Clinical Audit Annual Report
2012/13
Report by: Stuart Metcalfe, Clinical Audit & Effectiveness Manager.
Date: April 2013.
Introduction from the Chair of Clinical Audit Group ............................................................................ 3
1
2
Report from the Clinical Audit & Effectiveness Manager ............................................................... 4
1.1
Clinical Audit & Effectiveness Team ................................................................................................................................ 4
1.2
Clinical Audit Group ........................................................................................................................................................ 4
1.3
Quality Report ................................................................................................................................................................. 4
1.4
Forward programme 2013/14 ........................................................................................................................................ 5
1.5
National and Regional Involvement ............................................................................................................................... 5
Project Reports for 2012/2013 ..................................................................................................... 6
2.1
Introduction to Divisional Reports .................................................................................................................................. 6
2.1.1
Introduction and explanation of statistics .............................................................................................................. 6
2.1.2
Summary ‘dashboard’ of indicators ........................................................................................................................ 7
2.2
DIAGNOSTIC & THERAPY ................................................................................................................................................ 8
2.3
MEDICINE ...................................................................................................................................................................... 13
2.4
SPECIALISED SERVICES .................................................................................................................................................. 19
2.5
SURGERY AND HEAD AND NECK ................................................................................................................................... 22
2.6
WOMEN AND CHILDREN'S ............................................................................................................................................ 30
2.7
NON-DIVISION SPECIFIC ................................................................................................................................................ 39
Appendix A – UH Bristol Clinical Audit and Effectiveness Staff (as at April 2013) ................................. 41
Appendix B - Clinical audit projects abandoned during 2012/13 ......................................................... 42
Appendix C - University Hospitals Bristol Clinical Audit Forward Programme 2013/14 ........................ 44
Appendix D - National audit participation (extract from UH Bristol Quality Report 2012/13) .............. 59
Clinical Audit Annual Report 2012/13
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. With an
increasing requirement for individuals and organisations to provide evidence of the quality of the services
provided to patients, the expertise of the Clinical Audit and Effectiveness Team (CAET) will be increasingly
important. Over the last year, an independent view has been undertaken of the roles and remit of the CAET.
This has resulted in the centralisation of the team at Trust Headquarters and the streamlining of processes
underpinning clinical audit activity within University Hospitals Bristol.
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 Clinical Excellence (NICE), the National Patient Safety
Agency (NPSA), the Medical Royal Colleges, and projects initiated in response to local priorities. Out of 317
projects identified for the forward plan a total of 202 projects were completed in 2012/2013.
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 facilitates the implementation of actions where appropriate.
I would like to thank Stuart Metcalfe and the CAET 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 for their involvement in the work of the Clinical Audit Group on behalf of the Trust.
There has been a larger than usual number of changes to the membership of the Clinical Audit Group over the
year which you will find detailed in the report. I would like to thank all those who stepped down and welcome
all those of have joined the group. Particular thanks go to Tony Brooke & Paul Thomas for their long service to
the leadership of clinical audit in the Trust. We are delighted to welcome Dr Anne Frampton who becomes
Chair of the group.
Carol Inward
Chair, Clinical Audit Group
Clinical Audit Annual Report 2012/13
Page 3
1 Report from the Clinical Audit & Effectiveness Manager
1.1 Clinical Audit & Effectiveness Team
During the financial year 2012/13, clinical audit at the University Hospitals Bristol NHS Foundation Trust was
supported by a team of 3.8 whole time equivalent Clinical Audit Facilitators (CAFs) employed by the Trust
Services Division, and based mostly in the Clinical Divisions. In March 2013, Mairead Dent (CAF for Oncology
and Haematology) retired from her role after 22 years of service. On behalf of the Trust, I would like to thank
Mairead for her contribution over the years and wish her well in retirement. Additional support is provided by
a number of other staff employed by the Clinical Divisions with a specific remit for clinical audit (in Radiology
and Homeopathy). 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 that they support can be found at Appendix A of
this report.
In July 2012, the CAET completed the first phase of a ‘lean’ exercise as part of the Trust’s Transformation
Programme. This work was aimed at developing a more sustainable model of working for the future, focusing
on mapping current processes (‘current state’) and then considering how these processes could be
streamlined to improve efficiency and minimise waste (‘future state’). A number of workstreams were agreed
as part of this work, including the re-design of registration and reporting documentation, the re-design of the
Trust’s clinical audit database, as well as work around the proposed centralisation of the CAET in Trust
Headquarters. Implementation of these changes will continue during 2013/14
1.2 Clinical Audit Group
The Clinical Audit Group (CAG) met five times during the financial year 2012/13 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 parties (e.g.
commissioners).
A number of Clinical Audit Convenors (clinical audit leads) have served their term of office and have stepped
down in the last quarter of 2012/13. These changes are outlined below.
Laboratory Medicine – Joya Pawade has replaced Paul Thomas
Medical Specialties – Rachel Bradley has replaced Anne Frampton
Anaesthesia/Theatres – Diana Terry has replaced Mark Scrutton
Dental Services – Paul Wilson has replaced Tony Brooke
Surgical Specialties – Doug West has replaced Jane Blazeby
Children’s Services – Will Christian has replaced Will Marriage
Women’s Services – Naomi Crouch has replaced Rachael Liebling
Finally, the Group would like to express thanks to Carol Inward as outgoing Chair and to Anne Frampton for
taking on the role.
1.3 Quality Report
A mandated statement about participation in national clinical audits has been included in the Trust’s Quality
Report for 2012/13. The relevant extract has been reproduced at Appendix D of this report. The Quality
Report also includes reports on two clinical audit related corporate objectives: Implementing a proactive
Clinical Audit Annual Report 2012/13
Page 4
clinical audit programme for histopathology (which has been fully achieved), and re-focusing on ensuring
compliance with guidance published by NICE (which has been partially achieved). The Quality Report will be
available on the Trust’s internet site from late June 2013.
1.4 Forward programme 2013/14
Each year, clinical specialties agree a programme of planned clinical audit for the forthcoming financial year.
This process is co-ordinated by the Clinical Audit & Effectiveness Manager and overseen by the Clinical Audit
Group. The programme reflects agreed priority projects, based on considerations such as anticipated national
clinical audits, national guidance (NICE, Patient Safety Alerts, Royal College) and local clinical priorities.
Other local audits are undertaken during the year on an ad-hoc basis to address further clinical priorities as
and when these are identified. In response to previous comments from Non-Executive Directors and
recommendations following an internal audit, the programme clarify identifies the priority level of each
project within the programme. These priority categories are based on Healthcare Quality Improvement
Partnership (HQIP) national guidance. The forward programme for 2013/14 can be found at Appendix C.
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 Audit Governance Group, a national
peer group consisting of representatives from regional clinical audit forums. NAGG 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
April 2013
Clinical Audit Annual Report 2012/13
Page 5
2
Project Reports for 2012/2013
2.1 Introduction to Divisional Reports
2.1.1 Introduction and explanation of statistics
All project information for this report is taken from the UH Bristol Clinical Audit Project Management
Database. Lists of projects are broken down by Division/specialty and subspecialty, showing progress against
projects identified as priorities within the previous financial year. A number of these projects (those
highlighted with a status of ‘not initiated’) were not started during the financial year due to the changing
priorities that clinical staff face. Where these projects remain a priority, they have been carried forward to
2013/14. A list of projects undertaken ‘off plan’ has also been included.
The statistics presented are based on the total number of audits registered on the Trust clinical audit database
during the financial year 2012/13. This includes projects started in previous years and not yet complete as
well as projects completed in 2012/13. It does not include projects abandoned during the year - for details of
these, please see Appendix B.
Definition of terms:
Ongoing
(continuous) audit
Re-audit
NICE guidance
National
Interface
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 recommendations from National Institute of Clinical Excellence
Denotes national audits, e.g. those audits part of the National Clinical Audit & Patient
Outcome Programme (NCAPOP), Royal College and 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 2012/13
Page 6
2.1.2 Summary ‘dashboard’ of indicators
On-going (continuous) audits
First audits
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
74
7%
72%
21%
1
1
9%
4%
11%
0%
34%
54%
35
97%
3%
100%
Medicine
67
2%
82%
16%
5
1
25%
1%
10%
0%
33%
46%
30
100%
0%
77%
Non-division specific
12
25%
50%
25%
0
0
0%
8%
17%
8%
50%
58%
6
100%
0%
100%
Specialised Services
47
15%
66%
19%
7
0
34%
2%
15%
0%
19%
28%
9
67%
33%
78%
Surgery and Head and Neck
126
10%
57%
33%
13
10
13%
9%
10%
2%
27%
35%
51
88%
12%
84%
Women and Children's
187
19%
52%
29%
32
3
14%
4%
9%
0%
27%
55%
63
86%
14%
59%
TOTAL (2012/13)
513
13%
61%
26%
58
15
16%
5%
10%
1%
28%
46%
194
90%
10%
78%
TOTAL (2011/12)
500
12%
64%
24%
80
6
10%
6%
11%
3%
28%
41%
157
90%
10%
85%
* In progress 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 on only 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 2012/13
Page 7
UHBristol Clinical Audit Annual Report 2007/8
Total number of projects *
Diagnostic and Therapy
2.2
DIAGNOSTIC & THERAPY
Planned projects in progress or complete at end of financial year
This year
69% (24/35)
Previous year
60% (14/23)
The following table shows the status at year end of those projects in progress or completed during the financial
year that were identified as priorities within the forward plan for 2012/13.
Title
Sub-specialty
Proposed lead
Priority category
Status
Audit of blood sampling and labelling
Laboratory
Haematology
Sue Cooke (Transfusion
Practitioner)
P1 - National Audit (Quality
Accounts)
In progress ID3172
Audit of the use of Anti-D
Laboratory
Haematology
Tom Latham (Cons)
P1 - National Audit (Quality
Accounts)
Not initiated
Histology reporting of vulval carcinoma in
women
Histopathology
Joya Pawade (Cons)
P1 - Corporate objective/Board
assurance Clinical Risk / Patient
Safety
Completed ID3220
Bowel Cancer Screening Program: detected
colorectal cancer resection specimens – a
Histopathology
comparison of reporting between three
Trusts
Newton Wong (Cons)
P1 - Recommended audit by
South West Quality Assurance
Reference Centre
Completed ID3171
Re-audit of turnaround times in skin cancer
Histopathology
reporting
Nidhi Bhatt (Cons)
P1 - Strategic Framework for
Improving Health in the South
West 2008/9 - 2010/11
Completed ID3309
Audit of supplementary reports issued
after multi-disciplinary team meetings to
identify discrepancies across all cancer
specialties in UH Bristol
Histopathology
Joya Pawade (Cons)
P1 - Corporate objective/Board
assurance Clinical Risk /
Patient Safety
Completed ID3048
Correlation of breast tumour grading
between core biopsies and resection
specimens in a screened population
Histopathology
Muhammed Sohail (Cons)
P1 - Corporate objective/Board
assurance Clinical Risk /
Patient Safety
Completed ID2896
Audit of The Reporting of Cutaneous
Malignant Melanoma at UH Bristol
Histopathology
Nidhi Bhatt (Cons)
P1 - Corporate objective/Board
assurance Clinical Risk /
Patient Safety
Completed ID3089
Reporting of high grade endometrial
cancer
Histopathology
Joya Pawade (Cons)
P1 - Corporate objective/Board
assurance Clinical Risk /
Patient Safety
Completed ID2885
Turnaround time for reporting biopsies of
suspected paediatric Inflammatory Bowel
Disease
Histopathology
Pramila Ramani (Cons)
P1 - Corporate objective/Board
assurance Clinical Risk / Patient
Safety
Completed ID3325
Audit of microbiology sampling in stillbirth
post mortems
Histopathology
Craig Charles Platt (Cons)
P1 - Corporate objective/Board
assurance Clinical Risk / Patient
Safety
Completed ID3092
Quality of perinatal autopsy in South-West
of England
Histopathology
Corina Moldovan (Cons)
P1 - Corporate objective/Board
assurance Clinical Risk / Patient
Safety
In progress ID3216
Histological reporting of lung specimen
Histopathology
Joya Pawade (Cons)
P1 - Corporate objective/Board
assurance Clinical Risk / Patient
Safety
Completed ID2194
Audit on double-reporting of lung
pathology cases
Histopathology
P1 - Corporate objective/Board
Golda Shelley-Fraser (Cons)
assurance Clinical Risk /
Nidhi Bhatt (Cons)
Patient Safety
Completed ID3138
Renal tumour reporting
Histopathology
Muhammed Sohail (Cons)
P1 - Corporate objective/Board
assurance Clinical Risk /
Patient Safety
Completed ID3173
Audit of Linen policy
Infection Control
Senior Infection Control
Nurse
P2 - Infection control
programme
Not initiated
Audit of Tuberculosis policy
Infection Control
Senior Infection Control
Nurse
P2 - Infection control
programme
Not initiated
Laboratory Medicine
Clinical Audit Annual Report 2012/13
Page 8
Audit of Waste Policy
Infection Control
Senior Infection Control
Nurse
P2 - Infection control
programme
Not initiated
Frequency of repeat testing of clinical
biochemistry assays
Clinical
Biochemistry
Paul Thomas (Cons)
P3 - To assess the effective use
of laboratory tests
Not initiated
Diagnosis and initial management of
suspected community-acquired bacterial
meningitis
Microbiology
Martin Williams (Cons)
P3 - Re-audit ID 2632
Not initiated
Medical Physics
Ian Negus (Clinical
Scientist)
P2 - Requirement of IRMER
Not initiated
Audit of enteral tube feeding practice on
CICU
Nutrition &
Dietetics
Kate Tattersall (Dietitian)
P2 - UH Bristol Tube feeding
protocol
In progress ID3267
Nutritional screening and management of
upper GI surgical patients in pre-operative
assessment clinic
Nutrition &
Dietetics
Tom Landers (Dietitian)
P4 - UH Bristol Clinical guidelines.
Oesophageal surgery: preoperative nutritional screening.
Completed ID3192
Documentation Audit
Occupational
Therapy
Scott Allan (Deputy Head
OT)
P2 - CQC Outcome 21
In progress
Home visit
Occupational
Therapy
Scott Allan (Deputy Head
OT)
P3 - UHBristol Occupational
Therapy Home Assessment
Guidelines 2009.
Not initiated
Pharmacy
Margaret Monroe
(Pharmacist)
P2 - Part of Dementia strategy
Not initiated
Physiotherapy case note audit
Physiotherapy
Linda Clarke (Snr
Physiotherapist)
P2 - CQC Outcome 21
In progress
Outcomes of physiotherapy treatment of
Anterior Cruciate Ligament injuries
Physiotherapy
Lorna Harvey
(Physiotherapist)
P3 - Local concern
In progress ID3289
UH Bristol physiotherapy stroke service to
NICE Quality Standards for Stroke
Management
Physiotherapy
Chris Easton
(Physiotherapist)
P3 - NICE Quality Standards for
Stroke Management.
In progress ID3384
Audiology
P3 - British Society of Audiology
Regina Smith (Audiologist) protocol for REM for hearing
fittings.
Medical Physics & Bioengineering
CT radiation dose audit
Nutrition & Dietetics
Occupational Therapy
Pharmacy
Pharmacy audit of anti-psychotic drugs
Physiotherapy
Audiology
Real Ear Measurements (REM)
Not initiated
Speech & Language Therapy
Adult Speech and
Management of dysphagia patients in video
Vicki Weekes (Speech &
Language
fluoroscopy clinic and outcomes
Language Therapist)
Therapy
P3 - Royal College Physicians
stroke guidelines 2010.
Not initiated
P2 - Clinical Effectiveness Group
priority Introduction of a new
interventional procedure
Not initiated
P3 - Re-audit ID 2748. UH Bristol
Conscious Sedation Policy
In progress ID3238
Jonathan Rodrigues (SpR)
P3 - Re-audit ID 2792. ALARA
principle of Ionising Radiation
(Medical Exposures) Regulations
2000.
Completed ID3158
Elisa McAlindon (Clinical
Fellow)
P3 - Re-audit ID 2488. Local
protocols derived from national
guidelines
In progress –
ID3156
Radiology
Radioembolisation for the treatment of
colorectal liver metastasis
Re-audit non-anaesthetist conscious
sedation during intervention radiology
Effective dose in Computed Tomographic
Pulmonary Angiography
Radiology
Mark Callaway (Cons)
Radiology
Daire Allen McGee (SHO)
Radiology
A re-audit into the Cardiac Magnetic
Radiology
Resonance Imaging (MRI) Perfusion Service
The following activity was also in progress during the financial year (either rolled over from previous year or not
identified through plan):
Clinical Audit Annual Report 2012/13
Page 9
Ref
Provisional Title of Project
Status
Audiology (Adult)
2742
The completion of Glasgow Hearing Aid Benefit Profile
Completed
3347
Re-audit of Real Ear Measurements 2012
In Progress
Laboratory Medicine/Clinical Biochemistry
2695
National audit of management of familial hypercholesterolemia - NICE guidelines CG71
Completed
2696
Re-auditing NICE guidelines for management of Familial Hypercholesterolemia 2010
Completed
Laboratory Medicine/Infection Control
733
Infection Control Ward/Department audit
Ongoing
992
Are all Trust employees complying with the Infection Control Hand Hygiene Policy?
Ongoing
2798
A re- audit of peripheral intravenous catheter insertion and management in adult patients
Completed
3013
Infection Control Environment and Equipment Audit 2011-2012
Ongoing
3124
Documentation on discharge for patients with an infection/colonisation
Completed
Laboratory Medicine/Laboratory Haematology
2854
National Comparative Audit of Bedside Transfusion Practice (re-audit)
Completed
2912
Audit of medical patients with Hb>8g/dl receiving red cell transfusion
In Progress
3014
National Comparative Audit of the Medical Use of Blood
In Progress
3103
Management of major and massive haemorrhage at UHBristol
Completed
Laboratory Medicine/Microbiology
2898
Faecal specimen processing
Completed
3102
Turn-around times for urine sample culture and sensitivity reports at UH Bristol.
Completed
3308
3326
Is the antimicrobial management of Hospital Acquired Pneumonia consistent with local antibiotic guidelines at UH
Bristol?
Audit of clinical liaison for critical results in microbiology
In Progress
In Progress
Medical Physics & Bioengineering
2911
National Computed Tomography Radiation Dose Audit - Health Protection Agency Radiation Protection Division
In Progress
Nutrition & Dietetics
3115
Catering Ward Round rolling audit of mealtimes across the trust – managing the patient journey through nutritional
care
Ongoing
3116
Nutrition paperwork audit: a trust wide audit of the key prompts of CQC Outcome 5
Ongoing
3274
Dietetic Record Card Audit 2012
In Progress
Occupational Therapy
3290
Audit of the Early Supported Discharge Team for Stroke Professional Standards
In Progress
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
In Progress
3055
An Evaluation of Insulin Prescribing Safety in a Teaching Hospital
In Progress
3107
Intravenous to oral antibiotic switch – audit of practise within University Hospitals NHS Trust
In Progress
3215
Re-auditing compliance with prescribing policy – Medicines Codes Chapter M2
Completed
3345
Audit on the use of the Potassium Supplementation Standing Order
In Progress
3037
National audit of services for people with Multiple Sclerosis 2011 (Organisational Audit)
In Progress
Audit of exclusion value of minimal preparation computerized tomogram (MPCT) for colorectal cancer
Completed
Pharmacy
Radiology
2823
Clinical Audit Annual Report 2012/13
Page 10
2957
Audit of reporting standards of MRI of sacroiliac joints in arthritis
In Progress
2978
Accuracy of Fine Needle Aspiration Cytology in Neck Masses
Completed
2985
Interpretation recorded in the notes by the referrer re radiology investigations for which it has been agreed no
radiological report will be issued
Completed
3054
Minimising eye dose in paediatric CT head
In Progress
3062
Movement artefact in MRI scans for rectal cancer staging
In Progress
3113
Re-audit of radiographic quality in a neonatal intensive care unit
Completed
3114
Audit of radiographic quality in a paediatric intensive care unit
Completed
3141
Audit of CT Colonography in the Bowel Cancer Screening Programme
In Progress
3242
Audit of Reporting Turnaround of CT Colonography in the Bowel Cancer Screening Programme
Completed
3255
Abdominal ultrasound examinations performed and reported by Advanced Practitioner Sonographers with or
without discussion with Consultant Radiologist
In Progress
3256
Vetting of CT head scan requests during out of hours
Completed
3310
An audit of paediatric cardiac and chest CT doses
In Progress
3319
Accurate CRIS documentation of consultant checks on GP requested paediatric radiographs
Completed
3321
Audit of accuracy of CT staging of mesothelioma
In Progress
3327
Audit of radiation dose delivered for routine high resolution CT in adults
In Progress
3328
National Audit of Standards for the NPSA and RCR Safety Checklist for Radiological Interventions
In Progress
3348
RCR National Audit of Appropriate Imaging
In Progress
2063
Continuous assessment of the Radiographer Reporting Team against Royal College of Radiologists standards
Completed
2994
Paediatric head and neck radiography: Are images being acquired appropriately and is image quality fulfilling
paediatric imaging standards?
Completed
3073
Are radiographic markers being used appropriately in the A&E X-Ray department?
