Adam Bray
Outcomes monitoring - ongoing quality indicator/per
review outcome measure in cancer management.
2
Q1
Audit report on Basal Cell Carcinoma (BCC) waiting times for
surgery depending on site
Dermatology
David DeBerker
National guidance
3
Q1
Assessment of the non-Basal Cell Carcinoma skin cancers treated
on a Basal Cell Carcinoma pathway
Dermatology
David DeBerker
National guidance
3
Q1
National Diabetes Audit (NDA)
Diabetes and Endocrinology
Natasha Thorogood
National audit (NCAPOP)
1
Q1
Outpatient coding for endocrinology as per specialist CQUIN for
endocrinology
Diabetes and Endocrinology
Karin Bradley
Commissioning requirement (CQUIN)
2
Q1
Adherence of Hepatitis B screening in patients with Inflammatory
Bowel Disease (IBD) starting Immunosuppressive Therapy
Gastroenterology/
Hepatology
Aileen Fraser
National guidance (NICE CG165)
3
Q1
Suicide Audit
Liaison Psychiatry
Salena Williams
National guidance (National Confidential Inquiry into
Suicide and Homicide for people with Mental Illness)
3
Q1
National COPD audit
Respiratory
Nabil Jarad
National Audit (NCAPOP)
1
Q1
Plural procedures (British Thoracic Society audit programme)
Respiratory
Roly Jenkins
National Audit (Quality Accounts)
1
Q1
Adult Bronchiectasis (British Thoracic Society audit programme)
Respiratory
Nabil Jarad
National Audit (Quality Accounts)
1
Q3
Audit of Sweat test follow up for Ivacaftor use in CF
Respiratory
Kathryn Bateman
Local concern
3
Q3
Audit of Annual review points against CF trust guidelines
Respiratory
Kathryn Bateman
Local concern
3
Q3
Audit of adherence to CT Trust Guidelines for CF related low bone
mineral density
Respiratory
Kathryn Bateman
Local concern
3
Q3
Smoking cessation advice
Respiratory
Kathryn Bateman
Re-audit CAID 3523
3
TBC
Isolation in Patients with Possible Pulmonary Tuberculosis
Respiratory
Sarah Mungall
Infection control risk
Rheumatoid & Early Inflammatory Arthritis
Rheumatology
Robert Marshall
National audit (NCAPOP)
1
Q1
Clinical Audit Annual Report 2013/14
Page 59
The use of Tocilizumab in rheumatoid arthritis
Rheumatology
Matthew Roy
National guidance (NICE TA247)
3
Q1
TA104/125 Psoriatic arthritis - etanercept, infliximab &
adalimumab
Rheumatology
Roopa Prasade
Commissioning priority (NICE College)
1
Q3
Sub-Specialty
Lead
Rationale
Priority
Q Start
Adult Cardiac Surgery (ACS)
Cardiac Surgery
Alan Bryan
National audit (NCAPOP)
1
Q1
Acute Coronary Syndrome/Acute Myocardial Infarction (MINAP)
Cardiology
Julian Strange
National Audit (NCAPOP)
1
Q1
National Cardiac Arrhythmia Audit (HRM)
Cardiology
Tim Cripps
National Audit (NCAPOP)
1
Q1
National Heart Failure Audit (HF)
Cardiology
Angus Nightingale
National Audit (NCAPOP)
1
Q1
Adult Coronary Angioplasty
Cardiology
Tom Johnson
National Audit (NCAPOP)
1
Q1
TA230 Bivalirudin - Myocardial infarction (persistent ST-segment
elevation)
Cardiology
Julian Strange
Commissioning priority (NICE College)
1
Q3
Prescribing audit on critical medicine
Cardiac Intensive Care
Richard Bateman
Identified through patient safety/risk/incident reporting
2
Q2
Impact of the Anaesthetist on Mortality During Cardiothoracic
Surgery
Cardiac Anaesthesia
James Hillier
National Audit (Other)
3
Q1
Audit of missed appointments at a tertiary referral centre
Cardiology
Julian Strange
Links to productive outpatient work
3
Q2
Patient outcomes in Chest Pain Clinics
Cardiology
Jenny Tagney
National guidance (NICE CG95)
3
Q2
The usage of Ivabradine for treating chronic heart failure
Cardiology
Phoebe Sun
National guidance (NICE TA267)
3
Q1
Audit of quality of stress echo service
Cardiology
Angus Nightingale
National guidance (British Society of Echo-cardiography)
3
Q2
Percutaneous closure of patent foramen ovale for the secondary
prevention of recurrent paradoxical embolism in divers
Cardiology
Mark Turner
National guidance (NICE IPG372)
3
Q2
Audit of management of heart failure post primary percutaneous
coronary intervention (PCI)
Cardiology
Angus Nightingale
National guidance (NICE)
3
Q2
Re-audit of prescribing in hypertension
Cardiology
Angus Nightingale
National guidance (NPSA)
2
Q2
Division of Specialised Services
Title
Cardiac Services
Clinical Audit Annual Report 2013/14
Page 60
Oncology & Haematology
National Lung Cancer Audit (NLCA)
Oncology/Respiratory
Adam Dangoor
National Audit (NCAPOP)
1
Q1
TA129 Multiple myeloma - bortezomib
Oncology/Haematology
Jenny Bird
Commissioning priority (NICE College)
1
Q3
High dose rate brachytherapy for treatment of localised prostate
cancer
Oncology
Amit Bahl/Pauline Humphrey
New approved interventional procedure
2
Q3
Stereotactic Ablative Body Radiotherapy for peripheral lung
tumours
Oncology
Charlie Commins
New approved interventional procedure
2
Q4
PCA pump audit
Oncology/Haematology
Tracey Arthur
Identified in BHOC Clinical Governance Meeting
2
Q2
Extravasculation Audit
Oncology/Haematology
Rae Herrington
Identified in BHOC Clinical Governance Meeting
2
Q3
Patient Information - Pressure Sores
Oncology/Haematology
Jane Bailey
Identified in BHOC Clinical Governance Meeting
2
Q1
Drug chart audit
Oncology/Haematology
Charlie Comins
Local concern
3
Q3
Audit of Aprepitant for control of chemotherapy induced nausea
and vomiting
Oncology/Haematology
Helen Brookes
Re-audit CAID 2777
3
Q3
Audit of completion of pregnancy status and fertility status on the
radiotherapy form
Oncology
Jancis Kinsman
Re-audit CAID 2963
3
Q3
Medical documentation re-audit
Oncology/Haematology
Charlie Comins
Re-audit CAID 2998
3
Q3
Use of PCI for patients with small cell lung cancer
Oncology
Paula Wilson
Local concern
3
Q3
CHART Audit
Oncology
Gareth Ayre
National Audit (Other)
2
Q1
Haemoglobinopathies - Patients with recommended immunisations
Haematology
up-to-date
Anndeloris Chacon/ Kim
Bealing
National guidance (quality standards for
Haemoglobinopathy services)
3
Q1
Audit of regular pen V or equivalent
Haematology
Anndeloris Chacon/ Kim
Bealing
Local concern
3
Q1
An audit of patients attending in acute pain receiving first dose of
analgesia within 30 mins of arrival
Haematology
Anndeloris Chacon/ Kim
Bealing
Local concern
3
Q1
Thalassaemia audits - monitoring of iron overload including
imaging and new iron related complications
Haematology
Anndeloris Chacon/ Kim
Bealing
Local concern
3
Q1
Palliative Medicine
Colette Reid
National guidance (End of Life Care)
3
Q3
Palliative Care
Advanced Care Planning
Clinical Audit Annual Report 2013/14
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Usage of the Treatment Escalation Protocol (TEP)
Palliative Medicine
Rachel McCoubrie
National guidance (National Confidential Enquiry)
2
Q4
Sub-Specialty
Lead
Rationale
Priority
Q Start
An audit of analgesia prescribing in acute medical and surgical
admissions with renal impairment.
Acute Pain
Nilesh Chauhan
Local guidance (introduction of new guideline)
2
Q4
Emergency Laparotomy
Anaesthesia/Surgery
Rachel Craven /Jane Blazeby
National Audit (NCAPOP)
1
Q1
Perioperative Anaphylaxis
Anaesthesia
Nic Harvey
National Audit (Other)
3
Q2
Coagulation and epidural removal
Anaesthesia
Nic Harvey
Identified through patient safety/risk/incident reporting
2
Q1
Safer Care South West (Critical Care)
Critical Care
Sanjoy Shah
Clinical Audit/Monitoring arising from individual
workstreams
2
Q1
Adult Critical Care Case Mix Programme (ICNARC CMP)
Critical Care
Tim Gould
National Audit (Quality Accounts)
1
Q1
Trauma (TARN)
Critical Care
Matt Thomas
National Audit (Quality Accounts)
1
Q1
Potential Donor Audit
Critical Care
Fran O’Higgins
National Audit (Quality Accounts)
1
Q1
ALung Hemolung Respiratory Assist System
Critical Care
Tim Gould
New approved interventional procedure
2
Q2
‘Knowing the Risk’
Pre op assessment
Ben Howes
National guidance (National Confidential Enquiry)
3
Q2
Safer Care South West (Perioperative care)
Theatres
Liz Varian
Clinical Audit/Monitoring arising from individual
workstreams
2
Q1
Surgical Site Marking
Theatres
Andy Hollowood
Identified through patient safety/risk/incident reporting
2
Q3
National Head & Neck Cancer (DAHNO)
Oral and Maxillofacial
Surgery
Ceri Hughes
National audit (NCAPOP)
1
Q1
Bisphosphonate related osteocronosis of the jaw (BRONJ)
Oral and Maxillofacial
Surgery
Carla Fleming/ Chris Bell
Re-audit CAID 3387
3
Q2
Smoking cessation advice
Oral Medicine
Natalie Edwards
Re-audit CAID 3186
3
Q2
Division of Surgery, Head and Neck
Title
Anaesthesia, Critical Care & Theatres
Dental Services
Clinical Audit Annual Report 2013/14
Page 62
Audit of new trauma form in paediatric dentistry
Paediatric Dentistry
Rebecca John
Re-audit CAID 3155