Completed
Speech & Language Therapy
2834
Re-auditing management of adult dysphagia patients 2010
Completed
3401
Re-auditing management of adult dysphagia patients 2012
In Progress
3040
Chest drain procedure carried out in the Emergency Department
In Progress
Summary of benefits, actions or changes achieved in 2012/13 as a result of completed projects
2742
Patients will now have their Glasgow Hearing Aid Benefit Profile posted to them for completion prior to
their follow up appointment.
2695 Results of the national audit of management of familial hypercholesterolemia were shared with the PCT.
Discussions around resources to implement recommendations from the report are underway.
2194 The process for reporting lung specimens has been changed. Cases will now be reported by three
pathologists with specialist interest.
2885 The performance status and plans for further imaging will be recorded in Somerset Cancer Registry for all
high grade serous endometrial carcinoma cases.
2896 This audit demonstrated that the concordance between grade on core biopsy and that in the definitive
excision in breast tumour in a screened population is in line with national standards.
3048 Support and changes were made to minimise any delay in discussion multi‐disciplinary team meetings. It
has been agreed that specialist haematopathologist input will be required in all haematopathology cases in
UH Bristol.
3089 A National Minimum Data Set template for in situ and invasive Cutaneous Malignant Melanoma reporting
will be used.
3173 Further training to all reporting pathologists is being provided to ensure that requirements for reporting the
minimum datasets in all cancers is achieved.
3220 A proforma for cut-up and histological reporting of vulval cancer excision specimens at UH Bristol is being
designed and implemented.
3309 Five Biomedical Scientists have been trained in skin cut‐up technique to improve process. Laboratory staff
Clinical Audit Annual Report 2012/13
Page 11
2798
3124
2854
3103
2898
3102
3192
3215
2985
3113
3114
3158
3242
3256
3319
2063
2994
3073
2834
will now be working in two teams each assigned to three or four consultants. A paperless reporting ‘sign‐
out’ system has been implemented to streamline the pathway.
The outcome of this audit demonstrates that general management of peripheral cannula in adult patients
has improved. Benefits to patients are safer insertion and management practices in turn leading to
reduced risk of infection/colonisation from a commonly used intravenous device.
Further education to ward staff has been provided, highlighting the need to document information and
provide education leaflets given to the patient regarding infection control issues and their medical
condition.
The Trust has developed a standard operating procedure for quick reference to pre transfusion checking/
patient identity/care of transfused patient procedures to improve practice in transfusion care.
Education around the procedure for managing major and massive haemorrhage was provided to the BRI
Emergency Department, St. Michael's Hospital and Theatres. Guidelines have been updated to ensure that
they are in line with current clinical practice.
This audit identified the potential for cost savings if unnecessary culture on in-patient faecal samples can
be reduced. This reduction was achieved by modifying the Trust’s blood requesting and reporting system
(ICE) and simplifying department protocols on sending stool for virology.
New equipment is being used to increase the efficiency of processing urine sample for culture and
sensitivity at UH Bristol and the process of sensitivity testing is being automated.
Further education to staff in pre-operative assessment clinic for upper GI surgical patients is being
delivered highlight the importance of documenting the MUST score on the nutritional screening tool and
care pathway.
The prescribing policy has been amended and re-published. Pharmacy education sessions have been reintroduced into the induction programme.
Information regarding refers responsibility regarding IR(ME)R has been shared with the MDTs. The results
of the audit were also shared in the Trust’s Patient Safety Group.
Radiology will monitor numbers of radiographs performed on neonatal intensive care unit by general
radiographers and continue training for radiographers performing plain radiographs on the unit.
The use of electronic side markers has been adopted.
This audit demonstrated that the mean effective dose of test bolus phase of Computed Tomographic
Pulmonary Angiography (CTPA) were all performed at the optimum level (80kVp < 0.17mSv). The adoption
of performing of the test bolus phase at 80kVp is being considered as departmental standard in other
areas.
Administrative staff will now notify Radiologists to verified CT Colonography reports in the Bowel Cancer
Screening Programme when patients’ examinations have been performed.
The protocol of vetting of CT head scans was updated and radiographers have been educated to improve
scrutiny on all requests.
Re‐advertise policy within department that radiographer should ensure the name of review consultant and
patient’s outcome documented on CRIS for all GP requested paediatric radiographs.
This audit demonstrated that Reporting Radiographers are providing accurate reports in line with current
standards.
The paediatric imaging protocols were reviewed and updated as a result of the audit of paediatric head
and neck radiography on image quality.
A reminder notice of “use lead markers and spares are available if personal ones are lost” in the x‐ray
rooms has been developed. This will increase compliance with using radiographic markers in the A&E x-ray
department.
Dysphagia standards were reviewed to ensure that all remain are appropriate for current clinical practice.
Team members were informed via dysphagia seminar and day to day case discussions of necessary actions,
especially documenting consent in notes.
Clinical Audit Annual Report 2012/13
Page 12
2.3
MEDICINE
Planned projects in progress or complete at end of financial year
This year
59% (44/74)
Previous year
52% (14/27)
The following table shows the status at year end of those projects in progress or completed during the financial
year that were identified as priorities within the forward plan for 2012/13.
Title
Sub-specialty
Proposed lead
Priority category
Status
Fractured neck of femur
Emergency
Department
Sian Vasey (Cons)
P1 - National Audit (Quality
Accounts)
In progress ID3363
Renal colic
Emergency
Department
Emma Redfern (Cons)
P1 - National Audit (Quality
Accounts)
In progress ID3300
Stroke/TIA
Emergency
Department
Richard Jeavons (Cons)
P1 - CQUIN
In progress
Acute Kidney Injury
Emergency
Department
Emma Redfern (Cons)/
Anne Frampton (Cons)
P2 - National Confidential
Enquiries (NCEPOD)
In progress
Audit of the management of
cellulitis/sepsis
Emergency
Department
MAU
P3 - Re-audit ID 2400. New trust
Jessica Triay (Cons)/ Anne
guideline currently in
Frampton (Cons)
development
Completed ID3129
Sedation
Emergency
Department
Lead not specified
P3 - Re-audit
Completed ID3053
Computed tomography coronary
angiography (CTCA)
Emergency
Department
Lead not specified
P3 - Local guidance/ pathway
Not initiated
First fit
Emergency
Department
Lead not specified
P3 - NICE Guidance
Not initiated
Blood usage in ED
Emergency
Department
Emma Redfern (Cons)
P3 - Local guidance/pathway
In progress
Non-invasive ventilation
Acute Medicine
Respiratory
Nabil Jarad (Cons)
P1 - National Audit (Quality
Accounts)
In progress
Missed doses on the Medical Assessment
Unit/Short Stay Unit
Acute Medicine
Roly Jenkins
P2 - NHS Patient Safety Initiative
In progress
Medicines reconciliation
Acute Medicine
Lead not specified
P2 - NHS Patient Safety Initiative
Not initiated
Duplication of prescribed medication
Acute Medicine
Roly Jenkins (Cons)
P2 - Safety/Risk Issue
In progress ID3118
Clexane Dosing
Acute Medicine
Lead not specified
P3 - Local concern
Not initiated
Anti-biotic prescription within 60minutes
(STAT dose)
Acute Medicine
Ed Moran (Cons)
P3 - National Guidance/Initiative
Not initiated
Standard testing of patients admitted
under medicine
Acute Medicine
Lead not specified
P3 - Local concern
Not initiated
National Audit of Dementia (NAD)
Care of the
Elderly
Julie Dovey (Cons)
P1 - National Audit (NCAPOP)
In progress
National Hip Fracture Database (NHFD)
Care of the
Elderly
Rachel Bradley (Cons)
P1 - National audit (NCAPOP)
In progress ID2486
Parkinson’s Disease
Care of the
Elderly
Gerry Tobin (Cons)
P1 - National Audit (Quality
Accounts)
Not initiated
Snapshot audit of patients with dementia
(re-audit)
Care of the
Elderly
Julie Dovey (Cons)
P2 - Identified through the
Dementia Steering Group
In progress ID3095
Stroke National Audit Programme (SSNAP)
Care of the
Elderly
Sarah Caine (Cons)
P2 - Identified through the
Dementia Steering Group
In progress ID2601
Safe use of diabetic medication
Care of the
Elderly
Simon Croxson (Cons)
P2 - NPSA Guidance
Completed ID3120
The Acute Management of Hyponatraemia
Care of the
Elderly
Rachel Bradley (Cons)
P3 - Local concern
In progress ID3177
Division: Medicine
Emergency Department
Medical Specialties
Clinical Audit Annual Report 2012/13
Page 13
Management of vitamin D deficiency in
patients with hip fractures
Care of the
Elderly
Rachel Bradley (Cons)
P3 - Local concern
Asymptomatic Screening
Contraception/
Sexual Health
Andrew Leung (Cons)
Leonor Herrera-Vega
P3 - National Audit (British
Association for Sexual Health and Not initiated
HIV)
Management of pelvic inflammatory
disease
Contraception/
Sexual Health
Andrew Leung (Cons)
Leonor Herrera-Vega
P3 - Regional Audit (South West
BASHH)
Not initiated
Management of epididymitis
Contraception/
Sexual Health
Laura Cunningham (SpR)
P3 - National and local guidelines
In progress ID3251
Management of gonorrhoea
Contraception/
Sexual Health
Lead not specified
P3 - National and local guidelines
Abandoned ID3217
Management of balanitis
Contraception/
Sexual Health
Lead not specified
P3 - National and local guidelines
Not initiated
HIV testing in patients with hepatitis
Contraception/
Sexual Health
Helen Wheeler (Cons)
P3 - National and local guidelines
In progress ID3167
Management of young patients
Contraception/
Sexual Health
Judy Berry (Cons)
P3 - National and local guidelines
Not initiated
HIV testing in patients with lymphoma
Contraception/
Sexual Health
Helen Wheeler (Cons)
P3 - National and local guidelines
Not initiated
Management of patients in massage
parlours and saunas
Contraception/
Sexual Health
Michael Clarke (Cons)
P3 - Local guidelines
Not initiated
Management of partner notification
Contraception/
Sexual Health
Rachel Ford
P3 - National and local guidelines
Not initiated
One-25-Sexual Health Outreach services
Contraception/
Sexual Health
Nikki Jeal (Cons)
P3 - Local guidelines
In progress ID3205
Management of sexual assaults
Contraception/
Sexual Health
Beata Cybulska (Cons)
P3 - National and local guidelines Not initiated
1st time issue of CHC and monitoring of
BMI and BP
Contraception/
Sexual Health
Lead not specified
P3 - Faculty guidelines
Not initiated
Emergency IUD
Contraception/
Sexual Health
Suzanne Hall (Cons)
P3 - Faculty guidelines
Not initiated
PGD Nexplanon
Contraception/
Sexual Health
Lead not specified
P3 - Local guidelines
In progress ID3344
Long-acting reversible contraception
Contraception/
Sexual Health
Jody Craft (SHO)
P3 - Faculty guidelines
Not initiated
Emergency contraception
Contraception/
Sexual Health
Jody Craft (SHO)
P3 - Faculty guidelines
In progress ID2990
NICE TA180 Psoriasis - Ustekinumab
Dermatology
Giles Dunhill (Cons)
Tracey Wheeler (Nurse)
P1 - BNSSG NICE Commissioning
College priority
In progress ID3367
NICE TA134 Psoriasis - Infliximab
Dermatology
Jane Samson (Cons)
P1 - BNSSG NICE Commissioning
College priority
No longer
required
The prescription of biologics for the
treatment of moderate to severe psoriasis
Dermatology
Giles Dunnill (Cons)
P1 - BNSSG NICE Commissioning
College priority
Completed ID3128
PUVA audit
Dermatology
Giles Dunhill (Cons)
Tonia Clarke (Nurse)
P3 - Re-audit ID 773
Not initiated
Isotretinoin audit
Dermatology
Lynne Skrine (Mgr)
Jane Samson (Cons)
P3 - National Audit (British
Association of Dermatology)
Not initiated
Skin cancer excision rates
Dermatology
Adam Bray (Cons)
P3 - Re-audit ID 2623
Not initiated
Fumaric Acid Esters prescribing and
monitoring
Dermatology
Helen Whitley (SpR)
P3 - Local concern
In progress ID3124
Basel cell carcinoma waits
Dermatology
David DeBerker (Cons)
P3 - Re-audit ID 2935
Completed ID3265
Content of two week wait consultations
Dermatology
Suchi Rajan (Nur)
P3 - Local concern
In progress ID 3031
Dermoscopy in skin cancer consultation
Dermatology
Kat Nightingale (SpR)
P3 - Re-audit ID 2299
Completed ID3265
National Diabetes Inpatient Audit
Diabetes &
Endocrinology
Natasha Thorogood
(Cons)
P1 - National Audit (NCAPOP)
In progress ID 3336
Clinical Audit Annual Report 2012/13
In progress
Page 14
Diabetic foot audit
Diabetes &
Endocrinology
Natasha Thorogood
(Cons)
P3 - Local concern
In progress ID3263
Type 1 diabetes
Diabetes &
Endocrinology
Bushra Ahmed (Cons)
P3 - Local concern
Not initiated
NICE TA203 Diabetes (type 2) - liraglutide
Diabetes &
Endocrinology
Natasha Thorogood
(Cons)
P1 - BNSSG NICE Commissioning
College priority
In progress ID3266
Inflammatory Bowel Disease (IBD)
Gastroenterology Tom Creed (Cons)
P1 - National Audit (NCAPOP)
In progress 2603
NICE TA187 Infliximab and adalimumab for
Gastroenterology Tom Creed (Cons)
the treatment of Crohn’s disease
P1 - BNSSG NICE Commissioning
College priority
In progress ID3122
SpyGlass Peroral Direct Visualisation
Cholangioscopy
Hepatology
Jim Portal (Cons)
P2 - Clinical Effectiveness Group
priority Introduction of a new
interventional procedure
Not initiated
Upper GI bleeding
Hepatology
Anne McCune (Cons)
P3 - NICE Guidance
Not initiated
Autoimmune hepatitis management
Hepatology
Anne McCune (Cons)
P3 - National Guidance British
Society of Gastroenterology
Not initiated
Hepatitis B
Hepatology
Peter Collins (Cons)
P3 - NICE Guidance
Not initiated
Review of suicides
Liaison
Psychiatry
Lucy Griffin (Cons)
P2 - National Confidential
Enquiry
Not initiated
Antidepressant prescribing in chronic
physical health
Liaison
Psychiatry
Amy Green (CT3)
P3 - Re-audit ID 2703
In progress ID3197
Illicit drug users in Accident and
Emergency
Liaison
Psychiatry
Emergency
Department
Sally Lewis (Spec Nur)
P3 - Re-audit ID 2220
Not initiated
Out of hours calls to on-call psychiatric
doctors
Liaison
Psychiatry
Emergency
Department
Salena Williams (Cons)
P3 - Royal College guidance
In progress ID3145
Emergency use of oxygen
Respiratory
Nabil Jarad (Cons)
P1 - National Audit (Quality
Accounts)
In progress
Adult asthma
Respiratory
Lead not specified
P1 - National Audit (Quality
Accounts)
Not initiated
Bronchiectasis
Respiratory
Nabil Jarad (Cons)
P1 - National Audit (Quality
Accounts)
In progress ID3354
Asthma Deaths (NRAD)
Respiratory
Liz Gamble (Cons)
P1 - National Audit (Quality
Accounts)
In progress
Adult cystic fibrosis
Respiratory
Kathryn Bateman (Cons)
P1 - Quality dashboard/CQUIN
Completed ID3283
NICE TA161 Osteoporosis - secondary
prevention including strontium ranelate
Rheumatology
Shane Clarke (Cons)
P1 - BNSSG NICE Commissioning
College priority
In progress ID3406
NICE TA204 Denosumab - osteoporotic
fractures
Rheumatology
Shane Clarke (Cons)
P1 - BNSSG NICE Commissioning
College priority
Completed ID3407
Observation Chart/Early Warning Scores
Nursing
Sally Wilson (Matron)
P2 - Divisional Patient Safety
Priority Identified through
risk/incident reporting
In progress
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
In Progress
3111
re-audit of patient vital signs in the adult Emergency Department (ED)
In Progress
3112
Management of head injury to the observation unit
In Progress
Clinical Audit Annual Report 2012/13
Page 15
3130
College of Emergency Medicine - Consultant sign off
In Progress
Medical Specialties/Acute Medicine
2858
Audit of investigation handover from the medical take
Completed
3411
Defining the diagnosis of subarachnoid haemorrhage (SAH)
In Progress
2738
Clotting and D dimer use in the Medical Assessment Unit
In Progress
3183
An audit of the initial management of sepsis patients in the Medical Assessment Unit
Completed
3198
Audit of the management of cellulitis
In Progress
3258
Management of Atrial Fibrillation in Bristol Royal Infirmary medical admissions
Completed
3034
Oxygen Prescription Audit
Completed
Medical Specialties/Care of the Elderly
2968
Audit of Appropriateness of Blood Transfusions
In Progress
3104
Timely brain imaging for stroke patients
In Progress
Medical Specialties/Contraceptive & Sexual Health Services (CASH)
3075
Audit of consent for home Early Medical Abortion
Completed
3093
Management of chronic pelvic pain syndrome in males
Completed
Medical Specialties/Dermatology
3204
Screening prior to self-administered biologics therapy for psoriasis (re-audit)
Completed
3303
Is the use of Teledermatology service between the primary and secondary care trust improving the quality of
patient care?
Completed
3329
An audit of Surgical Request Forms in Dermatology
Completed
3360
Regional audit of TL01 therapy for chronic or guttate plaque psoriasis.
In Progress
Medical Specialties/Diabetes & Endocrinology
2497
Prevalence and Management of Benign Hypercalcaemia and Primary hyperparathyroidism
Completed
2868
Diabetic ketoacidosis management in the BRI
Completed
2886
Management of hypoglycaemic events in in-patients at the Bristol Royal Infirmary
Completed
3007
The management of Multiple Endocrine Neoplasia
Completed
3049
Audit of pre-conception care received by women with Type 1 or Type 2 diabetes attending St Michael’s Diabetes
Clinic 2011
Completed
Medical Specialties/Gastroenterology & Hepatology
3087
An audit of oral anticoagulation in patients receiving total parenteral nutrition for short bowel syndrome
Completed
Medical Specialties/General Medicine
3038
Audit of completion of learning disabilities risk assessment
In Progress
3259
Re-audit of Prescribing in Medicine
Completed
3355
Audit of DVT Diagnosis through the Thrombosis Clinic
In Progress
2741
Audit of Outpatient DVT Management
Completed
2770
Audit of the Management of pregnant outpatients with suspected DVT
Completed
Medical Specialties/Respiratory
2869
Non-invasive ventilation in the management of motor neurone disease - end of life considerations
Completed
3033
Management of neck lymph node tuberculosis
Completed
3176
Adult Community Acquired Pneumonia Audit
Completed
3291
Blood glucose monitoring in Cystic Fibrosis patients during first 48 hours of admission to cystic fibrosis unit
In Progress
Medical Specialties/Rheumatology
3237
A re-audit of the Rheumatoid Arthritis Care Pathway at the Bristol Royal Infirmary
In Progress
3257
Use of anti-TNF in Psoriatic Arthritis [NICE TA 199/220]
Completed
Clinical Audit Annual Report 2012/13
Page 16
Summary of benefits, actions or changes achieved in 2012/13 as a result of completed projects
3053 A sedation checklist has been developed and the current observation chart has been revised to
include/clarify oxygen monitoring requirements.
3129 A joint sepsis protocol has been developed in agreement with Medical Assessment Unit and a process for
the rapid assessment/triage has been implemented. Education sessions highlighting the need to take
cultures, lactate and early antibiotics have been introduced.
2858 An investigations template has been introduced on the post-take ward round page/medical of the medical
proforma.
3259 This audit demonstrated improvement in prescribing practice but further work needs to be done. The
advice and guidance given at the F1 doctors ‘scared to prepared’ session as part of the trust induction has
been revised.
3034 The oxygen prescription section of the drug chart is to be redesigned (in red) so that it looks more
prominent and is less likely to be overlooked. Oxygen ‘alert’ cards are now available on respiratory wards.
3120 The Trust drug chart to be amended to include a separate insulin section to improve prescribing practice.
3075 Education has been provided to departmental staff to improve the completion on consent forms.
3093 A revised clinic management protocol is being developed.
3128 This audit has led to a number of important improvements in how we prescribe new biologic treatments for
local patients with psoriasis. These have included introducing a new dedicated clinic, updated local patient
leaflets on biological therapy for psoriasis and improving our documentation.
3204 A process for x-rays to be report automatically rather than waiting for separate requests has been
introduced. The specialist nurse can now sign off normal bloods and bring abnormal / borderline results to
the consultant’s attention.
3264 This re-audit demonstrated an increase in the number of patients having pigmented lesions assessed with a
Dermascope (as is best practice).
3265 A prompt box has been added to the sticker that is put in the notes at time of excision improve the
recording of information and to ensure that excision margins are recorded for every procedure. A process
to ensure that GPs are faxed with information on patient’s diagnoses has been introduced; a form will be
inserted into notes at time of MDT to act as a prompt for faxing GP when telling patients their diagnosis.
3303 This audit demonstrated good practice in the quality (quality of images/history taking) of the
Teledermatology service. Work is to be done around the education and feedback to GPs to improve the
service further.