3
Q1
Sickle cell
Paediatric Dentistry
Sarah Dewhurst
Local guidance (revision of guideline)
3
Q2
Compliance with DNA Policy
Orthodontics
Nikki Attack
External accreditation/regulation (area of improvement
identified by CQC)
2
Q3
Periodontal screening in adult orthodontic patients
Orthodontics
Kate House
National guidance
3
Q3
Radiograph Quality Assurance in Out of Hours Dental Service
Primary Care Dental Service
Katherine Walls
Service priority
3
Q2
Tooth survival and restorative status of undergraduate root treated
Restorative Dentistry
teeth
Dominic O’Sullivan
Local guidance (introduction of new guideline)
3
Q2
Fluoride DPT prescriptions
Restorative Dentistry
Roger Yates/James Ban
Re-audit CAID 3459
3
Q3
Periodontal radiographs
Restorative Dentistry
Roger Yates /James Ban
Re-audit CAID 3292
3
Q3
Active Middle Ear Implant (Vibrant Soundbridge)
Adult ENT
Stephen Broomfield
New approved interventional procedure
2
Q4
Injection Snoreplasty
Adult ENT
Ade Oluwasanmi
New approved interventional procedure
2
Q4
A&E 4 hour breaches and follow-ups
A&E & Primary Care
Rafik Girgis
Significant waiting time targets for Trust. Assess
improvement since previous audit
3
Q3
Implantation of multifocal intraocular lenses during cataract
surgery
Cornea and Cataract
Phil Jaycock
New approved interventional procedure
2
Q2
Intraocular lens insertion for correction of refractive error with
preservation of the natural lens guidance
Cornea and Cataract
Phil Jaycock
New approved interventional procedure
2
Q2
Microbial Keratitis re-audit
Cornea and Cataract
Derek Tole
Re-audit CAID 3703
4
Q1
Cataract Outcomes
Cornea and Cataract
Derek Tole
National guidance (Royal College led initiative relating to
revalidation of cataract surgeons)
3
Q1
Deep Sclerectomy (non-penetrating glaucoma filtration surgery)
Glaucoma
Rani Sebastian
New approved interventional procedure
2
Q3
Selective Laser Trabeculoplasty (SLT)
Glaucoma
Rani Sebastian
New approved interventional procedure
2
Q3
Trabeculectomy outcomes
Glaucoma
John Sparrow/Peter Tsangaris
Outcomes minitoring
4
Q2
ENT
Ophthalmology
Clinical Audit Annual Report 2013/14
Page 63
Lucentis outcomes
Medical & Surgical Retina
Adam Ross
National guidance (NICE TA155)
2
Q3
Management of endophthalmitis
Medical & Surgical Retina
Adam Ross
Identified through patient safety/risk/incident reporting
2
Q1
TA287 Aflibercept - 1st line wet AMD
Medical & Surgical Retina
Claire Bailey
Commissioning priority (NICE College)
1
Q3
TA274 Ranibizumab - Diabetic Macular Oedema
Medical & Surgical Retina
Claire Bailey
Commissioning priority (NICE College)
1
Q3
Assessment of orbital trauma patients
Orthoptics and Optometry
Ann Starbuck
Re-audit
4
Q3
Periorbital filler injection
Paediatrics, Oculoplastics
and Squint
Mano Sira
New approved interventional procedure
2
Q2
Outcomes of nasolacrimal duct probing (re-audit)
Paediatrics, Oculoplastics
and Squint
Amanda Churchill
Re-audit CAID 1508
4
Q1
IV fluid management
All specialties
Meg Finch-Jones
National guidance (NICE CG174)
2
Q1
National Bowel Cancer Audit (NBOCAP)
Colorectal Surgery
Rob Longman
National audit (NCAPOP)
1
Q1
SECCA (Radiofrequency Ablation for Feacal Incontinence)
Colorectal Surgery
Paul Sylvester
New approved interventional procedure
2
Q2
Thoracic Society Returns
Thoracic Surgery
Tim Batchelor
National audit (Other)
3
Q1
CT-guided guidewire localisation of impalpable lung lesions before
minimal access surgical excision
Thoracic Surgery
Tim Batchelor/Doug West
New approved interventional procedure
2
Q2
Left cardiac sympathetic denervation
Thoracic Surgery
Tim Batchelor
New approved interventional procedure
2
Q2
Lung volume reduction surgery through a bronchoscope
Thoracic Surgery/Respiratory
Doug West /Nabil Jarad
Medicine
New approved interventional procedure
2
Q2
Bronchoscopic lung volume reduction using Lung Volume
Reduction Coil
Thoracic Surgery/Respiratory
Doug West/Nabil Jarad
Medicine
New approved interventional procedure
2
Q2
VATS sleeve lobectomy
Thoracic Surgery
Gianluca Casali
New approved interventional procedure
2
Q3
Cardiac denervation for VT
Thoracic Surgery
Tim Batchelor/Graham Stuart
New approved interventional procedure
2
Q3
Thoracic Surgery lobectomy patients – why are patients staying
longer than 5 days in hospital.
Thoracic Surgery
Tim Batchelor
Trust objective – links to patient flow
2
Q2
National Joint Registry (NJR)
Trauma & Orthopaedics
Sanchit Mehendale
National audit (NCAPOP)
1
Q1
Adult Surgical Specialties
Clinical Audit Annual Report 2013/14
Page 64
British Orthopaedic Standards for Trauma (BOAST) Fracture Service Trauma & Orthopaedics
Steve Mitchell
National guidance
3
Q2
National Oesophago-Gastric Cancer Audit (NAOGC)
Upper GI Surgery
Paul Barham
National audit (NCAPOP)
1
Q1
Oesophageal brachytherapy
Upper GI Surgery
Paul Barham
New approved interventional procedure
2
Q3
Endoscopic vacuum therapy for perforation/ leakage in the
oesophagus
Upper GI Surgery
Dan Titcomb
New approved interventional procedure
2
Q3
Microwave ablation for the treatment of liver metastases
Upper GI Surgery
Meg Finch-Jones
New approved interventional procedure
2
Q4
Insertion of wound catheters for post-operative pain control
Upper GI Surgery
Reyad Abbadi/Jeremy Bewley
New approved interventional procedure
2
Q4
VSGBI Vascular Surgery Database
Vascular Surgery
Marcus Brooks
National Audit (NCAPOP)
1
Q1
Surgical site infection
Vascular Surgery
Marcus Brooks
National guidance (NICE CG74)
3
Q1
Management of incidental AAA
Vascular Surgery
Marcus Brooks
National guidance (AAA screening programme)
3
Q1
Sub-Specialty
Lead
Rationale
Priority
Q Start
Paediatric Early Warning Scores
All areas/specialties
Hazel Moon
Identified through patient safety/risk/incident reporting
2
Q1
Any topics for audit arising from Child Death Reviews
All areas/specialties
James Fraser
Identified through patient safety/risk/incident reporting
2
Q4
Re-audit of pain after cardiac surgery
Anaesthetics
Richard Beringer
No specific rationale provided
4
Q4
Preoperative medical clerking
Anaesthetics
Philippa Seal
National guidance (AAGBI)
3
TBC
Re-Audit of Anaesthetic Record Keeping
Anaesthetics
Bev Guard
National guidance (RCOA standard and CQC AAGBI
‘Consent for Anaesthesia’ Guidelines)
3
Q2
Anaesthetic Pre-admission Information re-audit
Anaesthetics
Steve Sale
National guidance (AAGBI / RCOA / RCN ‘Best Practice’
Guide for management of epidurals)
3
Q2
Re-audit pre-op fasting
Anaesthetics
Bev Guard
Local guidance (introduction of new guideline)
3
Q3
Division of Women’s & Children’s
Title
Children’s Services
Clinical Audit Annual Report 2013/14
Page 65
Patient management post identification of bilateral permanent
childhood hearing impairment v national screening programme
standards.