3329 The electronic form has been modified to improve completion of ‘possible diagnosis’ and definition of
‘other’ when ticked on procedure section. Guidelines for use have been issued to the department so that
all requesting clinicians are aware of the importance of completing the forms fully.
2497 An additional alert has been added to the ICE system regarding hypercalcaemic results. A local
departmental approach to investigating all patients with primary hyperparathyroidism (ideally to include
urinary calcium to creatinine estimation and imaging of the renal tract) is to be agreed.
2868 A Diabetic ketoacidosis (DKA) integrated care pathway will be designed and introduced to increase
engagement at all stages of care. A separate intravenous insulin prescription chart will also be designed to
increase safe prescribing and reduce the number of insulin errors and a Trust wide user friendly blood
glucose monitoring chart will be used. A business case for the expansion of a further Diabetes Inpatient
Specialist Nurse has been made.
2886 A 'Hypoglycaemia' Guideline (Treatment of hypoglycaemia in adults with Diabetes Mellitus Guideline
Capillary Blood Glucose < 4 mmol/l) has been introduced. A Trust wide hypoglycaemia awareness week
was held and ‘Hypoboxes’ have been introduced across the Trust.
3007 An agreed guideline for use in the endocrine clinic when reviewing patients with Multiple Endocrine
Neoplasia (MEN) has been introduced
3049 A standard footnote highlighting the importance of planning pregnancy/need for pre-conception care
advice to female BRI diabetes clinic patients of childbearing age has been introduced. The annual review
proforma on Medway has been redesigned to highlight need for discussion of pre-conception care at
hospital diabetes annual review appointment.
2741 A new Deep Vein Thrombosis (DVT) care pathway has been introduced and staff within the DVT clinic
trained in its correct use.
Clinical Audit Annual Report 2012/13
Page 17
2770 The care pathway has been updated to specify that obstetricians will not need to be contacted routinely for
patients with negative duplex scan results unless further advice is required.
3183 This re-audit of the management of sepsis showed improvements in practice compared to the previous
audit. A sepsis guideline/pathway is in the process of being introduced and further audit work is planned.
3258 This audit has led to the creation of an anticoagulation risk assessment proforma for documentation of
clinical decision-making and patient communication.
2869 An improved pathway for patients with motor neuron disease at end of life has been introduced
3033 A referral pathway for patients with suspected lymph node tuberculosis has been developed.
3283 Physicians and nursing staff will now perform relevant tests whenever patient with cystic fibrosis related
diabetes has a hospital appointment, rather than just at annual review.
3257 Specialist nursing staff support is to be increased to ensure timely follow up to assess response. The antiTNF referral form has been amended to incorporate previous Disease-modifying Anti-rheumatic Drug
(DMARD) usage, including duration and dosage.
3407 A new GP referral sheet will be implemented. This will include fuller details of relevant patient history,
including most recent ‘none’ density, clinical risk factors and prior treatments. The current GP letter
following denosumab initiation will be amended to include further advice where GPs have clinical queries.
Clinical Audit Annual Report 2012/13
Page 18
2.4
SPECIALISED SERVICES
Planned projects in progress or complete at end of financial year
This year
55% (12/22)
Previous year
52% (11/21)
The following table shows the status at year end of those projects in progress or completed during the financial
year that were identified as priorities within the forward plan for 2012/13.
Title
Sub-Specialty
Proposed lead
Priority category
Status
Adult Cardiac Surgery (ACS)
Cardiac Surgery
Alan Bryan (Cons)
P1 - National audit (NCAPOP)
In progress ID549
Trans-apical TAVI (transcatheter aortic
valve implantation)
Cardiac Surgery
Mark Yeatman (Cons)
P2 - Clinical Effectiveness Group
priority Introduction of a new
interventional procedure
Not initiated
Thoracoscopic internal mammary artery
harvesting
Cardiac Surgery
George Asimakopoulos
(Cons)
P2 - Clinical Effectiveness Group
priority Introduction of a new
interventional procedure
Not initiated
Assessment of renal/respiratory function
after Minimally Invasive Direct Coronary
Artery Bypass (MIDCAB)
Cardiac Surgery
George Asimakopoulos
(Cons)
P3 - Audit of outcomes following
surgery
Not initiated
Assessment of renal & respiratory
function after minimally invasive Mitral
Valve repair (MVR)
Cardiac Surgery
George Asimakopoulos
(Cons)
P3 - Audit of outcomes following
surgery
Not initiated
Acute Coronary Syndrome/Acute
Myocardial Infarction (MINAP)
Cardiology
Julian Strange (Cons)
P1 - National Audit (NCAPOP)
In progress ID223
National Cardiac Arrhythmia Audit (HRM)
Cardiology
Glynn Thomas (Cons)
P1 - National Audit (NCAPOP)
In progress ID1578
National Heart Failure Audit (HF)
Cardiology
Angus Nightingale (Cons)
P1 - National Audit (NCAPOP)
In progress ID366
Adult Coronary Angioplasty
Cardiology
Andreas Baumbach
(Cons)
P1 - National Audit (NCAPOP)
In progress ID809
NICE TA95 Arrhythmia - implantable
cardioverter defibrillators
Cardiology
Tim Cripps (Cons)
P1 - BNSSG NICE Commissioning
College priority
In progress ID3262
Renal sympathetic denervation
Cardiology
Andreas Baumbach
(Cons)
P2 - Clinical Effectiveness Group
priority Introduction of a new
interventional procedure
Not initiated
Percutaneous mitral valve leaflet repair
for mitral regurgitation
Cardiology
Mark Turner (Cons)
P2 - Clinical Effectiveness Group
priority Introduction of a new
interventional procedure
Not initiated
NICE TA193 Leukaemia (chronic
lymphocytic, relapsed) - rituximab
Haematology
Jenny Bird (Cons)
P1 - BNSSG NICE Commissioning
College priority
Not initiated
National Lung Cancer Audit (NLCA)
Oncology
Adam Dangoor (Cons)
P1 - National Audit (NCAPOP)
In progress –
ID554
NICE TA192 Lung cancer (non-smallcell, first line) - gefitinib
Oncology
Adam Dangoor (Cons)
P1 - BNSSG NICE Commissioning
College priority
Not initiated
Adhereance to stereotactic protocol
Oncology
Alison Cameron (Cons)
P2 - Identified through incident
reporting
Completed –
ID3286
NICE TA145 Cetuximab in locally
advanced squamous cell cancer – head
& neck
Oncology
Hoda Booz (Cons)
P3 - Re-audit ID 2706
Completed –
ID3169
Post orchidectomy referrals
Oncology
Axel Walther (Cons)
P3 - Local concern/safety issue
Not initiated
Compliance with radiotherapy weekly
check protocol/work instruction
Oncology
Petra Jacobs
(Radiographer)
P3 - Local concern/safety issue
In progress ID3285
Completeness of Chemotherapy Charts
– re-audit
Oncology
Jeremy Braybrooke
(Cons)
P3 - Re-audit of new
documentation
In progress –
ID3351
Cardiac Services
Oncology & Haematology
Clinical Audit Annual Report 2012/13
Page 19
Prognostic documentation for last 12
months of life
Palliative
Medicine
Colette Reid (Cons)
P2 - Department of Health End of
Life Strategy
Completed –
ID3193
Re-audit of anticipatory prescribing
Palliative
Medicine
Rachel McCoubrie (Cons)
P2 - Local concern
Not initiated
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
2905
Audit of Infective complications following major aortic cases
In Progress
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
In Progress
3307
The effect of arterial cannulation strategy (axillary vs. femoral vs. ascending aortic) on outcomes following aortic
surgery
In Progress
207
Central Cardiac Audit Database/British Heart Foundation Cardiac Rehabilitation Database
Ongoing
Cardiac Services/Cardiology
2412
Arrhythmia Nurse Service
Ongoing
2433
Are patients with STEMi/NSTEMI or ACS+ve Troponin appropriately Managed
In Progress
2719
Audit of Left Ventricular Thrombin Management
Completed
2721
Audit of mitral valve assessment by Transoesophageal Echocardiogram (TOE)
In Progress
2881
Audit of PFO Closure in Divers (incorporating elements of NICE IPG371)
In Progress
2910
Audit of Echocardiographic follow-up after Aortic Valve Replacement (AVR)
In Progress
2922
Audit of the chronic heart failure NICE guidelines in UHBristol (NICE CG108).
In Progress
2933
Management of Pregnant Patients with Aortopathy
In Progress
2955
Is the Bristol adult shared care pulmonary hypertensive service meeting the national guidelines for treatment?
In Progress
2960
Should we still be Screening Patients with Coarctation of the Aorta for Intracranial Aneurysms? A Re-Audit.
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
Cardiac Services/Homeopathy
925
The use of a patient generated outcome measure to monitor outcome and completion of package of care and
facilitate goal setting in routine practice
In progress
1625
Homeopathy in Management of Childhood Eczema
In progress
Oncology & Clinical Haematology/Clinical Haematology
3060
Lenalidomide for the treatment of multiple myeloma in people who have received at least one prior therapy (NICE
TA171)
Completed
Oncology & Clinical Haematology/Oncology
2634
The use of GCSF (Neulasta) to prevent neutropenic sepsis post TAC chemotherapy in breast cancer patients (NICE
TA109)
Completed
3057
Trastuzumab in advanced breast cancer - NICE TA34/CG81
In Progress
3119
Use of sunitinib in advanced/metastatic renal cell carcinoma - re-audit of NICE TA169)
In Progress
2914
Erlotinib for the treatment of non-small-cell lung cancer - NICETA162
Completed
2998
Medical Documentation
Completed
2999
Keyworkers for Teenagers and Young Adults with cancer
In Progress
3101
Rituximab for aggressive non-Hodgkin’s Lymphoma - NICE TA65
Completed
3297
Adjuvant use of Docetaxel in Breast cancer - NICE TA109/CG80
In Progress
3322
Intravenous contrast during radiotherapy planning
In Progress
Clinical Audit Annual Report 2012/13
Page 20
3352
GCSF (Neulasta) and treatment of febrile neutropenia (FN) post TAC chemotherapy in breast cancer patients (reaudit)
In Progress
3378
Management of Metastatic Spinal Cord Compression - re-audit NICE CG75/92/29
In Progress
3389
Neutropenia Sepsis - re-audit
In Progress
Oncology & Clinical Haematology/Palliative Medicine
2993
Care after death for adults across UH Bristol
Completed
3416
Audit of ‘Do not attempt resuscitation’ documentation (part of a BNSSG-wide audit)
In Progress
3399
Audit of end of life discussions in patients with Chronic Obstructive Pulmonary Disease (COPD)
In Progress
Summary of benefits, actions or changes achieved in 2012/13 as a result of completed projects
2719
2634
3060
3101
3169
3286
2993
This audit demonstrated good practice in the management of left ventricular thrombin management.
This audit demonstrated good practice in the use of GCSF (Neulasta) to prevent neutropenic sepsis in post
TAC (taxotere, adriamycin and cyclophosphamide) chemotherapy in breast cancer patients (in line with
NICE guidance).
This audit demonstrated that patients being provided with Lenalidomide for the treatment of multiple
myeloma in people who have received at least one prior therapy (NICE TA171) are being treated
appropriately.
A future treatment route for patients with stage I disease will be agreed dependant on the view of the
local commissioners. This will be achieved by either amending current network protocol and agreeing
with PCT or agreeing that these patients will be treated though another route (Cancer Drugs Fund or
Emergency Funding).
The radiographer responsible for booking treatment slots will record the requirement for bloods in the
nurses tab on MOSAIQ. The indication for cetuximab will now be recorded at the patient’s first clinic visit
or if a change of treatment to cetuximab is required. Nursing staff on the treatment floor will now record
which bloods are required for each tumour site.
A proforma for recording key information e.g. WHO status, hearing grade, lesion size will be implemented.
A Dedicated Acoustic Neuroma Database will be deigned and used to record future data on these patients.
New property bags for deceased patients’ possessions will be sourced via the Privacy and Dignity Group.
The policy, guidelines and checklist relating to ‘care after death’ is in the process of being updated and
agreed in light of audit findings and to ensure that it in line with recent national guidance.
Clinical Audit Annual Report 2012/13
Page 21
2.5
SURGERY AND HEAD AND NECK
Planned projects in progress or complete at end of financial year
This year
62% (42/68)
Previous year
46% (19/41)
The following table shows the status at year end of those projects in progress or completed during the financial
year that were identified as priorities within the forward plan for 2012/13.
Title
Sub-Specialty
Proposed lead
Priority category
Pain assessment
Acute Pain
Team
Nilesh Chauhan (Cons)
P3 - Department priority
Completed ID3144
National Pain Audit
Anaesthesia
Peter Brook (Cons)
P1 - National Audit (NCAPOP)
In progress
Placement of nasogastric tubes
Anaesthesia
Nicola Harvey (Cons)
P2 - Patient Safety Issue/NPSA
Not initiated
NCEPOD recommendations
Anaesthesia
Ben Howes (Cons)
P2 - National Confidential Enquires
In progress ID3353
Thoracic workload out-of-hours
Anaesthesia
Matt Molyneux (Cons)
P3 - Local concern
Not initiated
The use of sugammadex
Anaesthesia
Matt Molyneux (Cons)
P3 - Ongoing audit (third cycle)
In progress ID2631
Post-operative anaesthetic care in high
risk fracture neck of femur patients
Anaesthesia
Claudia Paoloni (Cons)
P3 - Local concern/high risk group
Not initiated
Gynecology post op pain audit
Anaesthesia
Rebecca Aspinall (Cons) P3 - Local concern
Not initiated
Lower limb revascularisation
Anaesthesia
Nilesh Chauhan (Cons)
P3 - Local concern
Not initiated
Adult Critical Care (ICNARC)
Critical Care
Tim Gould (Cons)
P1 - National Audit (Quality Account)
In progress ID160
Streamlining the resuscitation bag on
adult intensive care
Critical Care
Richard Eve (Cons)
P3 - Local concern/High risk area
Abandoned ID2813
Compliance with the ventilator care
bundle on the intensive care unit
Critical Care
Richard Eve (Cons)
P3 - Local concern/High risk area
Not initiated
High risk surgical patient management admissions following elective upper GI
surgery
Critical Care
Dan Freshwater-Turner
(Cons)
P3 - Royal College of Surgeons guidance Not initiated
Extubation on the intensive care unit
Critical Care
Dan Freshwater-Turner
(Cons)
P3 - Local concern
In progress
An audit of whipple patients admitted to
the intensive care unit
Critical Care
Dan Freshwater-Turner
(Cons)
P3 - Higher Risk Surgical Patient
guidance
In progress
intensive care unit discharge summaries
Critical Care
James Walters (Cons)
P3 - Documentation issue
Not initiated
Pre-operative assessment for patients
with Dementia
Pre-Operative
Assessment
Clare Evans (Cons
Nurse)
P2 - South West Dementia Standards
Not initiated
Use of the ‘This is me’ booklet for
patients with dementia
Pre-Operative
Assessment
Clare Evans (Cons
Nurse)
P2 - South West Dementia Standards
Not initiated
National Head & Neck Cancer (DAHNO)
Dental and
Maxillofacial
Surgery
Ceri Hughes (Cons)
P1 - National audit (NCAPOP)
In progress ID2414
Inadequacy rates for Fine Needle
Aspirations (FNAs)
Dental and
Maxillofacial
Surgery
Jane Luker (Cons)
P3 - Re-audit specified in 2011/12
action plan
Not initiated
Extraction of third molars – indications
and nerve injury rates
Oral Surgery
Carla Fleming (Specialty
Dentist)/Tamara
Khayatt (Specialty
Dentist)
P3 - To assess compliance with NICE
Guidance TA1 and determine rate of
most significant post-operative
complication.
Completed ID3154
Failure rate of multi-stranded bonded
retainers
Orthodontics
Jason Matharu (SpR)
P4 - To determine whether
improvements have been made since
previous audit cycles
Completed ID3185
Anaesthesia/Critical Care Services
Dental Services
Clinical Audit Annual Report 2012/13
Page 22
Pre-formed metal crown failure rates
Primary Care
Dental Service
Katherine Walls (Senior
Dental Officer)
P4 - To assess 6 and 12 month failure
rates against evidence from the
literature
Not initiated
Use of fluoride
Paediatric
Dentistry
Lucy Williams (FTTA)
P3 - Department of Health guidance on
oral health
In progress ID3357
Dental implants: outcomes
Restorative
Dentistry
Paul Wilson (Cons)/Paul P4 - To determine success and failure
King (Cons)/Dominic
rates and assess impact of a new data
O’Sullivan (Cons)
sheet
In progress ID3224
Adult ENT
Claire Langton-Hewer
(Cons)
P3 - Re-audit ID 3022
Not initiated
Boston Type 1 Keratoprosthesis
Cornea &
Cataract
Derek Tole (Cons)
P2 - Clinical Effectiveness Group
priority Introduction of a new
interventional procedure
In progress ID3388
Phototherapeutic laser keratectomy
Cornea &
Cataract
Phil Jaycock (Cons)
P2 - Clinical Effectiveness Group
priority Introduction of a new
interventional procedure
Not initiated
Cataract outcomes
Cornea &
Cataract
Derek Tole (Cons)
P3 - Annual audit (4000 - 5000 cases
per annum) contributing to National
Ophthalmic Dataset,
Completed ID3195
Corneal endothelial keratoplasty
Cornea &
Cataract
Derek Tole (Cons)
Stuart Cook (Cons)
P3 - NICE Guidance IPG 304
In progress ID3181
Microbial keratitis
Cornea &
Cataract
Derek Tole (Cons)
Stuart Cook (Cons)
P3 - Drug sensitivities and treatment
response.
Not initiated
Glaucoma follow-ups and NICE Quality
Standard
Glaucoma &
Shared Care
Paul Spry (Cons)
John Sparrow (Cons)
P3 - NICE Guidance CG85. Monitoring
of follow-up delays in major area of
outpatient activity.
Completed ID2806
Optic nerve sheath fenestration via
supero-medial eyelid skin crease
approach
Medical &
Surgical Retina
Sachin Salvi (Cons)
P2 - Clinical Effectiveness Group
priority Introduction of a new
interventional procedure
Not initiated
Lucentis outcomes
Medical &
Surgical Retina
Clare Bailey (Cons)
P3 - NICE Guidance TA155. Large area
of service provision.
Completed ID3324
Diabetic Retinopathy screening and
management
Medical &
Surgical Retina
Abosede Cole (Cons)
P3 - National Screening Committee
guidelines. High volume service.
Completed ID3159
Endophthalmitis rate
Medical &
Surgical Retina
Richard Haynes (Cons)
P3 - Major surgical complication and
patient safety issue for cataract
surgery,
Completed ID3234
Retinal detachment surgery outcomes
Medical &
Surgical Retina
Richard Haynes (Cons)
Andrew Dick (Cons)
P3 - Assess improvement since previous
audit cycles. Change in surgical
Not initiated
technique requiring monitoring.
Immuno-suppression clinics (Uveitis and
Corneal external eye disease)
Medical &
Surgical Retina
/ Cornea &
Cataract
Catherine Guly (Cons)
Derek Tole (Cons)
P3 - Local protocol for monitoring of
patients on immuno-suppressants.
Important patient safety issue.
Completed ID3162
Retinopathy of prematurity screening
Paediatrics,
Oculoplastics &
Squint
Cathy Williams (Cons)
P3 - Royal College guidelines. Assess
improvement since previous audit
cycles.
In progress ID3210
Upper Eyelid Gold/Platinum Weight
Paediatrics,
Oculoplastics &
Squint
Helen Herbert (Cons)
P2 - Clinical Effectiveness Group
priority Introduction of a new
interventional procedure
Not initiated
Ptosis surgery outcomes
Paediatrics,
Oculoplastics &
Squint
Helen Garrott (Cons)
P3 - Using British Oculoplastic Surgery
Society national survey benchmarks
In progress ID3166
National Patient Safety Alert audit
Division Wide
Kate Thompson
(Patient Safety Mgr.)
P2 - Patient Safety issue
Not initiated
Poly Implant Prothèse (PIP) implant
referrals
Breast Surgery
Zen Rayter (Cons)
Rachel Forsythe (SHO)
P2 - Patient Safety issue
In progress ID3189
Ear, Nose & Throat (ENT)
Re-audit of functional endoscopic sinus
surgery (FESS)
Ophthalmology
Adult Surgical Specialties
Clinical Audit Annual Report 2012/13
Page 23
GP notification of a new cancer diagnosis Breast Surgery
Angie Nicholson (Breast
P2 - Cancer Peer Review
Care Nurse)
Completed ID3123
Multicentre audit of outcomes following
appendicectomy
General Surgery Alex Boddy (SpR)
P3 - National audit (other)
Completed ID3279
National Bowel Cancer Audit (NBOCAP)
Lower GI
Surgery
Rob Longman (Cons)
P1 - National audit (NCAPOP)
In progress ID2482
Abdomino-perineal surgery outcomes
for rectal and anal cancer (UHBFT and
ASWCS)
Lower GI
Surgery
Rob Longman (Cons)
P3 - Regional Audit
Completed ID3056
Audit of extended VTE prophylaxis in
colorectal cancer patients
Lower GI
Surgery
Rob Longman (Cons)
P2 - Re-audit ID 3140
Completed ID3414
Surgical site infections in emergency
laparotomies
Lower GI
Surgery
Rob Longman (Cons)
P2 - Re-audit ID 3084
In progress ID3084
Time-to-transfer and time-to-surgery for
urgent referrals for thoracic surgery
Thoracic
Surgery
Doug West (Cons)
P1 - CQIN
Not initiated
Society for Cardiothoracic Surgery
national thoracic audit (the “thoracic
returns”).