Audiology
Joanne O’Connell
National guidance (Newborn Hearing Screening
Programme)
3
Q3
Re-Audit of Hearing aid Review Clinics v national and local
standards
Audiology
Dawn O'Dwyer
National guidance
3
Q3
Child Protection
Child Protection
Lisa Goldsworthy
Identified through patient safety/risk/incident reporting
3
TBC
Congenital heart disease (CHD)
Cardiac Services
Andrew Parry
National Audit (NCAPOP)
1
Q1
Re-audit of anti-coagulation
Cardiac Services
Pat Weir
Identified through patient safety/risk/incident reporting
2
TBC
Communication abnormal laboratory results to Ward
Cardiac Services
Andrew Parry
Identified through patient safety/risk/incident reporting
2
TBC
Clinical data/information correlation audit
Cardiac Services
Serban Stoica
Area for cost saving
3
Q2
National Diabetes Audit (NDA)
Diabetes & Endocrinology
Christine Burren
National Audit (NCAPOP)
1
Q1
Re-audit growth hormone use
Diabetes & Endocrinology
Liz Crowne
National guidance (NICE TA188)
3
Q2
Fitting Child (College of Emergency Medicine)
Emergency Department
Lead to be confirmed
National Audit (Quality Accounts)
1
Q3
Trauma (TARN)
Emergency Department
Nick Sergeant
National Audit (Quality Account)
Service Requirement
1
Q1
EZ-IO needles
Emergency Department
Lead to be confirmed
Identified through Child Death Review
2
TBC
"Did not wait" policy
Emergency Department
Lead to be confirmed
Local guidance
3
TBC
Bereavement counselling
Emergency Department
Francis Edwards
External accreditation/regulation (identified from CQC
enquiry to Trust)
2
Q1
UTI sample collection and lab delivery - re-audit
Emergency Department
Will Christian
Re-audit ID 3552
2
Q1
Provision of information leaflets and advice
Emergency Department
Nick Sergeant
Identified through patient safety/risk/incident reporting
2
Q2
National Inflammatory Bowel Disease audit
Gastroenterology
Christine Spray
National audit (NCAPOP)
1
Q1
Re-audit Infliximab and Adalimumab use in children with Crohns
disease
Gastroenterology
Christine Spray
National guidance (NICE TA187)
Re-audit ID 3377
3
Q3
Kawasaki disease
General Paediatrics
Alison Kelly/ Jon Forsey
Local Guideline
3
Q1
Clinical Audit Annual Report 2013/14
Page 66
Iv fluid prescription chart audit
General Paediatrics
Elenor Tickner / Alison Kelly
Re-audit ID 3549
3
Q1
Use and usefulness of bronchiolitis patient information leaflet
General Paediatrics
Reg Bragonier
Identified through patient complaints process
2
Q1
Aseptic non-touch technique for Central Venous Lines
Haematology/ Oncology
Wendy Saegenschnitter
No specific rationale provided
4
Q1
Peripheral blood stem cell harvest on solid tumour patients in
2012/2013
Haematology/ Oncology
Balveer Kaur
No specific rationale provided
4
Q1
Review of admissions of cancer patients to PICU
Haematology/ Oncology
Barbara Torres
No specific rationale provided
4
Q1
Review of antiemetic medication use for inpatient chemotherapy
Haematology/ Oncology
Indril Dey
No specific rationale provided
4
Q1
Re-audit of antiemetic policy following review
Haematology/ Oncology
Vanessa Mcleland
No specific rationale provided
4
Q3
Fungal infection in leukaemia
Haematology/ Oncology
Peter Wassaa
No specific rationale provided
4
Q1
Blood product use in cancer patients
Haematology/ Oncology
Peter Wassaa
No specific rationale provided
4
Q1
Re-immunisation post chemotherapy-
Haematology/ Oncology
Frankie Toussaint
No specific rationale provided
4
Q1
Pneumococcal vaccination in Sickle cell patient
Haematology/ Oncology
Michelle Cummins
No specific rationale provided
4
Q4
Paediatric Intensive Care (PICANet)
Intensive Care (Paediatric)
Peter Davis
National Audit (NCAPOP)
1
Q1
National Neonatal Audit Project (NNAP)
Intensive Care (Neonatal)
Pam Cairns
National audit (NCAPOP)
1
Q1
Vermont-Oxford Benchmarking Project
Intensive Care (Neonatal)
David Harding
National Audit (other - National/International quality
improvement project)
2
Q1
Compliance with heel-prick blood sampling guideline
Intensive Care (Neonatal)
Anoo Jain
Local concern
4
Q2
Central line insertion in NICU
Intensive Care (Neonatal)
Madhavi Parvathareddy
National guidance (Matching Michigan project standards)
3
Q1
Car seat assessment in neonates
Intensive Care (Neonatal)
Pam Cairns/Anoo Jain
Local guidance
4
Q1
Newborn Life Support (Joint project with Obstetrics/Midwifery)
Intensive Care (Neonatal)