Thoracic
Surgery
Tim Batchelor (Cons)
P3 - National Audit (other)
In progress ID553
Audit patient satisfaction after surgery
for chest wall deformity (pectus
excavatum or carinatum)
Thoracic
Surgery
Doug West (Cons)
P3 - Local concern
Not initiated
Effectiveness of routine lung cancer
follow-up
Thoracic
Surgery
Doug West (Cons)
P3 - Planned work on streamlining outpatient follow up clinics.
In progress ID2384
Video Assisted (VATS) Lobectomy
Thoracic
Surgery
Gianluca Casali (Cons)
P2 - Clinical Effectiveness Group
priority - introduction of a new
interventional procedure
Not initiated
Transcervical thymectomy
Thoracic
Surgery
Tim Batchelor (Cons)
P2 - Clinical Effectiveness Group
priority - Introduction of a new
interventional procedure
Not initiated
National Joint Registry (NJR)
Trauma &
Orthopaedics
Adrian Weale (Cons)
P1 - National audit (NCAPOP)
In progress ID2568
Trauma (TARN)
Trauma &
Orthopaedics
James Livingstone
(Cons)
P1 - National Audit (Quality Accounts)
In progress
Post-operative orthopaedic notes
Trauma &
Orthopaedics
James Livingstone
(Cons)
P3 - Re-audit following change in
practice
Not initiated
Head injury management
Trauma &
Orthopaedics
Steve Mitchell (Cons)
P3 - NICE Guidance CG56
In progress ID3223
VTE Risk Assessment
Trauma &
Orthopaedics
Steve Mitchell (Cons)
Mark Jones (SHO)
P3 - NICE Guidance
In progress
National Oesophago-Gastric Cancer
Audit (NAOGC)
Upper GI
Surgery
Paul Barham (Cons)
P1 - National audit (NCAPOP)
In progress ID2484
HALO therapy for the treatment of
Dysplastic Barrett’s Oesophagus
Upper GI
Surgery
Dan Titcomb (Cons)
P2 - Clinical Effectiveness Group
priority - Introduction of a new
interventional procedure
Not initiated
Percutaneous tibial nerve stimulation
(PTNS) for faecal incontinence
Upper GI
Physiology
Katherine Mabey
(Physiologist)
P2 - Clinical Effectiveness Group
priority - Introduction of a new
interventional procedure
Not initiated
VSGBI Vascular Surgery Database
Vascular
Surgery
Peter Lamont (Cons)
P1 - National audit (Quality Accounts)
In progress
Carotid interventionsaudit (CIA)
Vascular
Surgery
Peter Lamont (Cons)
P1 - National Audit (NCAPOP)
In progress ID2485
Audit of follow up following
endovascular AAA repair (EVAR)
Vascular
Surgery
Marcus Brooks (Cons)
P3 - Re-audit ID 2526. BNSSG NICE
Commissioning College priority
In progress ID3282
Audit of recording of MDT results and
anaesthetic pre-operative assessment in
medical notes
Vascular
Surgery
Marcus Brooks (Cons)
P3 - Local concern
Completed ID3281
Audit of community AAA screening
clinics
Vascular
Surgery
Marcus Brooks (Cons)
P3 - Local concern
In progress ID3282
Clinical Audit Annual Report 2012/13
Page 24
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)
3078
Re-audit of clinical management in the SHO-run ENT Urgent Clinic
Completed
3079
ENT urgent clinic letters
In Progress
3080
Accuracy of MRI scans in the detection of primary and recurrent cholesteatoma
In Progress
3125
Coding by Theatre staff
In Progress
3270
Tympanomastoid surgery
In Progress
3278
Current practice in septoplasty
In Progress
Anaesthesia
2903
Hyperglycaemia in diabetic patients receiving carbohydrate drinks prior to elective surgery
Completed
2959
Fasting times in trauma surgery
In Progress
3035
Audit of Anaesthetic Chart Documentation
Completed
3175
Audit of record keeping standards during epidural injections for the management of spinal origin in adults
Completed
1704
Audit of accidental dural puncture (ADP)
Ongoing
2884
Drug Syringe labels in Heygroves Theatres and Queen’s Day Unit
Completed
2906
Obesity in Obstetric Anaesthesia (re-audit of 1966)
In Progress
Critical Care Services
537
Potential Donor Audit
Ongoing
3219
Critical illness rehabilitation from the intensive care unit
In Progress
3400
Delayed and out of hours discharges from the intensive care unit
In Progress
3365
Stress ulcer prophylaxis on discharge from intensive care unit, appropriate or inappropriate?
In Progress
2637
Management of Out-of-Theatre Intubations
In Progress
Dental Services
3143
Consent for clinical photographs (re-audit of 1763)
In Progress
3153
Odontogenic tumour recurrence, pre-operative radiographic assessment and follow-up
In Progress
3163
Patient satisfaction of Dental general anaesthesia care pathway for Special Care patients
In Progress
3313
Are Cone Beam Computerised Tomography (CBCT) scans using the smallest volume necessary to answer the clinical
question?
In Progress
Dental Services/Oral & Maxillofacial
2835
Post-operative complications of thyroid surgery
Completed
2928
Mandibulectomies in the SouthWest
Completed
3006
Preparation of patients for outpatient intravenous sedation (re-audit of 2658)
Completed
3042
Basal Cell Carcinoma (BCC) excision margins
Completed
3065
Utilisation of reserved emergency slots Bristol Dental Hospital day case general anaesthetic unit
Completed
3146
Quality of proforma referral letters received by Department of Oral Surgery
Completed
3168
Access to dental care for head and neck cancer patients
Completed
3330
Quality of radiographs received with Oral Surgery referrals
In Progress
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)
In Progress
Dental Services/Oral Medicine
2850
How effective are our glycerol blocks in achieving pain control in trigeminal neuralgia?
Clinical Audit Annual Report 2012/13
In Progress
Page 25
3094
Patient satisfaction for patients attending the Primary Care Unit and Oral Medicine department at Bristol Dental
Hospital (re-audit of 1581)
Completed
3317
Histopathological Diagnosis in Oral Medicine (re-audit)
In Progress
Dental Services/Orthodontics
2340
National Audit of Mini Screws / Temporary Anchorage Devices (TADs) - NICE IPG 238
In Progress
3076
Patient pathway for allocation to orthodontic clinics in Bristol Dental Hospital
Completed
3097
Occlusal outcomes following orthognathic surgery
Completed
3157
Management of orthodontic patients with a history of dental trauma to incisor teeth
In Progress
3187
Quality of Study Models at Orthodontic Department (re-audit of 2494)
In Progress
3226
Lost orthodontic appliances (re-audit)
In Progress
3248
New patient referrals to the orthodontic department.
In Progress
Dental Services/Paediatric Dentistry
2891
Quality of referral letters and radiographs undertaken for those receiving a dental general anaesthetic at Bristol
Dental Hospital
Completed
2892
Information provided to patients attending the pre-general anaesthesia assessment clinic
Completed
3155
Quality of record-keeping for paediatric dental trauma patients at Bristol Dental Hospital
In Progress
3331
Extraction of first permanent molars of poor prognosis in children (re-audit of 2545)
In Progress
3386
Users’ views of the paediatric dental clinic (re-audit of 2263)
In Progress
Dental Services / Restorative Dentistry
2773
Endodontic referrals received at Bristol Dental Hospital
In Progress
2827
Quality of molar endo obturation carried out by current Bristol Dental Hospital students
Completed
2890
Patient satisfaction with composite restorations for toothwear
Completed
3082
3147
Quality of life of patients with total prostheses before and after treatment with conventional dentures in Bristol
Dental Hospital
Technical Quality of Special Trays and Edentulous Wax Occlusal Rims and the Accuracy of Laboratory Prescriptions
(re-audit of 2239)
Deferred
Completed
3180
Rate of failure to attend appointments by patients on undergraduate IV sedation teaching clinics.
Completed
3186
Smoking cessation advice in Periodontal and Oral Medicine clinics
Completed
3188
Quality of TMJ patient referrals at Bristol Dental Hospital (re-audit of 531 / 583)
Completed
3341
Prescriptions, special trays and wax rims for complete denture construction (re-audit of 3147)
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
2694
Iritis primary care clinic and nurse-led treatment of anterior uveitis
Completed
2710
Standard of Care Provided to Patients Who Present to the Bristol Eye Hospital with a Clinical Diagnosis of Giant Cell
Arteritis
Completed
2836
Record-keeping for child casualty patients at Bristol Eye Hospital
Completed
3165
Record-keeping for child casualty patients at Bristol Eye Hospital (re-audit of 2836)
In Progress
Ophthalmology / Glaucoma & Shared Care
3011
Blindness in glaucoma patients
In Progress
3302
Glaucoma outpatient follow up appointments at Bristol Eye Hospital – NICE CG85
In Progress
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
Clinical Audit Annual Report 2012/13
Page 26
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 2007/2008
In Progress
2925
Referrals from Paediatric Rheumatology of children diagnosed with Juvenile Idiopathic Arthritis to the Eye Hospital
for uveitis screening
Impact of neuro-ophthalmic disorders on the Bristol Eye Hospital paediatric service
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
Completed
Completed
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 UHBristol guidelines for gentamicin prescribing in adults?
In Progress
Adult Surgical Specialties / Lower GI Surgery
3227
Reversal of ileostomies – have we improved since 2002/3?
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?
In progress
Summary of benefits, actions or changes achieved in 2012/13 as a result of completed projects
3078 It was agreed that patients needing more than two visits can continue to be booked on the SHO-led ENT
urgent clinic but need to be reviewed by a senior no later than their 3rd visit
2903 It was agreed to continue with the pre-op carbohydrate drinks before elective surgery but that patients
with a BM >11 should be started on an insulin sliding scale.
3035 A new anaesthetic chart incorporating all aspects of minimum standards of documentation will be
designed. The content of the chart will be agreed by the anaesthetic department and trial period for use
agreed.
Clinical Audit Annual Report 2012/13
Page 27
3175 A new proforma to record all epidurals and caudal epidurals performed to treat pain of spinal origin will be
implemented
3144 The Bristol Observation Chart has been amended Increase training to nursing/medical staff on use of tools
to assess pain in patients with cognitive impairment (i.e. Abbey pain scale). This is through nurse study days
and ward teaching. Training on use of action reporting for high early warning scores and pain scores
through the General Ward workstream and relevant Matrons.
2835 Demonstrated that complication rates for thyroid surgery compare favourably to national benchmarks.
2928 This audit demonstrated good practice and a flap failure rate for this Trust within the target from the British
Association of Head and Neck Oncologists.
3006 Criteria required for documentation in the notes will be agreed before a patient can be listed for treatment
under sedation.
3042 Demonstrated good practice with regard to documentation and outcomes for excision margins for basal
cell carcinomas of the head and neck.
3065 Systems refined for utilising slots for emergency patients on the day case general anaesthetic lists at Bristol
Dental Hospital.
3146 Indicated improvement in the quality of referral letters received by the Department of Oral Surgery
following changes made to the referral proforma after a previous audit.
3154 It has been agreed with our commissioners that SIGN guidelines rather than NICE guidelines will be
followed.
3168 A specific pre-treatment Dental screening clinic and a dental hygiene clinic have been established for new
Head and Neck cancer patients. Dental treatment sessions have been increased and agreement has been
made for their ongoing dental care to be carried out.
3094 Improved information for patients on what to expect when attending appointments at Primary Care Unit
and Department of Oral Medicine has been developed.
3076 The development of a joint orthodontic / oral surgery clinic is being discussed.
3097 Demonstrated excellent occlusal outcomes for patients undergoing orthognathic surgery.
3185 Improvements to systems of record keeping and to supervision of undergraduates fitting multi-stranded
bonded retainers at the Bristol Dental School have been made.
2891 Led to improvements in the referral proforma for treatment under a general anaesthetic at Bristol Dental
Hospital and provision of related training for undergraduates (i.e. future referrers) and new members of
staff at the hospital.
2827 Highlighted the need for a referral protocol to guide General Dental Practitioners in referring to the Dental
Hospital for endodontic treatment by undergraduates. This is under development.
2890 A patient information leaflet being produced for patients prescribed composite restorations for toothwear.
3147 Demonstrated improvement of written prescriptions to the dental prosthetics laboratory and in the quality
of special trays produced by the laboratory since a previous audit in 2009.
3180 A system of contacting patients a week before their appointments to reduce ‘Did Not Attend (DNA)’ rates is
to be implemented.
3186 A tobacco-use proforma to improve smoking cessation practice has been developed.
3188 Referral information is to be revised and recirculated to local GDPs to advise GDPs of returning referrals if
required information not included.
2893 A central record of endophthalmitis cases on the ward in Bristol Eye Hospital has been established to aid
identification of any future "outbreak". The protocol for managing cases has been clarified and awareness
amongst junior staff raised.
2694 Guidelines for the iritis Primary Care Clinic at Bristol Eye Hospital have been revised to clarify procedures
for nurses and improve awareness of referral criteria amongst doctors.
2710 A formal pathway for patients presenting to Bristol Eye Hospital with Giant Cell Arteritis has been agreed
with rheumatology and a patient information leaflet written.
2836 Demonstrated good practice of record keeping for child casualty patients at BEH
3162 Highlighted a key area for improvement in management of patients on immunosuppressive therapy in the
Corneal Service of Bristol Eye Hospital.
3195 Demonstrated outcomes for cataract surgery comparable to national benchmarks. A risk predictor has
been made available as part of Electronic Patient Record to allow operative risk calculations to be
performed for individual patients, informing decision-making prior to surgery.
2806 The risk stratification to manage lower-risk patients appropriately will be re-evaluated.
Clinical Audit Annual Report 2012/13
Page 28
2829 Guidelines for assessment of Central Retinal Vein Occlusion are to be developed to aid junior doctors at
Bristol Eye Hospital.
3159 Local guidelines for Fundus Fluorescein angiography (FFA) requests will be reviewed and amended.
3160 Led to the increase in clinic capacity for patients referred to the fast track clinic for Age Related Macular
Degeneration at Bristol Eye Hospital.
3234 The use of standard 5% Iodine, as recommended by the Royal College of Ophthalmologists, has been
adopted within the department.
3324 Demonstrated good clinical outcomes for Lucentis treatment at Bristol Eye Hospital compared to published
benchmarks and compliance with NICE guidance (TAG155).
3235 All paediatric referrals are now accepted at point of triage by consultant to consultant clinic to reduce
backlog of patients waiting for ‘orth/optom’ slots.
2838 Demonstrated the positive impact of nurse-led uveitis screening service for children diagnosed with
Juvenile Idiopathic Arthritis referred to the Bristol Eye Hospital and also highlighted opportunities for
further improvement.
2925 Demonstrated compliance with the national Referral to Treatment Time (RTT) standard for children with
neuro-ophthalmic disorders at Bristol Eye Hospital and contributed to business planning for expanded the
neuro-ophthalmology service.
3288 Demonstrated high levels of patient satisfaction with nurse-led Botox® clinics for treatment of
blepharospasm, hemi-facial spasm and entropion at Bristol Eye Hospital. The results also demonstrated
good outcomes for patients and good compliance with clinic protocols.
2908 A programme of training is being implemented to teach new Trauma and Orthopaedic ward staff the
principles of good care for hip fracture patients and dementia. New documents such as the integrated pain
score observation chart and the hip fracture admission proforma have been revised and developed. This
will be an ongoing piece of work.
3414 Demonstrated vast improvement in the management of colorectal patients on the Extended Venous
Thromboembolism Prophylaxis Programme (EVTEP) within the Trust.
3056 Demonstrated that the rates of perineal wound failure (using traditional technique) were less than those of
published rates.
3279 This multi-centre appendicectomy audit demonstrated that the Trust rates of wound infection and intraabdominal abscess were in line with other centres.
2817 An acute pancreatitis protocol with emphasis on the management of biliary pancreatitis is being developed.
This will help ensure that ultrasound will be requested on same day as admission by clerking doctor and
that all patients with biliary pancreatitis have either treatment during the same admission or have a
definitive management plan within two weeks of discharge.
3281 Areas of good practice in relation to Abdominal Aortic Aneurism (AAA) pre op assessment and MDT were
demonstrated as a result of this audit. A new checklist to ensure thorough pre op assessment and an MDT
documentation form are to be introduced to improve things further.
2884 A sustainable method for restocking the agreed drug labels and not ordering unwanted labels will be
implemented.
Clinical Audit Annual Report 2012/13
Page 29
2.6
WOMEN AND CHILDREN'S
Planned projects in progress or complete at end of financial year
This year
75% (73/97)
Previous year
63% (37/59)
The following table shows the status at year end of those projects in progress or completed during the financial
year that were identified as priorities within the forward plan for 2012/13.
Title
Sub-Specialty
Proposed lead
Priority category
Status
Anaesthetic record keeping
Anaesthesia
Gail Lawes (Cons)
P2 – Royal College standards and CQC
Outcome 21
In progress ID3410
Provision of anaesthetic preoperative
information
Anaesthesia
Steve Sale (Cons)
P2 - National Confidential Enquiry
Not initiated
Surgical site marking
Anaesthesia
Theatres
Gail Lawes (Cons)
P2 - World Health Organisation (WHO)
checklist / NPSA recommendations
Completed ID3230
NICE TA 166 Cochlear Implants
Audiology
Liz Midgley
(Audiologist)
P2 - BNSSG NICE Commissioning
College priority
In progress ID3404
Pulmonary valve implantation using NRIP
tissue valve without cardiopulmonary
Cardiac Services Andrew Parry (Cons)
bypass
Clinical Effectiveness Group priority Introduction of a new interventional
procedure
Not initiated
Pulmonary hypertension compliance
with guidelines
Cardiac Services Rob Tulloh (Cons)
Commissioning body: National Public
Health Service (NPHS)
In progress ID3231
Kawasaki disease compliance with
guidelines
Cardiac Services Rob Tulloh (Cons)
Local and National Guidelines
Completed ID3211
Respiratory syncytial virus (RSV)
compliance with guidelines
Cardiac Services Rob Tulloh (Cons)
Joint Committee Vaccination and
Immunisation (JCVI) Guidelines
Abandoned ID3261
Anticoagulation therapy for children in
Paediatric Cardiac Services
Cardiac Services Andy Tometzki (Cons)
National Patient Safety Alert No
18/UHB Warfarin Dosing Guidelines
In progress ID3247
Hybrid procedure for interim
management of hypoplastic left heart
syndrome
Cardiac Services Gareth Morgan (Cons)
Clinical Effectiveness Group priority
Introduction of a new interventional
procedure
Not initiated
Cancellation rates following the
introduction of new theatre list
Cardiac Services Andrew Parry (Cons)
Safe and Sustainable/Local concern
Not initiated
Congenital heart disease (CHD)
Cardiac Surgery
Andrew Parry (Cons)/
Jose Velasquez (Data
Mgr.)
National Audit (NCAPOP)
In progress ID947
National Diabetes Audit (NDA)
Diabetes &
Endocrinology
Christine Burren (Cons)
National Audit (Quality Accounts)
In progress ID1451
NICE TA188 Growth failure in children
Diabetes &
Endocrinology
Christine Burren (Cons)
BNSSG NICE Commissioning College
priority
In progress ID3373
Patient Education Models for children
with diabetes
Diabetes &
Endocrinology
Noeleen Lovell (CNS)/
Christine Burren (Cons)
Re-audit ID 1042. NICE Guidance TA60
Not initiated
NICE TA151 Insulin pumps
Diabetes &
Endocrinology
Carol Motteram (CNS)/
Christine Burren (Cons)
UK wide CSII/cGMS audit
commissioned by Diabetes UK
Not initiated
Vitamin D screening at diagnosis of
diabetes
Diabetes &
Endocrinology
Christine Burren (Cons)
UHB Vitamin D Guideline (new)
In progress ID3182
Accuracy of auxology on the wards
Diabetes &
Endocrinology
Liz Crowne (Cons)
Nicky Nicol (CNS)
STAMP criteria relevance to CQC
/NHSLA compliance
Abandoned ID3196
Safer administration of insulin
Diabetes &
Endocrinology
Christine Burren (Cons)
National Patient Safety Agency Rapid
Response Report 013
Not initiated
Children’s Services
HbA1c, GAD and C peptide in first year of Diabetes &
diagnosis of diabetes
Endocrinology
Julian Shield (Cons)
UHB Guidelines for the management of Completed Diabetes in Children
ID3381
Screening for auto-immune diseases at
diagnosis of diabetes
Diabetes &
Endocrinology
Julian Shield (Cons)
Children’s Nutritional Survey
Dietetics
Alison Dining (Dietitian) National Audit/CQC Outcome 5
In progress
Front sheet information audit
Dietetics
Shelley Easter
(Dietitian)
Not initiated
Clinical Audit Annual Report 2012/13
UHB Guidelines for the management of
Not initiated
Diabetes in Children
British Dietetic Association Standards
Page 30
Enteral feed discharge checklist
Dietetics
David Hopkins
(Dietitian)
Risk management / quality and safety
checking
Not initiated
Growth monitoring in renal disease
Dietetics
Laura Sealy (Dietitian)
P3 - Re-audit/National Guidelines
(BDA/Renal Association)
Completed ID3253
Audit of feed usage on the Special Feed
Unit
Dietetics
David Hopkins
(Dietitian)
P3 - Best practice/Cost efficiency
Not initiated
Timeliness of recipes to the Special Feed
Unit
Dietetics
David Hopkins
(Dietitian)
P3 - Best practice/Cost efficiency
Not initiated
Asthma Deaths (NRAD)
Emergency
Department
Nick Sargent (Cons)/
Deb Marriage (CNS)
P1 - National Audit (Quality Accounts)
In progress
Audit of the electronic discharge system
and GP satisfaction survey
General
Paediatrics
Reg Bragonier (Cons)
P3 - New system requiring evaluation.