Sue Braithwaite/Karen
MacDonald-Taylor
External accreditation/regulation (CNST Maternity
Standard 3.5.2)
2
Q1
Occupational Therapy Provision
Occupational Therapy
Lisa Mills
Identified through patient safety/risk/incident reporting
2
Q3
Clinical Audit Annual Report 2013/14
Page 67
Renal Registry (UKRR)
Nephrology
Carol Inward
National Audit (Quality Accounts)
1
Q1
Renal biopsy
Nephrology
Jan Dudley
National guidance (Specialty Group)
3
Q2
Dialysis line locks
Nephrology
Jenny Haylor
National guidance (NPSA /Toft report)
2
Q1
Epilepsy 12 (Childhood Epilepsy)
Neurology
Phil Jardine
National Audit (NCAPOP)
1
Q1
Paediatric Pneumonia (British Thoracic Society audit programme)
Respiratory
Deb Marriage
National Audit (Quality Accounts)
1
Q3
Medication information contained in Paediatric Rheumatology
clinic letters and discharge summaries v RCPCH standards
Rheumatology
Alison Kelly
National guidance
3
Q1
Use of Etanercept in Juvenile Idiopathic Arthritis (JIA) against NICE
guidelines
Rheumatology
AV Ramanan
National guidance (NICE TA35)
3
Q1
Use of Tocilizumab in Systemic Juvenile Idiopathic Arthritis (sJIA)
versus NICE guidelines
Rheumatology
AV Ramanan
National guidance (NICE TA238)
3
Q1
Recording of core outcome variables for patients with juvenile
idiopathic arthritis (JIA) versus national standards
Rheumatology
AV Ramanan
National guidance
3
Q1
Errors in radiology reports using voice recognition software
Radiology
David Grier
Change in practice, evaluation required
3
Q1
Biofeedback in management of dysfunctional voiding
Surgery
Mark Woodward
Evaluation of outcomes post implementation of a new
clinic
3
Q1
Human Fertilisation and Embryology Authority (HFEA) statutory
compliance
Reproductive Medicine
David Cahill
National guidance (regular audit of compliance with
national standard operating procedure)
2
Q4
Outpatient Hysteroscopy
Gynaecology
Katherine O’Brien/ Naomi
Crouch
To determine whether clinically suitable patients are being
4
managed as outpatients
Q1
Heavy Menstrual Bleeding (NICE QS47)
Gynaecology
Munawar Hussain/Martin
Mills
National guidance (NICE QS47)
4
Q1
Female Genital Mutilation in pregnancy
Obstetrics/Midwifery
Sara-Jane Sheldon
Re-audit / joint audit with North Bristol Trust
3
Q2
Magnesium sulphate for neuroprotection in pre-term birth (Joint
project with Neonatology)
Obstetrics/Midwifery
Emma Treloar/Karen Luyt
Regional project managed by West of England Academic
Health Science Network
3
Q2
Care of Women in Labour, incl. Intermittent Auscultation,
Continuous Electronic Fetal Monitoring, Fetal Blood Sampling, Use
of Oxytocin
Obstetrics/Midwifery
Emma Treloar/Jane Farey
External accreditation/regulation (CNST Maternity
standards 3.2.1 to 3.2.5)
2
Q1
Caesarean Section – Decision to Delivery times (NICE CG132)
(Joint project with Obs and Gynae Anaesthesia)
Obstetrics/Midwifery
Emma Treloar/Stephen
Kinsella
External accreditation/regulation (CNST Maternity
Standard 3.2.6)
2
Q1
Women’s Services
Clinical Audit Annual Report 2013/14
Page 68
Intrauterine resuscitation in cases of suspected acute hypoxia
(Joint project with Obs and Gynae Anaesthesia)
Obstetrics/Midwifery
Rachna Bahl/Stephen Kinsella
Local guidance (caesarean section guideline)
4
Q1
Shoulder Dystocia
Obstetrics/Midwifery
Rachna Bahl
External accreditation/regulation (CNST Maternity
Standard 3.3.6)
2
Q1
Perineal Tear
Obstetrics/Midwifery
Rachna Bahl/Di Dorrington
External accreditation/regulation (CNST Maternity
Standard 3.3.5)
2
Q1
Obstetric Haemorrhage
Obstetrics/Midwifery
Rachna Bahl/Caryn Albury
External accreditation/regulation (CNST Maternity
Standard 3.3.7)
2
Q1
UNICEF UK Baby Friendly Initiative / Newborn Feeding
Obstetrics/Midwifery
Joan Beales
External accreditation/regulation (UNICEF standards &
CNST Maternity Standard 3.5.5)
2
Q1
Examination of the Newborn
Obstetrics/Midwifery
Anne Duffner
External accreditation/regulation (CNST Maternity
Standard 3.5.6)
2
Q1
Postnatal care
Obstetrics/Midwifery
Sara-Jane Sheldon
External accreditation/regulation (CNST Maternity
Standard 3.3.7)
2
Q2
Support for Parents
Obstetrics/Midwifery
Louise Howarth
External accreditation/regulation (CNST Maternity
Standard 3.5.8)
2
Q3
Immediate Care of the Newborn (Joint project with Neonatology)
Obstetrics/Midwifery
Sara-Jane Sheldon /Anoo Jain
External accreditation/regulation (CNST Maternity
Standard 3.5.4).
2
Q3
Handover of Care (Onsite)
Obstetrics/Midwifery
Sara-Jane Sheldon
External accreditation/regulation (CNST Maternity
Standard 3.4.8)
2
Q3
Title
Sub-Specialty
Lead
Rationale
Priority
Q Start
Blood Transfusion
All areas/specialties
Tom Latham
Transfusion Group Priority
2
Q2
Audit of suspected VTE management
All areas/specialties
Amanda Clark
Commissioning requirement (Links to Quality Schedule)
1
Q2
Audit of patient transfer
All areas/specialties
Anne Reader
Commissioning requirement (Links to Quality Schedule)
1
Q2
Sepsis
All areas/specialties
Jeremy Bewley
Commissioning requirement (CQUIN)
1
Q2
Audit of patient discharge
All areas/specialties
Anne Reader
Commissioning requirement (Links to Quality Schedule)
Link to Board Assurance Framework/Corporate Objectives
1
Q2
Medical Records audit
All areas/specialties
Jane Luker
External accreditation/regulation (links to CQC Outcome
work)
1
Q2
Nursing documentation audit
All areas/specialties
Helen Morgan
External accreditation/regulation (links to CQC Outcome
work)
1
Q2
Non Division Specific
Clinical Audit Annual Report 2013/14
Page 69
Appendix E - National audit participation (extract from Quality Report 2013/14)
Participation in clinical audits and national confidential enquiries
For the purposes of Quality Accounts and Reports, the Department of Health publishes an annual list of national
audits and confidential enquiries, participation in which is seen as a measure of quality of local clinical audit
programmes. This list is not exhaustive, but rather aims to provide a baseline for trusts in terms of percentage
participation and case ascertainment1. The information which follows relates to this list.
During 2013/14, 39 national clinical audits and three national confidential enquiries covered NHS services that
University Hospitals Bristol NHS Foundation Trust provides. During that period, University Hospitals Bristol
participated in 95% (37/39) national clinical audits and 100% (3/3) national confidential enquiries of which it was
eligible to participate in.
The national clinical audits and national confidential enquiries that University Hospitals Bristol NHS Foundation
Trust was eligible to participate in during 2013/14 are as follows:
Name of audit / Clinical Outcome Review Programme
Eligible
Participated
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Severe sepsis and septic shock
Yes
Yes
Severe trauma (Trauma Audit & Research Network, TARN)
Yes
Yes
Blood and Transplant
National Comparative Audit of Blood Transfusion programme
Yes
Yes
Cancer
Bowel cancer (NBOCAP)
Head and neck oncology (DAHNO)
Lung cancer (NLCA)
Oesophago-gastric cancer (NAOGC)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Heart
Acute coronary syndrome or Acute myocardial infarction (MINAP)
Cardiac Rhythm Management (CRM)
Congenital heart disease (Paediatric cardiac surgery) (CHD)
Coronary angioplasty
National Adult Cardiac Surgery Audit
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
National Cardiac Arrest Audit (NCAA)
Yes
Yes
National Heart Failure Audit
Yes
Yes
National Vascular Registry
Yes
Yes
Acute
Case Mix Programme (CMP)
Emergency use of oxygen (British Thoracic Society)
Medical and surgical clinical outcome review programme: National confidential
enquiry into patient outcome and death
National Audit of Seizures in Hospitals (NASH)
National emergency laparotomy audit (NELA)
National Joint Registry (NJR)
Paracetamol overdose (care provided in emergency departments)
Long term conditions
1
i.e. the number of individual patents we submit data on compared to how many we should have submitted data on (usually outlined
through Hospital Episode Statistics or similar)
Clinical Audit Annual Report 2013/14
Page 70
Diabetes (Adult) ND(A), includes National Diabetes Inpatient Audit (NADIA)*
Diabetes (Paediatric) (NPDA)
Inflammatory bowel disease (IBD)
National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme
BTS Paediatric bronchiectasis (British Thoracic Society)
Renal replacement therapy (Renal Registry)
Rheumatoid and early inflammatory arthritis**
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Older People
Falls and Fragility Fractures Audit Programme (FFFAP)
Sentinel Stroke National Audit Programme (SSNAP)
Yes
Yes
Yes
Yes
Other
Elective surgery (National PROMs Programme)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Women’s & Children’s Health
Child health clinical outcome review programme (CHR-UK)
Epilepsy 12 audit (Childhood Epilepsy)
Maternal, Newborn and Infant Clinical Outcome Review Programme
(MBRRACE-UK)
Moderate or severe asthma in children (care provided in emergency
departments)*
Neonatal intensive and special care (NNAP)
Paediatric asthma
Paediatric intensive care (PICANet)
* Organisational aspects only
The Trust did not participate in two national audits under the auspices of the British Thoracic Society and is
undertaking relevant local audit activity instead.
The national clinical audits and national confidential enquiries that University Hospitals Bristol NHS Foundation
Trust participated in, and for which data collection was completed during 2013/14, are listed below alongside the
number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required
by the terms of that audit or enquiry.