Recommendation from previous audit
Completed ID3044
Management of croup
General
Paediatrics
Anna Thursby Pelham
(Cons)
P3 - UHB Guideline New guideline
In progress ID3203
Intravenous fluid prescriptions
General
Paediatrics
Alison Kelly (Cons)
P3 - UHB New Guideline
Not initiated
Urinary Tract Infection: MC&S requesting General
and reporting
Paediatrics
Alison Kelly (Cons)
P3 - NICE Guidance CG54
Not initiated
Appropriateness of antibiotic prescribing
Immunology
Jolanta Bernatoniene
(Cons)
P3 - Medicines Management Antibiotic
Not initiated
Guidelines
Paediatric Intensive Care (PICANet)
Intensive Care
Peter Davis (Cons)
P1 - National Audit (NCAPOP)
In progress ID2583
Blood product transfusion practices
Paediatric
Intensive Care
Peter Davis (Cons)
P3 - Guidelines for blood product and
fluid administration – rationalising
blood product usage
In progress ID3394
Regional diabetic ketoacidosis (DKA)
admissions to PICU
Paediatric
Intensive Care
Peter Davis (Cons)
Reg Bragonier (Cons)
P3 - Re-audit ID 2102. South West DKA
Pathway
Completed ID3249
Patient retrieval audit
Paediatric
Intensive Care
P3 - Audit of retrieval process to
Helene Craddock (Nur)/
include parent satisfaction (National
Michaela Dixon (Nur)
Audit PICANET)
Retrieval advice calls
Paediatric
Intensive Care
Will Marriage (Cons)
P3 - Audit of outcome of advice calls to
Not initiated
the Paediatric Intensive Care Unit
Peritoneal dialysis following paediatric
cardiac surgery
Paediatric
Intensive Care
Will Marriage (Cons)/
Lucy Fitzgerald (F2)
P3 - Audit of local guidelines
In progress ID3207
Neonatal intensive and special care
(NNAP)
Neonatal Care
David Grant (Cons)
P1 - National Audit (NCAPOP)
In progress ID1902
Renal Registry (UKRR)
Nephrology
Carol Inward (Cons)
P1 - National Audit (NCAPOP)
In progress
Not initiated
Not initiated
Re-audit of renal transplantation
Nephrology
Jan Dudley (Cons)
P3 - National standards from British
Transplant society and renal National
Service Framework
Management of patients on dialysis with
focus on growth
Nephrology
Carol Inward (Cons)
P3 - Renal association standards and
renal National Service Framework
In progress ID3382
Epilepsy 12 (Childhood Epilepsy)
Neurology
Phil Jardine (Cons)
P1 - National Audit (NCAPOP)
Completed ID3110
Appropriateness of EEG request
Neurology
Phil Jardine (Cons)
P3 - Recommendation from national
epilepsy audit
Not initiated
Vermont-Oxford Benchmarking Project
Neonatal
Intensive Care
David Harding (Cons)
P2 - National/International quality
improvement project
In progress ID1142
Admission to Neonatal Unit
Neonatal
Intensive Care
Anoo Jain (Cons)
P2 - CNST Maternity Standard 3.5.3
Completed ID3332
Postnatal care
Neonatal
Intensive Care
Janet Pollard (Patient
Safety Manager)/
Anoo Jain (Cons)
P2 - CNST Maternity Standard 3.5.9
Completed ID3024
Immediate care of the newborn
Neonatal
Intensive Care
Anoo Jain (Cons)
Lisa Damsell (Matron)
P2 - CNST Maternity Standard 3.5.4
Not initiated
Examination of the newborn
Neonatal
Intensive Care
Anoo Jain (Cons)/
Lisa Damsell (Matron)
P2 - CNST Maternity Standard 3.5.6
Completed ID3017
Support for parents
Neonatal
Intensive Care
Anoo Jain (Cons)
P2 - CNST Maternity Standard 3.5.8
Completed ID3339
Clinical Audit Annual Report 2012/13
Page 31
Paediatric asthma
Respiratory
Deb Marriage (CNS)/
Huw Thomas (Cons)
P1 - National Audit (Quality Accounts)
In progress ID3109
Paediatric pneumonia
Respiratory
John Henderson (Cons) P1 - National Audit (Quality Accounts)
Not initiated
Cystic fibrosis management
Respiratory
Simon Langton Hewer
(Cons)/Kathy Wedlock
(CNS)
P3 – UH Bristol Cystic Fibrosis
Guidelines
Not initiated
Asthma management
Respiratory
Deb Marriage (CNS)/
Tom Hilliard (Cons)
P3 - NICE Guidance TA10/TA38/TA131
Completed ID3213
Management and outcome of isolated
preputial reconstruction in distal
hypospadias
Surgery
Mark Woodward (Cons)
P3 - Comparison of national outcomes/
local parent feedback
In progress ID3150
Consent audit
Surgery
Janet McNally (Cons)
P2 - NCEPOD self-assessment
recommendations/local policy
In progress ID3358
Antibiotic prescribing for children
following Appendicectomy
Surgery
Janet McNally (Cons)/
Jon Wells (SpR)
P3 - New hospital guideline
In progress ID3201
Genetic antenatal care pathway for
haemoglobinopathies
Clinical Genetics
Sarah Buston (Genetic
Counsellor)
P2 - Assess effectiveness of new
pathway
Completed ID3164
Heavy menstrual bleeding (HMB)
Gynaecology
Pip Mills (Cons)
P1 - National Audit (NCAPOP)
In progress ID2661
Maternity records
Obstetrics &
Midwifery
Janet Pollard (Patient
Safety Manager)
P2 - CNST Maternity Standard 3.1.7
In progress ID2930
Care of women in Labour
Obstetrics &
Midwifery
Emma Treloar (Cons)/
Belinda Cox (Midwife)
P2 - CNST Maternity Standard 3.2.1
In progress ID2844
Intermittent auscultation
Obstetrics &
Midwifery
Emma Treloar (Cons)/
Belinda Cox (Midwife)
P2 - CNST Maternity Standard 3.2.2
In progress ID2845
Continuous electronic fetal monitoring
Obstetrics &
Midwifery
Emma Treloar (Cons)/
Belinda Cox (Midwife)
P2 - CNST Maternity Standard 3.2.3
In progress ID2846
Fetal blood sampling
Obstetrics &
Midwifery
Emma Treloar (Cons)/
Belinda Cox (Midwife)
P2 - CNST Maternity Standard 3.2.4
In progress ID2847
Use of Oxytocin
Obstetrics &
Midwifery
Emma Treloar (Cons)/
Belinda Cox (Midwife)
P2 - CNST Maternity Standard 3.2.5
In progress ID2849
Caesarean section
Obstetrics &
Midwifery
Emma Treloar (Cons)/
Belinda Cox (Midwife)
P2 - CNST Maternity Standard 3.2.6
In progress ID2391
Induction of labour
Obstetrics &
Midwifery
Emma Treloar (Cons)/
Belinda Cox (Midwife)
P2 - CNST Maternity Standard 3.2.7
In progress ID3260
Severely ill women
Obstetrics &
Midwifery
Emma Treloar (Cons)/
Belinda Cox (Midwife)
P2 - CNST Maternity Standard 3.2.8
In progress ID2730
High Dependency care
Obstetrics &
Midwifery
Emma Treloar (Cons)/
Belinda Cox (Midwife)
P2 - CNST Maternity Standard 3.2.9
Completed ID3126
pVaginal birth after caesarean section
Obstetrics &
Midwifery
Emma Treloar (Cons)/
Belinda Cox (Midwife)
P2 - CNST Maternity Standard 3.2.10
In progress ID2796
Severe pre-eclamplsa
Obstetrics &
Midwifery
Rachna Bahl (Cons)/
Ann Tizzard (Matron)
P2 - CNST Maternity Standard 3.3.1
Completed ID3151
Eclampsia
Obstetrics &
Midwifery
Rachna Bahl (Cons)/
Ann Tizzard (Matron)
P2 - CNST Maternity Standard 3.3.2
Completed ID3151
Operative vaginal delivery
Obstetrics &
Midwifery
Rachna Bahl (Cons)/
Ann Tizzard (Matron)
P2 - CNST Maternity Standard 3.3.3
In progress ID2450
Multiple pregnancy and birth
Obstetrics &
Midwifery
Rachna Bahl (Cons)/
Ann Tizzard (Matron)
P2 - CNST Maternity Standard 3.3.4
Completed ID3137
Perineal trauma
Obstetrics &
Midwifery
Rachna Bahl (Cons)/
Ann Tizzard (Matron)
P2 - CNST Maternity Standard 3.3.5
In progress ID3233
Shoulder dystocia
Obstetrics &
Midwifery
Rachna Bahl (Cons)/
Ann Tizzard (Matron)
P2 - CNST Maternity Standard 3.3.6
In progress ID2276
Postpartum haemorrhage
Obstetrics &
Midwifery
Rachna Bahl (Cons)/
Ann Tizzard (Matron)
P2 - CNST Maternity Standard 3.3.7
In progress ID2449
Venous thromboembolism
Obstetrics &
Midwifery
Rachna Bahl (Cons)/
Ann Tizzard (Matron)
P2 - CNST Maternity Standard 3.3.8
Completed ID 3135
Women’s Services
Clinical Audit Annual Report 2012/13
Page 32
Pre-existing diabetes
Obstetrics &
Midwifery
Rachna Bahl (Cons)/
Ann Tizzard (Matron)
P2 - CNST Maternity Standard 3.3.9
Completed ID3025
Obesity
Obstetrics &
Midwifery
Rachna Bahl (Cons)/
Ann Tizzard (Matron)
P2 - CNST Maternity Standard 3.3.10
Completed ID3071
Booking appointments
Obstetrics &
Midwifery
Sara-Jane Sheldon
(Matron)
P2 - CNST Maternity Standard 3.4.1
Completed ID3127
Missed appointments
Obstetrics &
Midwifery
Sara-Jane Sheldon
(Matron)
P2 - CNST Maternity Standard 3.4.2
In progress ID3067
Clinical Risk Assessment (Antenatal)
Obstetrics &
Midwifery
Sara-Jane Sheldon
(Matron)
P2 - CNST Maternity Standard 3.4.3
In progress ID3023
Patient information
Obstetrics &
Midwifery
Sara-Jane Sheldon
(Matron)/Naomi Jobson P2 - CNST Maternity Standard 3.4.4
(ST6)
Not initiated
Maternal antenatal screening tests
Obstetrics &
Midwifery
Wendy Ring (Antenatal
P2 - CNST Maternity Standard 3.4.5
Screening Co-ordinator)
Not initiated
Clinical Risk Assessment (Labour)
Obstetrics &
Midwifery
Emma Treloar
(Cons)/Belinda Cox
(Practice Development
Midwife)
P2 - CNST Maternity Standard 3.4.6
In progress ID3232
Mental health
Obstetrics &
Midwifery
Sara-Jane Sheldon
(Matron)/Rachel
Liebling (Cons)
P2 - CNST Maternity Standard 3.4.7
In progress ID3232
Handover of care (Onsite)
Obstetrics &
Midwifery
Lisa Damsell (Matron)/
Janet Pollard (Patient
Safety Manager)
P2 - CNST Maternity Standard 3.4.8
In progress ID3369
Maternal transfer by ambulance
Obstetrics &
Midwifery
Ann Tizzard (Matron)
P2 - CNST Maternity Standard 3.4.9
Completed ID3252
Non-obstetric emergency care
Obstetrics &
Midwifery
Naomi Jobson (ST6)
P2 - CNST Maternity Standard 3.4.10
Completed ID3294
Referral when a fetal abnormality is
detected
Obstetrics &
Midwifery
Wendy Ring (Antenatal
P2 - CNST Maternity Standard 3.5.1
Screening Co-ordinator)
Completed ID3083
Bladder care
Obstetrics &
Midwifery
Janet Pollard (Patient
Safety Manager)
P2 - CNST Maternity Standard 3.5.7
Completed ID3088
Recovery
Obstetrics &
Midwifery
Claire Dowse (Cons)
P2 - CNST Maternity Standard 3.5.10
In progress ID2729
Caesarean section
Obstetrics &
Midwifery
Rachel Liebling (Cons)
P3 - NICE Clinical Guideline CG132
In progress ID3312
Multiple pregnancy
Obstetrics &
Midwifery
Mark Denbow (Cons)
P3 - NICE Clinical Guideline CG129
Completed ID3137
Chlamydia screening in surgical
investigation for infertility (Re-audit)
Reproductive
Medicine
David Cahill (Cons)
P3 - NICE Clinical Guideline CG11
Completed ID3254
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
BCH PONV and Pain Management up to 6 hours post day surgery with next day Telephone follow up (2011)
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
Clinical Audit Annual Report 2012/13
Page 33
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 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
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
Clinical Audit Annual Report 2012/13
Page 34
3398
Epilepsy12 - UK Collaborative audit of healthcare for children and young people with suspected epileptic seizures
(Second Round 2013)
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
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 Modfied 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
Clinical Audit Annual Report 2012/13
Page 35
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
Summary of benefits, actions or changes achieved in 2012/13 as a result of completed projects
3044 Confirmed improved detail and legibility of important clinical information in the new eDis discharge
summaries compared to previous audit(s) of ‘old style’ hand-written discharge summaries.
3152 Observed improvement over three audit cycles in terms of documentation of tube details and positioning
of nasogastric feeding tubes.
3017 Audit demonstrated good compliance with guidance on examination of newborn. CNST standards changed
and further audit developed.
3268 Significant improvement demonstrated in the compliance of the four elements of gentamicin bundle care
in comparison to the compliance shown in an audit in 2011
3277 Good compliance with standards on referral of newborn babies was demonstrated. A subgroup is to be
established to assess scope for improvement to the systems for follow up.
3332 Demonstrated full compliance with local criteria for admission to Neonatal Intensive Care Unit.
3339 This audit of support for parents of babies with actual or suspected poor outcomes showed good
compliance with local standards. The importance of these parents being seen by senior staff has been
flagged by e-mail and in Patient Safety Newsletter.
2822 Ward stocks of appropriate drugs maintained at appropriate level following audit and guidelines updated
Clinical Audit Annual Report 2012/13
Page 36
3105 Changes to clinic slots used for carb counting to help with dietetic input for annual review are underway.
3253 The position of growth charts in medical notes has been reviewed so that they are consistently in the same
place and monitoring advice will be added. A head circumference field will be added to Proton (clinical
database).
3106 The BRHC prescription chart has been redesigned to include a separate page for antibiotic prescribing,
separate box for indications and an automatic review date.
3117 Introduced a departmental standards document which is being used for all Children's Emergency
Departments in the UK. A patient advice leaflet has also been produced. An automatic button on ICE has
been introduced for ordering non blanching rashes bloods to help streamline processes.
3221 A guideline document for observation frequency has been written and is now used in practice. The
department has completed the rearrangement of triage-boxes and installed monitors in all cubicles
3222 All staff will be enrolled on a specifically designed adolescent health e-learning Programme. The proforma
has been redesigned to enable the recording of full HEADSS assessment.
2818 A ‘symptoms’ column has been added to the current chart.
3381 An automated process has been developed to enter results from the laboratory reports directly onto the
diabetes database; this will improve the reliability and accuracy of data. Ready-prepared ‘investigations at
diagnosis kit’ with all the necessary tubes and equipment for the recommended tests are to be made
available at clinic to ensure that all screening tests are carried out.
2639 A new observations chart has been developed.
2988 Three monthly MRSA screening criteria have been added to the checklist of routine tests for dialysis
patients.
3110 Children with a new diagnosis of epilepsy are to be prioritised for referral to the Epilepsy Specialist Nurse.
An ‘appropriate first clinical assessment’ proforma is being developed to help ensure developmental and
emotional/behavioural assessments are undertaken.
2769 The medicines policy has been updated to allow physiotherapists to act as second signers. Change in
physio shift patterns have been implemented to ensure there is always a presence on the ward.
3213 A joint Emergency Department and Respiratory Department asthma care pathway is to be to be created.
3228 This audit to assess compliance with national guidance in the management of women attending joint
Gynaecology-Haematology Clinic showed good compliance with relevant standards. The results were
accepted for presentation at South West Obstetrics and Gynaecology Society
3271 A hysteroscopy a pro-forma is to be produced to guide clinicians booking patients for hysteroscopy.
3311 This audit to assess compliance with standards from NHS Cervical Screening Programme showed > 90% at
follow up, exceeding relevant national standard. An additional letter to patients is being introduced to
encourage timely attendance at follow up clinic.
3316 Actions in hand to identify new capacity in service provision following this audit of compliance with
National Health Service Cervical Screening Programme standards.
2801 Demonstrated good practice in the management of pregnant women with prosthetic heart valves under
therapeutic anticoagulation.
2802 The guideline for antenatal and intrapartum management of very preterm labour has been revised and
updated.
2927 The neonatal hypoglycaemia protocol and flow chart are to be used for all mothers on beta-blocker therapy
2956 A ward handover sheet has been introduced as a result of this audit on care of pregnant women seen in the
emergency department, or cared for on non-obstetric wards.
3024 This audit on documentation of provision of postnatal provision of information to parents showed excellent
compliance with local standards.
3025 This audit to assess compliance with the approved documentation for the management of pre-existing
diabetes, demonstrated good compliance with CNST standards.
3026 This audit of standards for diabetes management in pregnancy, which went beyond those specified by
CNST, showed good compliance overall. Reminders were provided regarding record keeping points, and
the presence of “Hypo” boxes on St Michael’s women’s wards.
3064 This audit of confirmed the management of venous thromboembolism episodes in pregnant women
demonstrated compliance with agreed local standards.
3071 This audit of women with obesity in pregnancy showed that almost all women had a BMI calculation and
documentation. Further review of body mass index (BMI) stickers, care plans, manual handling
assessments planned for 2013.
Clinical Audit Annual Report 2012/13
Page 37
3083 This audit to assess compliance with local guidance on early appropriate referral when fetal abnormality
detected demonstrated 100% compliance with relevant CNST standards.
3088 Following this audit of bladder care in women following childbirth, which demonstrated good compliance
with CNST standards, the guideline was revised and a further audit carried out of women who experienced
voiding problems.
3126 Demonstrated compliance with relevant CNST standards for women receiving intensive care in a suitable
environment. It was also agreed to incorporate relevant points from the audit into Obstetric staff training,
and explore use of Medway computer system to record women on non-St Michael's wards.
3127 This audit assessing booking gestation, and the process to book women if >12+6 weeks gestation is already
exceeded at the first meeting, demonstrated that practice was compliant with relevant CNST standards.
3134 Demonstrated good practice in relation to TORCH screening.
3135 This audit to assess compliance with local guidance in relation to assessment for risk of venous
thromboembolism, actions taken and documentation of relevant management plan was compliant with
relevant CNST Standards.
3137 This audit to assess compliance with local guidance on management of multiple pregnancy demonstrated
compliance with relevant CNST standards, and relevant items have been incorporated into Obstetric
Emergency training.
3151 This audit to assess compliance with local guidance on management of pre-eclampsia demonstrated 100%
compliance with relevant CNST standards, and was part of the portfolio of audits in the successful Level 3
CNST assessment.
3212 This audit to assess compliance with local guidance on bladder care in women who experience problems
postnatally demonstrated good compliance with standards re use of catheters (i.e. appropriate women
identified/women not catheterised unnecessarily).
3240 Confirmed that midwives are providing appropriate high quality service in their newborn baby checks
3252 This audit to assess compliance with local guidance on transfer of women by ambulance demonstrated
good compliance with relevant CNST standards.
3294 This re-audit of compliance with local guidance on care of obstetric patients entering A&E and cared for on
non-non obstetric wards demonstrated compliance with relevant local standards. In addition, design
changes were incorporated into the paper handover sheet.
3335 This audit to assess compliance with requirement for consultant obstetrician attendance at specified high
risk situations demonstrated 100% compliance with CNST related standards.
2789 A management pack containing a standard operating procedure, x-ray request form, patient information
and prescription card has been introduced.
3254 A system to ensure that the notes of patients undergoing pre-operative screening for chlamydia
trachomatis are available in theatre has been implemented.
Clinical Audit Annual Report 2012/13
Page 38
2.7
NON-DIVISION SPECIFIC
Planned projects in progress or complete at end of financial year
This year
33% (7/21)
Previous year
78% (7/9)
The following table shows the status at year end of those projects in progress or completed during the financial
year that were identified as priorities within the forward plan for 2012/13.