Name of audit / Clinical Outcome Review Programme
% cases submitted
Acute
Case Mix Programme (CMP)
National Audit of Seizures in Hospitals (NASH)
National Joint Registry (NJR)
Paracetamol overdose (care provided in emergency departments)
Severe sepsis & septic shock
Severe trauma (Trauma Audit & Research Network, TARN)
1190*
100% (30/30)
98% (49/50)
100% (50/50)
100% (50/50)
68% (200/294)
Blood and Transplant
National Comparative Audit of Blood Transfusion programme
38*
Cancer
Bowel cancer (NBOCAP)
Head and neck oncology (DAHNO)
Lung cancer (NLCA)
Oesophago-gastric cancer (NAOGC)
94% (162/173)
90*
80% (144/180)
99% (149/150)
Heart
Clinical Audit Annual Report 2013/14
Page 71
Acute coronary syndrome or Acute myocardial infarction (MINAP)
985*
Cardiac Rhythm Management (CRM)
Congenital heart disease (Paediatric cardiac surgery) (CHD)
Coronary angioplasty
National Adult Cardiac Surgery Audit
100% (792/792)
100% (742/742)
100% (1423/1423)
100% (1481/1481)
National Cardiac Arrest Audit (NCAA)
133*
National Heart Failure Audit
100% (403/403)
National Vascular Registry
98% (145/148)
Long term conditions
Diabetes (Adult) ND(A), includes National Diabetes Inpatient Audit (NADIA)
Diabetes (Paediatric) (NPDA)
Inflammatory bowel disease (IBD)
99% (100/101)
1354*
100% (40/40)
Older People
Falls and Fragility Fractures Audit Programme (FFFAP)
Sentinel Stroke National Audit Programme (SSNAP)
345*
100% (121/121)
Other
Elective surgery (National PROMs Programme)
27% (33/122)
Women’s & Children’s Health
Moderate or severe asthma in children (care provided in emergency departments)
Neonatal intensive and special care (NNAP)
Paediatric intensive care (PICANet)
100% (50/50)
100% (2739/2739)
100% (671/671)
*No case requirement outlined/unable to establish baseline from HES data
The reports of ten national clinical audits were reviewed University Hospital Bristol NHS Foundation Trust in
2013/14. The Trust is taking the following actions to improve the quality of healthcare provided:
College of Emergency Medicine (CEM) audits
 The Medway system has been altered to allow better electronic capture of data relating to consultant review
or discussion.
 Monthly reporting against the CEM quality standard has been introduced to inform further actions required
by pinpointing times / days when standards are less likely to be adhered to.
National Audit of Dementia
 A care pathway for frail older people which incorporates people with a dementia will be developed. Access to
intermediate care services to allow people with dementia to be admitted to intermediate care directly will be
part of this review.
 A review of the model of care for the older adult admissions wards is to be undertaken.
 A clinical guideline is being developed to ensure that patients with dementia or cognitive impairment are
assessed for the presence of delirium at presentation using a recognised tool (Confusion Assessment
Method).
 An electronic discharge summary for all patients who are 75 years and over will be developed which contains
mandatory fields to include abbreviated mental test score, cause of cognitive impairment, symptoms of
delirium, and behavioural and psychological symptoms of dementia.
National Cancer Audits
 Significant progress has been made with the lung, bowel and head and neck audits in 2013. All three audits
returned their best ever standard of submission in terms of data completeness and quality.
 Easy format written guidance on data entry has been produced, along with reports that allow MDT
coordinators to easily identify and rectify data gaps, and their managers to monitor this. This system has
received positive feedback from coordinators and clinicians.
Clinical Audit Annual Report 2013/14
Page 72


All national audit submissions have undergone clinical quality assurance prior to submission. Monthly
submission has been introduced along with a robust system for identifying ‘rejected’ records enabling these
to be quickly fixed.
The Trust’s cancer manager continues to work closely with the Somerset Cancer Register to ensure the best
use of the register and influence its development.
National Diabetes Audit (NADIA)
 Increased diabetes specialist nursing input was allocated via CQUIN funding to help improve the care that
diabetic patients receive as inpatients.
National Cardiac Arrest Audit (NCCA)
 All cardiac arrests are now reported on the Trust incident reporting system (Ulysses Safeguard) to enable
learning from these incidents.
Falls and Fragility Fractures Audit Programme - National Hip Fracture Database
 The appointment of a specialist hip fracture nurse (and audit nurse responsible for data) has resulted in a
significant improvement in data quality, and patient care as a whole.
 A business case was approved and implemented to increase orthogeriatrician input, increase trauma theatre
allocation and implement direct access beds.
National Vascular Registry
 A written pathway of care for Transient Ischaemic Attacks (TIAs) and non-disabling stroke for Bristol Bath and
Weston Vascular Network is being developed to ensure that the agreed protocol for referral is followed to
help avoid any unnecessary delay.
National Neonatal Audit Project
 A preterm breast feeding project has been started aiming to improve rates of breastfeeding at discharge.
The outcome and action summaries of 205 local clinical audits were reviewed by University Hospital Bristol NHS
Foundation Trust in 2013/14; summary outcomes and actions reports are reviewed on a bi-monthly basis by the
Trust’s Clinical Audit Group. Details of the changes and benefits of these projects will be published in the Trust’s
Clinical Audit Annual Report for 2013/142.
2
Available via the Trust’s internet site from June 2013
Clinical Audit Annual Report 2013/14
Page 73