Title
Sub-Specialty
Lead
Rationale
Status
Audit of ward moves for patients with
dementia
Care of the
Elderly
Helen Morgan (Dept.
Chief Nurse)
P1 - CQUIN
Completed ID3396
National Cardiac Arrest Audit (NCAA)
Resuscitation
Jo Bruce Jones
(Resuscitation
Manager)
P1 - National Audit (Quality Accounts)
In progress ID3139
Health promotion in hospital (NHPHA)
Trustwide
Lead not specified
P1 - National Audit (Quality Accounts)
No longer
required
Inpatient documentation audit
Records
Jane Luker
P2 - NHSLA
In progress ID2945
Outpatient documentation audit
Records
Lead not specified
P2 - Information Risk Issue
Not initiated
End of life care in the acute hospital
setting
Palliative Care
Karen Forbes (Cons)
P1 - CQUIN
Completed ID3193
Medicines loading doses
Medicines
Management
Lead not specified
P2 - Identified by Medicines
Governance Group NPSA priority
Not initiated
Injectable medicines
Medicines
Management
Lead not specified
P2 - Identified by Medicines
Governance Group NPSA priority
Not initiated
Gentamicin
Medicines
Management
Georgina Holmes (antiinfective pharmacist)
P2 - Identified by Medicines
Governance Group NPSA priority
In progress
IV Medications
Medicines
Management
Lead not specified
P2 - Identified by Medicines
Governance Group NPSA priority
Not initiated
Anticoagulation
Medicines
Management
Lead not specified
P2 - Identified by Medicines
Governance Group NPSA priority
Not initiated
Midazolam
Medicines
Management
Lead not specified
P2 - Identified by Medicines
Governance Group NPSA priority
Not initiated
Low Molecular Weight Heparin
Medicines
Management
Lead not specified
P2 - Identified by Medicines
Governance Group NPSA priority
Not initiated
Medicines Storage
Medicines
Management
Steve Brown (Director
of Pharmacy)
P1 - Identified by Medicines
Governance Group Re-audit ID 3174.
CQC priority for inspection
Completed ID3174
Insulin usage
Medicines
Management
Lead not specified
P2 - Identified by Medicines
Governance Group NPSA priority
Not initiated
The following activity was also in progress during the financial year (either rolled over from previous year or not
identified through plan):
Status
3095
Provisional Title of Project
Specialty
Are we following the Did Not Attend (DNA) Policy
Sub-Specialty
Audit of dementia care – in response to national audit findings
3100
Completion of DNACPR forms within UH Bristol
Completed
3323
Dementia screening (CQUIN)
In Progress
3336
National Diabetes Inpatient Audit 2012
In Progress
Ref
2864
Clinical Audit Annual Report 2012/13
Completed
Completed
Page 39
Summary of benefits, actions or changes achieved in 2012/13 as a result of completed projects
2864 A bespoke ‘did not attend’ (DNA) training package has been developed by the Safeguarding Children Team
and delivered to all out-patient areas which see children/young People under 18 years of age.
3193 Demonstrated that the majority of patients are being started on an end of life care plan and appropriately
managed. The current end of life assessment tool is being revised and further work is underway to educate
staff in this sensitive area.
3095 Focused work is underway to increase the use of the ‘This is me’ tool, Abbey pain assessment and visual
identification system (‘forget me not’) for all patients who have communication difficulties including those
with a cognitive impairment. This is being done through dementia training, dementia resource files /
displays on wards, dementia awareness ages on the intranet and further support for ward from ‘dementia
champions’. The confusion assessment method (CAM) has been added to all clerking proforma’s to enable
screening for delirium to take place on admission (National CQUIN requirement within 72hrs of admission).
3100 Areas of good practice demonstrated in terms of the completion of DNACPR form but further education
needed. On-going teaching is underway as part of month doctors induction to reinforce importance of
accurate DNACPR documentation.
Clinical Audit Annual Report 2012/13
Page 40
Appendix A – UH Bristol Clinical Audit and Effectiveness Staff (as at April 2013)
Division
Specialty
CA Facilitator
CA Convenor
Radiology
Sally King
Dr Huw Roach
Laboratory Medicine
Diagnostics
& Therapy
Dr Joya Pawade
Medical Physics & Bioengineering
Pharmacy
0.8wte
Adult Therapies
Medicine
Specialised
Services
Mr Phil Quirk
Isabella To
Medical Specialties
Mr Kevin Gibbs
Usual contact is Head of Service
Stuart Metcalfe/
Isabella To
Dr Rachel Bradley
Emergency Services
Homeopathy
Sue Barron
Dr Liz Thompson
Oncology & Haematology
James Osborne
Dr Charlie Comins
Dr Anne Frampton
Cardiology & Cardiac Surgery
Dr Mandie Townsend
Anaesthesia
Critical Care
Surgery,
Head &
Neck
Dr Diana Terry
Stuart Metcalfe/
Jon Penny
Theatres
Surgical Specialities
Mr Doug West
Trauma & Orthopaedics
Mr Steve Mitchell
Dental Services & Max Fax Surgery
Ophthalmology
Jonathan Penny
0.6wte
Adult ENT
Women &
Children’s
Mr Derek Tole
Mrs Claire Langton Hewed
Obstetrics & Gynaecology
Richard Hancock
0.8wte
Chrissie Gardner
1.0wte
Neonatology
Children’s Services (BRCH)
Clinical Audit Central Office
Mr Paul Wilson
Ms Naomi Crouch
Dr Will Christian
Stuart Metcalfe
Clinical Audit & Effectiveness Manager (1.0)
James Osborne
Joanna Snietura
NICE Manager (1.0)
Clinical Audit Clerk (0.8)
Membership of the Clinical Audit Group
Dr Anne Frampton (Chair)
Chris Swonnell (Head of Quality – Patient Experience and Clinical Effectiveness)
Stuart Metcalfe (Clinical Audit and Effectiveness Manager)
James Osborne (NICE Manager)
Clinical Audit Convenors - see above
Clinical Audit Annual Report 2012/13
Page 41
Appendix B - Clinical audit projects abandoned during 2012/13
The projects listed below were abandoned after the project was started (i.e. after data collection had commenced). In the majority of
cases this is due to projects leads leaving the Trust and no identified replacement identified. There have also been a number of occasions
during the year where the facilitator team have been unable to obtain any results or reports despite regular chasing.
This list is in addition to those projects outlined within Divisional forward plans for 2012/13 that were also classified as abandoned.
Ref
Provisional Title of Project
Diagnostic and Therapy/Nutrition & Dietetics
2352
Cook/chill: Meeting national nutritional standards for hospital catering
Medicine/Acute Medicine
2931
An audit of the immediate management of confirmed Trans-ischemic Attacks (TIAs) in the TIA clinic on Ward 17
Medicine/Medical Specialties
3032
Audit of current GP referral practice
3217
Management of Gonorrhoea
2347
Surgical Attire of Staff and Patients During Skin Surgery in the Bristol Dermatology Centre
2934
Bone mineral density (BMD) of patients on long term total parenteral nutrition (TPN)
Specialised Services/Cardiac Services
2939
Audit of follow-up imaging after aortic surgery
2980
An audit of In-Hospital Cardiac Arrest post - Cardiac Surgery
2882
Audit of indications for Trans Venous Lead (TVL) and Cardiovascular implantable electronic device (CIED) extractions 2008-10
Specialised Services/Oncology & Clinical Haematology
3030
Hydroxyurea treatment in sickle cell patients
3070
Bortezomib monotherapy for relapsed Multiple Myeloma - NICE TA129
2870
Late bowel toxicity following radiotherapy for prostate cancer
3074
Awareness of the potential toxicity of low dose methotrexate as a radiosensitizer during radiotherapy
Surgery Head & Neck/Anaesthesia
2662
Retrospective audit of C-Sections under General Anaesthesia at St Micheal’s in 2009
2814
Audit of PCA use in post-op pain management following major Gynaecological Surgery
Surgery Head & Neck/Dental Services
2750
National study on avascular necrosis of the jaws including bisphosphonate-related osteonecrosis
2828
Clinical justification and quality of referrals of children for treatment under general anaesthesia
2899
Repeat GA for extraction in children - re-audit
Surgery Head & Neck/Integrated Critical Care Services
2813
Audit of the Resuscitation bag and Drug box
2941
Audit of the use of Inotropes on ITU
Surgery Head & Neck/Surgical Specialties
2629
Audit of Group and Save requests in patients with closed, isolated ankle fractures undergoing open reduction/internal fixation
2880
Audit of Complications from Orthopaedic Revision Procedures
2909
Audit of time from admission to theatre in neck of femur fractures
2943
Management of open lower limb fractures, how are we doing?
3061
Discharge summaries for patients undergoing elective major hepatobiliary resections
Clinical Audit Annual Report 2012/13
Page 42
2923
Urology patient ward transfer audit: Are safe standards being met
Women's and Children's/Children’s Services
2684
Audit of cerebral spinal fluid collection (lumbar punctures) in febrile children - NICE TA102)
2774
Admission times and cohorting in patients with suspected respiratory viruses
2819
Audit of prescribing practice in cases of patient safety incidences on paediatric medical wards at Bristol Royal Hospital for Children
2643
Audit of application of monitoring during anaesthesia of children
2747
Audit of blood product use in paediatric cardiac bypass surgery
3000
Management of out of theatre intubations
2866
Removal of pacing wires in children post cardiac surgery
2946
Paediatric shared care guidelines for Pulmonary Hypertension (PH) between Bristol Royal Hospital for Children and London
Specialist PH Centres
2952
An audit of the reasons for referral and timing of fetal echocardiography during the second trimester
2981
An audit to review sleep studies in children with pulmonary hypertension
2987
Are we effectively diagnosing and managing Kawasaki Disease?
3261
An audit of the use of RSV prophylaxis in congenital heart disease
2989
Audit on Checklist Completion for Patients Discharged Home with a Feeding Tube
2620
Audit of Head Injury National Institute for Health and Clinical Excellence – NICE CG56
2797
Safeguarding children; How effective is the practice of front line professionals?
2820
Bronchiolitis management in the Emergency Department
2794
Paediatric Diabetic Retinopathy audit
3196
Quality of nutritional screening and auxology carried out on paediatric wards
2008
Management of Paediatric Inflammatory Bowel Diseases in the South West Region
2589
Blood product use after paediatric cardiac surgery
2610
Audit of end of life planning for children who have died from life limiting conditions at Bristol Royal Hospital for Children
2915
Compliance with central venous catheter care bundles guidelines at Paediatric Intensive Care in Bristol Royal Hospital for Children
2782
Use of drug stickers for prescribing within Paediatric Oncology and Haematology and BMT
2244
Anaphylaxis: An audit of management in the Children's Emergency Department
3051
Management of bronchiolitis in children
2688
Audit of paediatric joint injections
2588
Discharge Summaries in Paediatric Surgery
2619
Audit of intravenous cannula management in paediatric surgical patients at Bristol Royal Hospital for Children
2744
Audit of urethral catheterization in children
2821
Correct site surgery (CSS) National Patient Safety Agency Alert Number Five (2005) in the Bristol Royal Hospital for Children
2953
Appendicectomy analgesia audit
2693
Correlation of clinical episodes with clinical coding on patients seen by Rheumatology over a four week period
Clinical Audit Annual Report 2012/13
Page 43
Appendix C - University Hospitals Bristol Clinical Audit Forward Programme 2013/14
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 2013/14; 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’.
Category 1
Category 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.
Category 3
Category 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 2012/13
Page 44
Division: Diagnostics & Therapies
Title
Sub-Specialty
Lead
Rationale/comment
Category Start date
Audit of the management of patients with haemoglobinopathies
Laboratory Haematology
(Blood and Transplant audit programme)
Tom Latham (Cons)
National Audit (Quality Accounts)
1
Q3 (Oct 2013)
Audit of patient information and consent (Blood and Transplant
audit programme)
Laboratory Haematology
Tom Latham (Cons)
National Audit (Quality Accounts)
1
Q3 (Oct 2013)
Compliance with transfusion procedures.
Laboratory Haematology
Tom Latham (Cons)
NHSLA requirement
1
Q1 (Apr 2013)
Transfusion information availability
Laboratory Haematology
Tom Latham (Cons)
Clinical issue
2
Q1 (Apr 2013)
Audit of microbiology sampling in stillbirth post mortems
Histopathology
Craig Charles Platt (Cons)
Re-audit ID 3092, confirmed from previous
action plan
2
Q2 (Aug 2013)
Audit of double-reporting protocol in gastro-intestinal cancers
Histopathology
Golda Shelley-Fraser (Cons)
Trust objective
2
Q2 (Aug 2013)
Supplementary reports after MDT meetings
Histopathology
Rob Pitcher (Cons)
Trust objective
Re- audit ID 3048
2
Q2 (Aug 2013)
Audit of reporting of Cutaneous Malignant Melanoma at
UHBristol
Histopathology
Nidhi Bhatt (Cons)
Re-audit ID 3089
2
Q2 (Aug 2013)
Endometrial cancer analysis and comparison of endometrial
curettage with subsequent hysterectomy section
Histopathology
Joya Pawade (Cons)
Joint audit with NBT
Trust objective
2
Q1 (Apr 2013)
Comparison of cytology and histology
Histopathology
Nidhi Bhatt (Cons)
Joint audit with NBT
Trust objective
2
Q2 (Aug 2013)
Percentage of pre-treatment non-small cell carcinoma not
otherwise specified (NSCLC-NOS)
Histopathology
Nidhi Bhatt (Cons)
Regional audit, led by UH Bristol
2
Q1 (Apr 2013)
Turnaround time for reporting of biopsies suspected
Inflammatory Bowel Disease
Histopathology
Pramila Ramani (Cons)
Re-audit ID 3325
2
Q4 (Jan 2014)
Clinical relevance of histology reporting of the placenta
Histopathology
Corina Moldovan (Cons)
Re-audit ID 2091
2
Q3 (Oct 2013)
Prophylaxis in orthopaedic surgery
Microbiology
Martin Williams (Cons)
To ensure patients are getting the correct
prophylaxis
4
Q3 (Oct 2013)
Diagnosis and Initial Management of Suspected Communityacquired Bacterial Meningitis in Adults
Microbiology
Ed Barton (Cons)
Re-audit ID 2632
4
Q2 (Aug 2013)
An audit of the use and management of blood glucose point of
care testing results in UH Bristol
Clinical Biochemistry
Paul Thomas (Cons Clinical
Patient Safety
Scientist)/ Graham Bayly (Cons)
2
Q3 (Oct 2013)
Medical Physics &
Bioengineering
Ian Negus (Clinical Scientist)
2
Q1 (Apr 2013)
Laboratory Medicine
Medical Physics & Bioengineering
CT radiation dose audit
Rollover from 2012-13. Requirement of
IRMER
Nutrition & Dietetics
Clinical Audit Annual Report 2012/13
Page 45
Nutritional screening of upper gastro-intestinal surgical patients
in pre-op clinic
Nutrition & Dietetics
Tom Lander (Dietitian)
Clare Evans (Cons. Nurse)
Re-audit ID 3192
3
Q2 (Aug 2013)
Nutritional Screening
Nutrition & Dietetics
Rachel Cooke (Snr Dietitian)
Trust Quality Objectives
1
Q1 (Apr 2013)
Parenteral Nutrition within Critical Care
Nutrition & Dietetics
Rebecca Pooley (Dietitian)
Demonstrating compliance with NCEPOD
recommendations (A Mixed Bag 2010)
3
Q2 (Aug 2013)
2
Q4 (Jan 2014)
Occupational Therapy
Documentation Audit
Physiotherapy /Occupational Linda Clarke, Scott Allan
CQC Outcome 21
Therapy
(Divisional Heads of Therapies)
Pharmacy
South West Quality and Patient Safety Improvement Programme
Pharmacy
(Medicines Management)
Kevin Gibbs (Pharmacist)
Clinical audit/monitoring arising from individual
workstreams
2
Q1 (Apr 2013)
Re-audit compliance with prescribing policy Medicines Codes
Chapter M2
Pharmacy
Anne Edwards (Pharmacist)
Re-audit ID 3215
2
Q2 (Aug 2013)
Audit of the prescribing and monitoring of sliding scale heparin
infusions
Pharmacy
Jacqueline Criper (Pharmacist)
Previous incidents with sliding scale heparin
prescribing and monitoring errors.
2
Q3 (Dec 2013)
Vancomycin prescribing audit
Pharmacy
Elizabeth Jonas (Pharmacist)
Patient safety risk/incidents reported with a
narrow therapeutic range drug
2
Q4 (Mar 2013)
Audit of adherence to the pharmacy prescription endorsing
policy
Pharmacy
Elin Wallis (Pharmacist)
NHSLA evidence for ensuring prescriptions are
accurate
2
Q1 (Apr 2013)
Audit of medicines reconciliation on transfer between adult
intensive care unit (ICU) and post-ICU wards.
Pharmacy
John Warburton (Pharmacist)
NICE technical safety solution. Area of risk if
ICU-initiated medication carried on
unnecessarily.
3
Q2 (Aug 2013)
Re-audit of insulin prescribing to agreed prescribing bundle
Pharmacy
Kevin Gibbs (Pharmacist)
Re-audit after implementation of new drug
chart and guidance in 2013.
3
Q4 (Mar 2013)
Audit of medicines reconciliation on discharge
Pharmacy
Emily Marshall (Pharmacist)
Confirmed as an area of risk by us and GPs.
2
Q2 (Aug 2013)
Audit of consultant names on in-patient prescription charts and
out-patient prescription forms
Pharmacy
Kevin Gibbs (Pharmacist)
Essential information to be able to cost
medication accurately to Consultants and
enable accurate drug expenditure information
2
Q1 (Apr 2013)
Physiotherapy
Jo Bond-Kendall (Snr. Physio)
Monitoring local guidelines
4
Q1 (Apr 2013)
Audiology
Regina Smith (Audiologist)
To assess the primary outcome measures as
part of a quality assurance programme
1
Q1 (Apr 2013)
Speech and Language
Therapy
Vicki Weekes (Speech &
Language Therapist)
Local guidelines RCSLT guidelines
3
Q2 (Sept 2013)
Physiotherapy
Home visit for cystic fibrosis patients on home intravenous
antibiotics
Audiology
Re-audit Glasgow Hearing Aid Benefit Profile
Speech & Language Therapy
Standards for and outcomes of videofluoroscopy referral
Clinical Audit Annual Report 2012/13
Page 46
Radiology
Radiological interpretation recording in notes
Radiology
Sally King (Sup. Rad.)
Re-audit confirmed from previous action plan
3
Q2 (Aug 2013)
Appropriateness of radiographic markers
Radiology
Simon Brown (Sup. Rad.)
Confirmed by Clinical Audit Group for inclusion
in plan
3
Q3 (Oct 2013)
Vascular interventional radiology outcome data
Radiology
Amit Goyal (SpR)
Standards of Royal College of Radiology
3
Q1 (Apr 2013)
Sub-Specialty
Lead
Rationale
Category Start date
Paracetamol Overdose (College of Emergency Medicine)
Emergency Department
Lead to be confirmed
National Audit (Quality Accounts)
1
Q2 (Aug 2013)
Severe Sepsis (College of Emergency Medicine)
Emergency Department
Lead to be confirmed
National Audit (Quality Accounts)
1
Q2 (Aug 2013)
Radiology reporting (College of Emergency Medicine)
Emergency Department
Lead to be confirmed
National Audit (Quality Accounts)
1
Q2 (Aug 2013)
Consultant Sign Off
Emergency Department
Lead to be confirmed
National Audit (Quality Accounts)
1
Q1 (Apr 2013)
Community Acquired pneumonia
Emergency Department
Acute Medicine
Lead to be confirmed
Local issue/re-audit
3
Q2 (Aug 2013)
Child protection/C4C
Emergency Department
Lead to be confirmed
Local issue
2
Q2 (Aug 2013)
Chest Drain
Emergency Department
Lead to be confirmed
Re-audit
3
Q2 (Aug 2013)
Sedation
Emergency Department
Lead to be confirmed
Patient safety issue and re-audit
2
Q2 (Aug 2013)
Prescribing
Emergency Department
Lead to be confirmed
Patient safety issue
2
Q2 (Aug 2013)
Pancreatitis
Emergency Department
Lead to be confirmed
Introduction of new guideline
3
Q2 (Aug 2013)
Severe sepsis
Acute Medicine
Emergency Department
Jessica Triay (Cons)
Introduction of a new local guideline
National Hip Fracture Database (NHFD)
Care of the Elderly
Rachel Bradley (Cons)
National audit (NCAPOP)
Division: Medicine
Title
Emergency Department
Medical Specialties
Clinical Audit Annual Report 2012/13
To be
confirmed
1
Q1 (Apr 2013)
Page 47
National Audit of Dementia
Care of the Elderly
Julie Dovey (Cons)
National audit (NCAPOP)
1
Q4 (Jan 2014)
Stroke National Audit Programme (SSNAP)
Care of the Elderly
Sarah Caine (Cons)
National audit (NCAPOP)
1
Q1 (Apr 2013)
VTE prophlaxis management
Care of the Elderly
Peter Murphy (Cons)/Sarah
Caine (Cons)
Audit as a results of a serious incident
2
Q2 (Aug 2013)
Thrombolysis management
Care of the Elderly
Peter Murphy (Cons)/Sarah
Caine (Cons)
Further in depth review of the safety the
outcome of patients previously thrombolised
2
Q2 (Aug 2013)
Management of genital herpes
Contraception and Sexual
Health
Andrew Leung (Cons)
National and local guidelines
3
To be
confirmed
Management of early syphilis
Contraception and Sexual
Health
Andrew Leung (Cons)
National and local guidelines
3
To be
confirmed
Management of late syphilis
Contraception and Sexual
Health
Andrew Leung (Cons)
National and local guidelines
3
To be
confirmed
Management of lymphogranuloma venereum
Contraception and Sexual
Health
Andrew Leung (Cons)
National and local guidelines
3
To be
confirmed
HIV testing in patients with lymphoma
Contraception and Sexual
Health
Helen Wheeler (Cons)
National and local guidelines
3
To be
confirmed
Management of sexual assaults
Contraception and Sexual
Health
Beata Cybulska
National and local guidelines
3
To be
confirmed
BASE – Sexual Health Outreach services
Contraception and Sexual
Health
Nikki Jeal (Cons)
Local guidelines
3
To be
confirmed
Integrated service at Bristol Sexual Health Centre
Contraception and Sexual
Health
Judith Berry (Cons)
Service provision
3
To be
confirmed
HIV Partner Notification
Contraception and Sexual
Health
Andrew Leung (Cons) / Leonor
National Audit
Herrera Vega (Cons)
3
To be
confirmed
Emergency IUD
Contraception and Sexual
Health
Leonor Herrera-Vega (Cons)
National and local guidelines
3
To be
confirmed
Emergency contraception
Contraception and Sexual
Health
Leonor Herrera-Vega (Cons)
National and local guidelines
3
To be
confirmed
Audit of NICE guidance on management of patients with
psoriasis
Dermatology
David de Berker (Cons)
NICE guidance with patient safety and care as
priorities
2
Q1 (Apr 2013)
Audit of completeness of excision of non-melanoma skin cancer
in Bristol Dermatology
Dermatology
Adam Bray (Cons)
Ongoing quality indicator/per review outcome
measure in cancer management.
2
Q1 (Apr 2013)
Audit of notification of GPs of patient melanoma diagnosis
within 24 hours
Dermatology
Gemma Gregory (CNS)
NICE guidance and peer review measure. Reaudit
2
Q1 (Apr 2013)
National Diabetes Audit (NDA)
Diabetes and Endocrinology
Natasha Thorogood (Cons)
National audit (NCAPOP)
1
Q2 (Aug 2013)
Clinical Audit Annual Report 2012/13
Page 48
Management of multiple endocrine neoplasia
Diabetes and Endocrinology
Karin Bradley (Cons)
Re-audit confirmed from previous action plan
3
Q2 (Aug 2013)
Management of hypoglycaemic events
Diabetes and Endocrinology
Karin Bradley (Cons)
Confirmed by Clinical Audit Group for inclusion
in plan
3
To be
confirmed
Prevalence and management of benign hypercalcaemia
Diabetes and Endocrinology
Karin Bradley (Cons)
Confirmed by Clinical Audit Group for inclusion
in plan
3
To be
confirmed
Audit of Adult Outpatient Diabetes Care
Diabetes and Endocrinology
Natasha Thorogood (Cons)
14 key interventions set out by the Department
of Health in 2012
2
Q2 (Sept
2013)
TA64 Growth hormone deficiency (adults)
Diabetes and Endocrinology
Karin Bradley (Cons)
NICE Commissioning College requirement
2
To be
confirmed
National Inflammatory Bowel Disease audit
Gastroenterology
Tom Creed (Cons)
National audit (NCAPOP)
1
Q1 (Apr 2013)
National COPD audit
Respiratory
Nabil Jarad (Cons)
National Audit (NCAPOP) – newly contracted
1
Q2 (Sept
2013)
British Thoracic Society audit programme
(5 topics to be confirmed)
Respiratory
Lead to be confirmed
National Audit (Quality Accounts)
1
To be
confirmed
Bronchoscopic lung volume reduction with airway valves for
advanced emphysema and air leak
Respiratory/Thoracic
Surgery
Nabil Jarad (Cons)/Tim
Batchelor (Cons)
New interventional procedure approved by the
Clinical Effectiveness Group
2
To be
confirmed
Oxygen prescription
Respiratory
Liz Gamble (Cons)
Re-audit confirmed from previous action plan
3
Q2 (Aug 2013)
Suspected lymph node tuberculosis audit
Respiratory
Sarah Mungall (Cons)
Re-audit confirmed from previous action plan
3
Q1 (Apr 2013)
Rheumatoid arthritis
Rheumatology
Robert Marshall (Cons)
NICE Commissioning College requirement
2
To be
confirmed
Sub-Specialty
Lead
Rationale
Category Start date
Adult Cardiac Surgery (ACS)
Cardiac Surgery
Alan Bryan (Cons)
National audit (NCAPOP)
1
Q1 (Apr 2013)
Acute Coronary Syndrome/Acute
Myocardial Infarction (MINAP)
Cardiology
Julian Strange (Cons)
National Audit (NCAPOP)
1
Q1 (Apr 2013)
National Cardiac Arrhythmia Audit (HRM)
Cardiology
Tom Johnson (Cons)
National Audit (NCAPOP)
1
Q1 (Apr 2013)
National Heart Failure Audit (HF)
Cardiology
Angus Nightingale (Cons)
National Audit (NCAPOP)
1
Q1 (Apr 2013)
Division: Specialised Services
Title
Cardiac Services
Clinical Audit Annual Report 2012/13
Page 49
Adult Coronary Angioplasty
Cardiology
Tom Johnson (Cons)
National Audit (NCAPOP)
1
Q1 (Apr 2013)
TA230 Myocardial infarction (persistent ST-segment elevation) –
Cardiology
bivalirudin
Julian Strange (Cons)
BNSSG Commissioning College requirements
2
To be
confirmed
Sutureless Aortic Valve Replacement
Cardiac Surgery
George Asimakopoulos (Cons)
New interventional procedure approved by the
Clinical Effectiveness Group
2
To be
confirmed
National Lung Cancer Audit (NLCA)
Oncology
Respiratory
Adam Dangoor (Cons)
National Audit (NCAPOP)
1
Q1 (Apr 2013)
VTE Prophylaxis
Haematology
Amanda Clarke (Cons)
CQUIN
1
Q2 (July 2013)
NICE Specialist Commissioning audits
Oncology/Haematology
Lead to be confirmed
BNSSG NICE Commissioning College priority
(yet to be confirmed due to change in
commissioning structures)
1
To be
confirmed
NICE TA193 Leukaemia (chronic lymphocytic, relapsed) rituximab
Haematology
Jenny Bird (Cons)
BNSSG NICE Commissioning College priority,
carried over from previous year
1
To be
confirmed
An audit of Identification of patients in the last year of life and
advance care planning in respiratory disease
Palliative Medicine
Respiratory
Colette Reid (Cons)
CQUIN target based on DoH End of Life Strategy
1
Q1 (Apr 2013)
An audit of Identification of patients in the last year of life and
advance care planning in patients with dementia
Palliative Medicine
Care of the Elderly
Colette Reid (Cons)
CQUIN target based on DoH End of Life Strategy
1
Q1 (Apr 2013)
An audit of Identification of patients in the last year of life and
advance care planning in patients with advanced cancer
Palliative Medicine
Oncology
Colette Reid (Cons)
CQUIN target based on DoH End of Life Strategy
1
Q1 (Apr 2013)
An audit of Identification of patients in the last year of life and
advance care planning in frail elderly patients
Palliative Medicine
Care of the Elderly
Colette Reid (Cons)
CQUIN target based on DoH End of Life Strategy
1
Q1 (Apr 2013)
An audit of interventions and investigations in the last week of
life
Palliative Medicine
Colette Reid (Cons)
Patient safety issue
2
Q1 (Apr 2013)
Sub-Specialty
Lead
Rationale
Category Start date
Emergency Laparotomy
Anaesthesia
Surgery
Rachel Craven (Cons)/Jane
Blazeby (Cons)
National Audit (NCAPOP) – newly contracted
1
Q3 (Dec 2013)
SPINT/ASAP audit
Anaesthesia
Frances Forrest (Cons)/Rachel
Bradley (Cons)
National drive through hip fracture network to
look at anaesthetic practices for hip fracture
patients across the UK
2
Q2 (May
2013)
Oncology & Haematology
Palliative Care
Division: Surgery, Head and Neck
Title
Anaesthesia, Critical Care & Theatres
Clinical Audit Annual Report 2012/13
Page 50
Abbey pain chart for patients with dementia/cognitive
impairment
Anaesthesia/Acute Pain
Team
Lead to be confirmed
Confirmed through incidents
2
To be
confirmed
Presence of essential emergency information in theatres
Anaesthesia
Diana Terry (Cons)
Links to productive ward/patient safety
3
To be
confirmed
Safe prescribing and completion of drug charts
Anaesthesia
Diana Terry (Cons)
AAGBI recommendations
2
To be
confirmed
South West Quality and Patient Safety Improvement
Programme (Perioperative care)
Theatres
Sanjoy Shah (Cons)
Clinical Audit/Monitoring arising from individual
workstreams
2
Q1 (Apr 2013)
Adult critical care case mix programme (ICNARC CMP)
Critical Care
Tim Gould (Cons)
National Audit (Quality Accounts)
1
Q1 (Apr 2013)
Potential Donor Audit
Critical Care
Fran O’Higgins (Cons)
National Audit (Quality Accounts)
1
Q1 (Apr 2013)
ALung Hemolung Respiratory Assist System
Critical Care
Tim Gould (Cons)
New interventional procedure approved by the
Clinical Effectiveness Group
2
Q1 (Apr 2013)
Audit of medication errors on ICU
Critical Care
John Warburton/John Bell
Local drive to improve patient safety
2
Q1 (Apr 2013)
Audit of blood transfusion practice
Critical Care
Dan Freshwater-Turner (Cons)
New national and local guidelines
3
Q1 (Apr 2013)
Audit of appropriate PPI prescribing
Critical Care
Tim Gould (Cons)
Locally driven guidelines
3
Q1 (Apr 2013)
Liz Varian
Clinical Audit/Monitoring arising from individual
workstreams
2
Q1 (Apr 2013)
National audit (NCAPOP)
1
Q1 (Apr 2013)
South West Quality and Patient Safety Improvement Programme
Theatres
(Perioperative care)
Dental Services
National Head & Neck Cancer (DAHNO)
Oral and Maxillofacial
Surgery
Ceri Hughes (Cons)
Pre-formed metal crown failure rates
Primary Care Dental Service
Katherine Walls (Senior Dental Rolled over from 2012/13 plan as 12 month
Officer)
failure rates required
4
Q4 (Jan 2014)
Dental undergraduate treatment plans (re-audit)
Restorative Dentistry
Rob Jagger (Cons)
To determine whether improvements have
been made since previous audit cycle
4
Q2 (Jul 2013)
Extraction of first permanent molars (re-audit)
Child Dental Health
Sarah Dewhurst (Cons)
To determine whether improvements have
been made since previous audit cycle
4
Q1 (Apr 2013)
Salivary gland imaging (re-audit)
Dental Radiology
Jane Luker (Cons)/Rebecca
Davies (Cons)
To determine whether improvements have
been made since previous audit cycle
4
Q3 (Sep 2013)
Condition of surgical margins in resections for cancer of the oral
cavity and oropharynx
Oral and Maxillofacial
Surgery
Ceri Hughes (Cons)
Compare success of curative oral cancer surgery
against national benchmarks
4
Q4 (Jan 2014)
Primary Care Unit protocols for patients with suspected
coagulation defects
Oral Medicine / Oral Surgery
Sarah Ellison (Associate
Impact on onward referral and use of diagnostic
Specialist)/Tony Brooke (Cons) testing
4
Q4 (Jan 2014)
Primary Care Unit patient satisfaction (re-audit)
Oral Medicine
Tony Brooke (Cons)
4
Q3 (Sep 2013)
Clinical Audit Annual Report 2012/13
Re-assessment of patient satisfaction following
impending changes to service provision
Page 51
Hospital wide
Sarah Foy (SpR)/Tony Brooke
(Cons)
To determine staff knowledge of principles and
application of Mental Capacity Act
3
Q3 (Sep 2013)
Endoscopic sinus surgery outcomes (re-audit)
Adult ENT
Claire Langton-Hewer (Cons)
To assess improvement
4
To be
confirmed
Turbinate surgery
Adult ENT
Claire Langton-Hewer (Cons)
To assess outcomes
4
To be
confirmed
Implantation of multifocal intraocular lenses during cataract
surgery
Cornea and Cataract
Phil Jaycock (Cons)
New interventional procedure approved by the
Clinical Effectiveness Group
2
Q4 (Mar
2014)
Boston Type 1 Keratoprosthesis
Cornea and Cataract
Derek Tole (Cons)
New interventional procedure – rolled over
from 2012/13 plan to allow for sufficient cases
2
Q1 (Apr 2013)
Intraocular lens insertion for correction of refractive error with
preservation of the natural lens guidance
Cornea and Cataract
Phil Jaycock (Cons)
New interventional procedure approved by the
Clinical Effectiveness Group
2
Q4 (Mar
2014)
TA229 Macular oedema (retinal vein occlusion) –
dexamethasone
Cornea and Cataract
Claire Bailey (Cons)
NICE Commissioning College requirement
2
To be
confirmed
Deep Sclerectomy (non-penetrating glaucoma filtration surgery) Glaucoma
Rani Sebastian (Cons)
New interventional procedure approved by the
Clinical Effectiveness Group
2
Q1 (Apr 2013)
Selective Laser Trabeculoplasty (SLT)
Glaucoma
Rani Sebastian (Cons)
New interventional procedure approved by the
Clinical Effectiveness Group
2
Q4 (Mar
2014)
Trabeculectomy outcomes
Glaucoma
John Sparrow (Cons)/Peter
Tsangaris (SpR)
Monitoring of success and complications of
main surgical treatment of Glaucoma.
4
Q1 (Apr 2013)
Microbial Keratitis re-audit
Cornea and Cataract
Derek Tole (Cons)/Stuart Cook Re-audit of drug sensitivities and treatment
(Cons)
response. Rolled over from 2012/13 plan.
4
Q2 (Jul 2013)
Cataract Outcomes
Cornea and Cataract
Derek Tole (Cons)
National Audit. Royal College-led initiative
relating to revalidation of cataract surgeons.
3
Q1 (Apr 2013)
A&E 4 hour breaches and follow-ups
A&E & Primary Care
Derek Tole (Cons)/Rafik Girgis
(Cons)
Significant waiting time targets for Trust.
Assess improvement since previous audit
cycles.
3
Q3 (Oct 2013)
Lucentis outcomes
Medical & Surgical Retina
Adam Ross (Cons)
NICE guideline TA155. Large area of service
provision.
3
Q2 (Jul 2013)
Referral and treatment times for Diabetic retinopathy and
maculopathy
Medical & Surgical Retina
Abosede Cole (Cons)/Kate
Powell (Senior Optometrist)
National Screening Programme standards
3
Q4 (Feb
2014)
Outcomes of nasolacrimal duct probing (re-audit)
Paediatrics, Oculoplastics
and Squint
Amanda Churchill (Cons)
To determine whether improvements have
been made since previous audit cycle
4
Q1 (Apr 2013)
Documenting Non-Accidental Injury
Paediatrics, Oculoplastics
and Squint
Cathy Williams (Cons)
Recent systematic review and new suggested
way of documenting findings nationally
4
Q2 (Jul 2013)
Paediatric Eye Service Satisfaction Survey
Paediatrics, Oculoplastics
and Squint
Amanda Churchill (Cons)
Deferred from 2012/13 due to changes on ward
and staff availability
4
Q2 (Jul 2013)
Mental Capacity Act
ENT
Ophthalmology
Clinical Audit Annual Report 2012/13
Page 52
Discharge of paediatric patients from orthoptic department
Orthoptics and Optometry
Ann Starbuck (Orthoptist)/
Estelle Bishop (Orthoptist)
Departmental standards - Increased activity and
fewer clinicians
4
Q1 (Apr 2013)
Assessment of orbital trauma patients (re-audit)
Orthoptics and Optometry
Ann Starbuck (Orthoptist/
Estelle Bishop (Orthoptist)
Departmental standards – not audited for
several years
4
Q2 (Jul 2013)
Instilling of dilating drops in children for refraction and fundus
and media examination
Orthoptics and Optometry
Ann Starbuck (Orthoptist)/
Estelle Bishop (Orthoptist)
New Departmental standards
4
Q3 (Sep
2013)
Visual outcomes in Congenital cataract patients
Orthoptics and Optometry
Sarah Smith (Orthoptist)
Departmental standards
4
Q2 (Jul 2013)
National Bowel Cancer Audit (NBOCAP)
Colorectal
Lead to be confirmed
National audit (NCAPOP)
1
Q1 (Apr 2013)
SECCA (Radiofrequency Ablation for Feacal Incontinence)
Colorectal
Paul Sylvester (Cons)
New interventional procedure approved by the
Clinical Effectiveness Group
2
To be
confirmed
CT-guided guidewire localisation of impalpable lung lesions
before minimal access surgical excision
Thoracic
Tim Bachelor (Cons)
New interventional procedure approved by the
Clinical Effectiveness Group
2
To be
confirmed
National Joint Registry (NJR)
Trauma & Orthopaedics
Sanchit Mehendale (Cons)
National audit (NCAPOP)
1
Q1 (Apr 2013)
Trauma (TARN)
Trauma & Orthopaedics
Emergency Department
Lead to be confirmed
National Audit (Quality Accounts)
1
Q1 (Apr 2013)
National Oesophago-Gastric Cancer Audit (NAOGC)
Upper GI
Paul Barham (Cons)
National audit (NCAPOP)
1
Q1 (Apr 2013)
VSGBI Vascular Surgery Database
Vascular
Peter Lamont (Cons)
National Audit (NCAPOP) – newly contracted
1
Q1 (Apr 2013)
NICE TA167 Abdominal aortic aneurysm - endovascular stent
grafts
Vascular
Marcus Brooks (Cons)
BNSSG NICE Commissioning College priority,
carried over from previous year
1
Q1 (Apr 2013)
Carotid interventions (CIA)
Vascular
Peter Lamont (Cons)
National Audit (NCAPOP)
1
Q1 (Apr 2013)
Fenestrated endovascular aortic stent graft for juxta-renal
abdominal aortic aneurysm repair (F-EVAR)
Vascular
Marcus Brooks (Cons)
New interventional procedure approved by the
Clinical Effectiveness Group
2
To be
confirmed
Sub-Specialty
Lead
Rationale
Category Start date
Severe Sepsis (College of Emergency Medicine)
Emergency Department
Lead to be confirmed
National Audit (Quality Accounts)
1
Q2 (Aug 2013)
Congenital heart disease (CHD)
Cardiac Surgery
Andrew Parry (Cons)
National Audit (NCAPOP)
1
Q1 (Apr 2013)
Adult Surgical Specialties
Division: Women’s & Children’s
Title
Children’s Services
Clinical Audit Annual Report 2012/13
Page 53
National Diabetes Audit (NDA)
Diabetes & Endocrinology
Christine Burren (Cons)
National Audit (NCAPOP)
1
Q2 (Jul 2013)
National Inflammatory Bowel Disease audit
Gastroenterology
Christine Spray (Cons)
National audit (NCAPOP)
1
Q1 (Apr 2013)
Paediatric Intensive Care (PICANet)
Intensive Care
Peter Davis (Cons)
National Audit (NCAPOP)
1
Q1 (Apr 2013)
Renal Registry (UKRR)
Nephrology
Carol Inward (Cons)
National Audit (Quality Accounts)
1
Q2 (Jul 2013)
Epilepsy 12 (Childhood Epilepsy)
Neurology
Phil Jardine (Cons)
National Audit (NCAPOP)
1
Q1 (Apr 2013)
National Neonatal Audit Project
Neonatal Intensive Care
Pam Cairns (Cons)
National audit (NCAPOP)
1
Q1 (Apr 2013)
Vermont-Oxford Benchmarking Project
Neonatal Intensive Care
David Harding (Cons)
National/International quality improvement
project
2
Q1 (Apr 2013)
Audit of Anaesthetic Record Keeping (to include detailed audit
of documentation of consent process)
Anaesthesia
Gail Lawes (Cons)
RCOA standard and CQC
AAGBI ‘Consent for Anaesthesia’ Guidelines
3
Q2 (Jul 2013)
Audit of the provision of Anaesthetic Preoperative Information
Anaesthesia
Steve Sale (Cons)
AAGBI / RCOA / RCN ‘Best Practice’ Guide for
management of epidurals
3
Q2 (Jul 2013)
Anaesthesia
Bev Guard (Audit Lead)
Local Guidelines plus perceived clinical need
3
Q2 (Jul 2013)
Cochlear Implants
Audiology
Liz Midgley
NICE TA166 - Rolled over from 2012/13 plan
1
Q1 (Apr 2013)
Hospital passport
Cross Hospital
Sara Palmer (Disability Lead
Nurse)
National Service Framework
Rolled over from 2012/13 plan
1
To be
confirmed
Audit of growth monitoring practice
Endocrinology
Liz Crowne (Cons)
Re-audit confirmed from previous action plan
Rolled over from 2012/13
1
Q1 (Apr 2013)
An Audit of the physical and psychological management of selfharm in the emergency department
Emergency Department
Lisa Goldsworthy (Cons)
Audit based on NICE Guidance
3
Q1 (Apr 2013)
Audit of paediatric asthma management
Emergency Department
Nick Sargant (Cons)
National college of Emergency Medicine audit
based on BTS/SIGN Asthma guideline 2012
1
Q1 (Apr 2013)
Consultant sign off for febrile children < 1 year old in the ED
Emergency Department
Mark Lyttle (Cons)
National college of emergency medicine audit
and DoH clinical quality indicator
1
Q1 (Apr 2013)
An Audit of the Management of Head Injury in the Children’s
Emergency Department
Emergency Department
Mark Lyttle (Cons)
NICE head injury guidelines (2007)
3
Q1 (Apr 2013)
An Audit of the Management of Children in the Children’s
Emergency Department with Suspected Urinary Tract Infection
Emergency Department
Will Christian (Cons)
Actions resulting from a recent national audit
suggesting areas for improvement in the ED
3
Q2 (July 2013)
Neonatal resuscitation
Neonatology
Ward Managers / NICU
Governance
CNST Maternity Standard 3.5.2
2
To be
confirmed
Re-audit of Antibiotic Policy Compliance Audit
Clinical Audit Annual Report 2012/13
Page 54
Immediate Care of the Newborn (Joint project with Obstetrics
and Midwifery)
Neonatology
Jackie Moxham (Patient Safety
CNST Maternity Standard 3.5.4
Manager)/Anoo Jain (Cons)
2
Q1 (Apr 2013)
Newborn feeding (Joint project with NICU)
Neonatology
Joan Beales (Infant Feeding
Co-ordinator)
CNST Maternity Standard 3.5.5
2
To be
confirmed
Examination of the Newborn (joint project with Obstetrics and
Midwifery)
Neonatology
Wendy Ring (Screening Co-CoCNST Maternity Standard 3.5.6
ordinator)/Anoo Jain (Cons)
2
To be
confirmed
Support for Parents (Joint project with Obstetrics and
Midwifery)
Neonatology
Jackie Moxham (Patient Safety
CNST Maternity Standard 3.5.8
Manager)/Anoo Jain (Cons)
2
Q2 (July 2013)
Anaemia in Chronic Kidney Disease 3b to 5
Nephrology
Moin Saleem (Cons)
NICE Guidance
3
Q2 (Apr 2013)
Dialysis Access Complications
Nephrology
Jane Tizzard (Cons)
Renal NSF & Renal Association Guidelines
3
Q2 (Apr 2013)
Care of patients on Dialysis
Nephrology
Jan Dudley (Cons)
NSF & Renal Association Guidelines
3
Q2 (Apr 2013)
Management of Renal Bone Disease
Nephrology
Martin Mraz
NSF & Renal Association Guidelines
3
Q2 (Apr 2013)
Prescription of Dialysis Line Locks
Nephrology
Rebekah Rogers (Pharm)
Local Guidelines
3
Q2 (Apr 2013)
Vancomycin – monitoring and dose adjustment
Pharmacy
Jenny Haylor
Related to missed doses and patient safety
initiatives
2
To be
confirmed
Patient administration and compliance issues when prescribed
Proton Pump Inhibitors
Pharmacy
Nicola Singh (Pharm)
Cost-effectiveness and patient safety across the
SW region
2
To be
confirmed
Accurate CRIS documentation of consultant checks
Radiology
David Grier (Radiologist)
Re-audit confirmed from previous action plan
3
To be
confirmed
Genetic Haemoglobinopathy screening (re-audit)
Clinical Genetics
Jessica Bailey (Trainee Genetic
Check improvement following change in system
Counsellor)
3
To be
confirmed
Key identifiers in dictation
Clinical Genetics
Ingrid Scurr (Consultant Clinical
To assess use of key identifiers by clinicians
Geneticist)
3
Q1 (Apr 2013)
Case note peer review
Clinical Genetics
Alan Donaldson (Cons)
To assess standards of record keeping
3
To be
confirmed
West of Britain Group joint audit – probably Lynch syndrome
screening
Clinical Genetics
Alan Donaldson
West of Britain Group Genetics audit –
2013/2014
3
To be
confirmed
Total Laparoscopic Hysterectomy (TLH)
Gynaecology
Caroline Overton (Cons)
New interventional procedure approved by the
Clinical Effectiveness Group
2
To be
confirmed
Swab management on CDS / Handover to Theatres
Obstetrics/Midwifery
Bryony Strachan / E Treloar
Response to Incident
2
To be
confirmed
Women’s Services
Clinical Audit Annual Report 2012/13
Page 55
Care of Women in Labour
Obstetrics
Emma Treloar (Consultant)/
Belinda Cox (PD Midwife)
CNST Maternity standard 3.2.1
2
Q1 (Apr 2013)
Intermittent Auscultation
Obstetrics/Midwifery
Emma Treloar (Consultant)/
Belinda Cox (PD Midwife)
CNST Maternity Standard 3.2.2
2
Q1 (Apr 2013)
Continuous Electronic Fetal Monitoring
Obstetrics/Midwifery
Emma Treloar (Consultant)/
Belinda Cox (PD Midwife)
CNST Maternity Standard 3.2.3
2
Q1 (Apr 2013)
Fetal Blood Sampling
Obstetrics/Midwifery
Emma Treloar (Consultant)/
Belinda Cox (PD Midwife)
CNST Maternity Standard 3.2.4
2
Q1 (Jun 2013)
Use of Oxytocin
Obstetrics/Midwifery
Emma Treloar (Consultant)/
Belinda Cox (PD Midwife)
CNST Maternity Standard 3.2.5
2
Q1 (Jun 2013)
Caesarean Section
Obstetrics/Midwifery
Emma Treloar (Consultant)/
Belinda Cox (PD Midwife)
CNST Maternity Standard 3.2.6
2
Q1 (Apr 2013)
Induction of Labour
Obstetrics/Midwifery
Emma Treloar (Consultant)/
Belinda Cox (PD Midwife)
CNST Maternity Standard 3.2.7
2
Q2 (July 2013)
Severely Ill Women
Obstetrics/Midwifery
Emma Treloar (Consultant)/
Belinda Cox (PD Midwife)
CNST Maternity Standard 3.2.8
2
Q1 (Apr 2013)
High Dependency Care
Obstetrics/Midwifery
Emma Treloar (Consultant)/
Belinda Cox (PD Midwife)
CNST Maternity Standard 3.2.9
2
Q1 (Apr 2013)
Vaginal Birth after Caesarean Section
Obstetrics/Midwifery
Emma Treloar (Consultant)/
Belinda Cox (PD Midwife)
CNST Maternity Standard 3.2.10
2
Q1 (Jun 2013)
Operative Vaginal Delivery
Obstetrics/Midwifery
Rachna Bahl (Consultant)/Lisa
Damsell (Modern Matron)
CNST Maternity Standard 3.3.3
2
Q1 (Apr 2013)
Multiple Pregnancy and Birth
Obstetrics/Midwifery
Rachna Bahl (Consultant)/Lisa
Damsell (Modern Matron)
CNST Maternity Standard 3.3.4
2
Q4 (Jan 2014)
Perineal Trauma
Obstetrics/Midwifery
Rachna Bahl (Consultant)/Lisa
Damsell (Modern Matron)
CNST Maternity Standard 3.3.5
2
To be
confirmed
Shoulder Dystocia
Obstetrics/Midwifery
Rachna Bahl (Consultant)/Lisa
Damsell (Modern Matron)
CNST Maternity Standard 3.3.6
2
Q1 (Apr 2013)
Obstetric Haemorrhage
Obstetrics/Midwifery
Rachna Bahl (Consultant)/Lisa
Damsell (Modern Matron)
CNST Maternity Standard 3.3.7
2
01 (Apr 2013)
Pre-existing Diabetes
Obstetrics/Midwifery
Rachna Bahl (Consultant)/Lisa
Damsell (Modern Matron)
CNST Maternity Standard 3.3.9
2
To be
confirmed
Obesity
Obstetrics/Midwifery
Rachna Bahl (Consultant)/S-J
Sheldon (Community Matron)
CNST Maternity Standard 3.3.10
2
Q1 (Jun 2013)
Mental Health
Obstetrics/Midwifery
S-J Sheldon (Community
CNST Maternity Standard 3.4.7
Matron)/Rachel Liebling (Cons)
2
To be
confirmed
Handover of Care (Onsite)
Obstetrics/Midwifery
S-J Sheldon (Community
Matron)
2
Q1 (Apr 2013)
Clinical Audit Annual Report 2012/13
CNST Maternity Standard 3.4.8
Page 56
Non-Obstetric Emergency Care
Obstetrics/Midwifery
Rachna Bahl (Consultant)/Lisa
Damsell (Modern Matron)
2
To be
confirmed
Neonatal resuscitation
Obstetrics/Midwifery
Ward Managers / CDS Working
CNST Maternity Standard 3.5.2
Party
2
TBC
Immediate Care of the Newborn (Joint project with NICU)
Obstetrics/Midwifery
Jackie Moxham (Patient Safety
CNST Maternity Standard 3.5.4
Manager)/Anoo Jain (Cons)
2
Q1 (Apr 2013)
Newborn feeding (Joint project with NICU)
Obstetrics/Midwifery
Joan Beales (Infant Feeding
Co-ordinator)
CNST Maternity Standard 3.5.5
2
To be
confirmed
Examination of the Newborn (Joint project with NICU)
Obstetrics/Midwifery
Wendy Ring (Screening Coordinator) / Anoo Jain (Cons)
CNST Maternity Standard 3.5.6
2
To be
confirmed
Bladder Care
Obstetrics/Midwifery
Jackie Moxham (Patient Safety
CNST Maternity Standard 3.5.7
Manager)
2
To be
confirmed
Support for Parents (Joint project with NICU)
Obstetrics/Midwifery
Jackie Moxham (Patient Safety
CNST Maternity Standard 3.5.8
Manager)/Anoo Jain (Cons)
2
Q2 (July 2013)
Recovery
Obstetrics/Midwifery
Claire Dowse (Cons)
CNST Maternity Standard 3.5.10
2
Q1 (Apr 2013)
Title
Sub-Specialty
Lead
Rationale
Category Start date
Audit of Staff Support and Being Open Policy (Duty of Candour)
and follow up re-audit 6/12 later
Corporate
Anne Reader (Head of Quality) NHSLA Compliance
1
Q1 (Apr 2013)
Q3 (No 2013)
Audit of Serious Incident Policy and Policy for the Management
of Incidents and follow up re-audit 6/12 later
Corporate
Anne Reader (Head of Quality
NHSLA Compliance
1
Q1 (Apr 2013)
Q3 (No 2013)
Audit of Policy for the Management of Incidents and follow up
re-audit 6/12 later
Corporate
Simon Harrison Boyle (Pateint
Safety)/Mel Fewkes
NHSLA Compliance
1
Q1 (Apr 2013)
Q3 (No 2013)
Audit of VTE Policy and follow up re-audit 6/12 later
Corporate
Anne Reader (Head of Quality)
NHSLA Compliance
/ Amanda Clarke (Cons)
1
Q1 (Apr 2013)
Q3 (No 2013)
Medicines Storage
Medicines Management
Steve Brown (Director of
Pharmacy)
CQC priority for inspection
2
Q4 (Feb 2014)
Inpatient prescribing audit
Pharmacy
Helen Badham (Pharmacist)
Re-audit
3
Q2 (Jun 2013)
South West Quality and Patient Safety Improvement
Programme (General Ward)
Patient Safety
Anne Reader (Head of
Quality)/Catherine Hughes
Clinical Audit/Monitoring arising from individual
workstreams
2
Q1 (Apr 2013)
National Cardiac Arrest Audit (NCAA)
Resuscitation
Jo Bruce Jones (Resuscitation
Manager)
National Audit (Quality Accounts)
1
Q1 (Apr 2013)
Inpatient documentation audit
Records
Jane Luker (Cons)
CQC Outcome 21/NHSLA
2
Q3 (Nov 2013)
CNST Maternity Standard 3.4.10
Division: Trust-wide
Clinical Audit Annual Report 2012/13
Page 57
Dementia Screening
Trustwide
Natalie Godfrey (Dementia
Lead Nurse)
Regional CQUIN/Trust Quality Objective
1
Q1 (Apr 2013)
Ward Transfers for patients with cognitive impairment
Trustwide
Natalie Godfrey (Dementia
Lead Nurse)
Regional CQUIN/Trust Quality Objective
1
Q1 (Apr 2013)
Patient Safety Thermometer
Wards
Helen Morgan (Dep Head of
Nursing)
Local CQUIN
1
Q1 (Apr 2013)
Ward based monthly monitoring work
Wards
Helen Morgan (Dep Head of
Nursing)
Streamlining of current ward based data
collection. Ongoing quality measurement
2
Q2 (July 2103)
Clinical Audit Annual Report 2012/13
Page 58
Appendix D - National audit participation (extract from UH Bristol Quality Report 2012/13)
Participation in clinical audits and national confidential enquiries
For the purpose of the Quality Account, the Department of Health published an annual list of national
audits and confidential enquiries, participation in which is seen as a measure of quality of any trust
clinical audit programme. This list is not exhaustive, but rather aims to provide a baseline for Trusts in
terms percentage participation and case ascertainment. The detail which follows, relates to this list.
During 2012/13, 44 national clinical audits and national confidential enquiries covered NHS services that
University Hospitals Bristol NHS Foundation Trust provides.
During that period University Hospitals Bristol NHS Foundation Trust participated in 91% (40/44) national
clinical audits and 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 2012/13 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 trauma (Trauma Audit & Research Network, TARN)
Yes
Yes
Blood and Transplant
National Comparative Audit of Blood Transfusion programme
Potential donor audit (NHS Blood & Transplant)
Yes
Yes
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)
Adult cardiac surgery audit (ACS)
Cardiac arrhythmia (HRM)
Congenital heart disease (Paediatric cardiac surgery) (CHD)
Coronary angioplasty
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Heart failure (HF)
Yes
Yes
National Cardiac Arrest Audit (NCAA)
Yes
Yes
National Vascular Registry
Yes
Yes
Long term conditions
Adult asthma (British Thoracic Society)
Yes
No
Acute
Adult community acquired pneumonia (British Thoracic Society)
Adult critical care (Case Mix Programme – ICNARC CMP)
Emergency use of oxygen (British Thoracic Society)
Medical and Surgical programme: National Confidential Enquiry into Patient
Outcome and Death (NCEPOD)
National Joint Registry (NJR)
Non-invasive ventilation - adults (British Thoracic Society)
Renal colic (College of Emergency Medicine)
Clinical Audit Annual Report 2012/13
Page
Bronchiectasis (British Thoracic Society)
Diabetes (Adult) ND(A), includes National Diabetes Inpatient Audit (NADIA)
Diabetes (Paediatric) (NPDA)
Inflammatory bowel disease (IBD)
National Review of Asthma Deaths (NRAD)
Pain database
Renal replacement therapy (Renal Registry)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Older People
Carotid interventions audit (CIA)
Fractured neck of femur (College of Emergency Medicine)
Hip fracture database (NHFD)
National audit of dementia (NAD)
Sentinel Stroke National Audit Programme (SSNAP)
Yes
Yes
Yes
Yes
Yes
Yes
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
No
Yes
No
Women’s & Children’s Health
Child health programme (CHR-UK)/ Child Health Clinical Outcome Review
Programme (CH-CORP)
Epilepsy 12 audit (Childhood Epilepsy)
Maternal, infant and newborn programme (MBRRACE-UK)*/ Maternal,
Newborn and Infant Clinical Outcome Review Programme (MNI-CORP)
Neonatal intensive and special care (NNAP)
Paediatric asthma (British Thoracic Society)
Paediatric fever (College of Emergency Medicine)
Paediatric intensive care (PICANet)
Paediatric pneumonia (British Thoracic Society)
*This programme was previously also listed in our 2010/11 and 2011/12 Quality Accounts as ‘Perinatal Mortality’.
Of those national audits that the Trust did not participate in, the reasons/details of future participation are
outlined below:


British Thoracic Society audit programme – Other national asthma audit undertaken
Paediatric fever (College of Emergency Medicine) – Data collection period missed
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 2012/13 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
Adult community acquired pneumonia (British Thoracic Society)
Adult critical care (Case Mix Programme – ICNARC CMP)
Emergency use of oxygen (British Thoracic Society)
Medical and Surgical programme: National Confidential Enquiry into Patient Outcome
and Death (NCEPOD)
100% (1212/1212)
8*
National Joint Registry (NJR)
58% (19/30)
88% (8/9)
Clinical Audit Annual Report 2012/13
Page
Non-invasive ventilation - adults (British Thoracic Society)
18*
Renal colic (College of Emergency Medicine)
Severe trauma (Trauma Audit & Research Network, TARN)
100% (50/50)
27*
Blood and Transplant
National Comparative Audit of Blood Transfusion programme
Potential donor audit (NHS Blood & Transplant)
232*
Data not available
Cancer
Bowel cancer (NBOCAP)
Head and neck oncology (DAHNO)
Lung cancer (NLCA)
Oesophago-gastric cancer (NAOGC)
89% (164/185)
89% (52/71)
72% (130/180)
100% (142/142)
Heart
Acute coronary syndrome or Acute myocardial infarction (MINAP)
Adult cardiac surgery audit (ACS)
Cardiac arrhythmia (HRM)
Congenital heart disease (Paediatric cardiac surgery) (CHD)
Coronary angioplasty
100% (866/866)
100% (1452/1452)
765*
100% (766/766)
100% (1331/1331)
Heart failure (HF)
384*
National Cardiac Arrest Audit (NCAA)
106*
National Vascular Registry
98% (45/46)
Long term conditions
Adult asthma (British Thoracic Society)
Bronchiectasis (British Thoracic Society)
Diabetes (Adult) ND(A), includes National Diabetes Inpatient Audit (NADIA)
Diabetes (Paediatric) (NPDA)
Inflammatory bowel disease (IBD)
National Review of Asthma Deaths (NRAD)
Pain database
Renal replacement therapy (Renal Registry)
17*
100% (89/89)
382*
100% (40/40)
100% (2/2)
145*
Data not available
Older People
Carotid interventions audit (CIA)
Fractured neck of femur (College of Emergency Medicine)
Hip fracture database (NHFD)
National audit of dementia (NAD)
Sentinel Stroke National Audit Programme (SSNAP)
100% (46/46)
100% (50/50)
100% (342/342)
100% (40/40)
100% (111/111)
Other
Elective surgery (National PROMs Programme)
70% (168/239)
Women’s & Children’s Health
Child health programme (CHR-UK)/ Child Health Clinical Outcome Review Programme
(CH-CORP)
Epilepsy 12 audit (Childhood Epilepsy)
Maternal, infant and newborn programme (MBRRACE-UK)*/ Maternal, Newborn and
Infant Clinical Outcome Review Programme (MNI-CORP)
Neonatal intensive and special care (NNAP)
Paediatric asthma (British Thoracic Society)
Paediatric fever (College of Emergency Medicine)
100% (1/1)
100% (59/59)
N/A
795*
100% (17/17)
Clinical Audit Annual Report 2012/13
Page
Paediatric intensive care (PICANet)
100% (682/682)
Paediatric pneumonia (British Thoracic Society)
* No case requirement outlined/unable to establish baseline from HES data
The reports of ten national clinical audits were reviewed by the provider in
2012/13. University Hospital Bristol NHS Foundation Trust intends to take the following actions to improve the
quality of healthcare provided:
College of Emergency Medicine audits
 A joint sepsis protocol has been developed with the Emergency Department and the Medical Admissions
Unit
 Teaching sessions have taken place to highlight need for cultures and lactate measurement and the early
use of antibiotics
 A process for the rapid assessment and triage of patients has been implemented
Epilepsy 12 audit (Childhood Epilepsy)
 Children with a new diagnosis of epilepsy are to be prioritised for referral to the Epilepsy Specialist Nurse
 An ‘appropriate first clinical assessment’ proforma is being developed to help ensure developmental and
emotional/behavioural assessments are undertaken
National Cancer Audits
 To improve the quality of cancer data, a ‘data entry guide’ will be created to help identify the correct
places for key cancer information to be recorded on the Somerset Cancer Registry
 Regular checks for missing gaps in datasets will be conducted through the use of formal data quality
reports created via the information team
 A review of administrative services for cancer (including data collection resources) is taking place and a
business case has been for data co-ordinator has been put forward
National Cardiac Arrest Audit (NCCA)
 It has been agreed that all cardiac arrests will be reported on the Trust incident reporting system (Ulysses
Safeguard) to improve data quality and to enable learning from these incidents.
National comparative re-audit of platelet transfusion
 The Trust has developed a Standard Operating Procedure for quick reference to pre transfusion checking
/ patient identity / care of transfused patients to improve practice in transfusion care.
The reports of 197 local clinical audits were reviewed by University Hospital Bristol NHS Foundation Trust in
2012/13; summary outcomes and actions reports were reviewed on a quarterly basis by the Clinical Audit Group.
Details of the changes and benefits of these projects will be published in the Trust’s Clinical Audit Annual Report
for 2012/131.
1
Available via the Trust’s internet site from June 2013
Clinical Audit Annual Report 2012/13
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