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Key Title of Audit/Project

Audit Lead Brief Description Lead Division

Date Started

Status Date Completed

Results and Recommendations Changes made

2876 Audit of Acute Pain Management

Barbara Leach, Senior Acute Pain Nurse, Nicky Vallance, Pain Nurse Specialist, Dr Martyn Ezra, CT1, Anaesthetics

To ensure that all staff are complying with Epidural and Patient Controlled Analgesia Trust guidelines by reviewing documentation.

Surgery and Critical Care

05/01/2010 Complete 07/03/2011 Recommendations: Present audit at nurse forums; review teaching packages; include larger section on documentation in teaching session; regular snapshot repeat audit on documentation.

The outcome of the audit was presented at some nurse forums. Teaching packages are being reviewed at present and documentation is being highlighted more in all pain sessions. Repeat audit to review any improvement has not been carried out but an improvement has been noticed during ward rounds. However, a re-audit will be performed to assess improvement.

2874 Audit of INR Control for Acute Medical Admissions on Warfarin (WH)

Dr Oneme Ogona, FY2, Respiratory Medicine, WH, Dr Wathen, Respiratory Medicine, Consultant

Audit of patients admitted on warfarin who have INRs outside the chosen therapeutic range. To assess strength of indictaion for warfarin treatment and assess the reasons for poor INR control.

Medicine 13/01/2010 Cancelled 02/11/2010 Cancelled Cancelled - not applicable.

2875 Audit of Use of Sliding Scales & Appropriate Requesting of HbA1c (SMH)

Dr S Mapara, FYI, Dr R Lloyd FY1, Dr R Evans FY1, Dr S Chatterjee, Consultant, Diabetes

New evidence shows that HbA1cs are useful in diagnosis and monitoring of diabetes. The aim of this audit is to encourage appropriate requesting of HbA1cs and to ensure sliding scales are used appropriately and reviewed regularly by the medical team.

Medicine 14/01/2010 Complete 30/06/2010 > 80% of patients were initiated on a sliding scale for reasons listed in guidelines. Sliding scales are not being reviewed every six hours as recommended. Poor documentation of who stops the sliding scale. Very few teams are requesting HbA1c for diabetic patients. In many patients with poor BM control, diabetes referral not made. Recommendations: Continue to initiate sliding scales for appropriate reasons. Review sliding scales more frequently. Clearly document when sliding scale should be stopped and who has made this decision. Request HbA1c in any patient with a history of DM or hyperglycaemia. Contact the diabetes team in the following circumstances: poor glycaemic control, recurrent hypoglycaemia, diabetic emergencies, patients with hyperglycaemia and MI and discharge planning.

No changes made.

2877 Audit of Pressure Ulcers - A Shared Responsibility Which Starts With Appropriate Referral (PCT)

Gbonyefa Samani, Community Dietitian

Local policy and NICE guidance recommend that patients on admission should be screened immediately to establish if they are at risk of developing pressure ulcers, using a valid and reliable assessment tool and then referred appropriately.

Community & Integrated Care

14/01/2010 Complete 07/07/2010 1. A re-audit to be carried out using a larger sample size - 10 residents from 5 different care homes. 2. Presentation on findings to care homes to raise awareness.

Annual re-education on pressure ulcers and its management.

2878 Royal College of Radiologists National Audit of Liver Biopsy (US/CT Guided)

Dr Phil Cadman, Consultant, Radiology

To assess diagnostic adequacy, accuracy and complications of image-guided or assisted liver biopsy.

Clinical Support Services

19/01/2010 Complete 15/09/2010 Results good, no action required. None required

2879 Audit of Compliance with NICE Guideline 50 - looking after the acutely ill adult in hospital (BHNHST)

Jenny Ricketts, Outreach Lead Nurse

An audit to assess compliance with NICE Guideline 50 - looking after the acutely ill adult in hospital. This is being carried out as part of a MSc dissertation.


08/01/2010 Complete 05/01/2011 NICE guideline 50 should be implemented as a priority: 1. All staff working in acute hospital wards must use the EWS with every set of observations recorded. 2. The Graded Response Strategy for patients identified as being ‘at risk’ of clinical deterioration, must be followed, especially at night and out of hours. 3. Matrons and ward managers should be held accountable for ensuring that the Trust standard for Physiological Observations of Adult Non-Obstetric Inpatients (CG 26) is implemented in their area. 4. The SBAR communication tool should be rolled out Trust wide to improve multi-professional communication. 5. Education needs to be provided for the intensive care clinical staff to improve the accurate completion of the ICU discharge paperwork. 6. The business case for the provision of Outreach and Follow up services cross site should be revisited. 7. Provision of ALERT and BEACH courses, which should be mandatory for all new clinical staff, should be continued. 8. Re-audit, linked in with the critical care point prevalence audit in 2011.

Changes are being implemented as a result of this audit and also of the Critical Care Point Prevalence Audit 3212. The CCDG must review progress with implementation of this guideline since 2009 and must compile, implement and audit an action plan to accomplish full implementation. Divisional Lead Nurses and Matrons to ensure this is done by outlining expectations to their ward managers and by updating job descriptions and personal specifications.Develop local audit tool to monitor compliance with Trust standard frequently – weekly suggested – feedback results to staff. Formal education via

ALERT, BEACH, BLS, induction and preceptor courses. Explore possibility of mandatory e-learning module. Informal teaching in the clinical area by outreach team, resuscitation team and other competent staff members.

2880 H1N1: Local Descriptive Epidemiology for BHNHST

Dr Kathryn Lang, F2, Microbiology

To analyse each case of H1N1 confirmed and compare with national and international finds.


19/01/2010 Complete 25/05/2010 Epidemiological study, no results or recommendations.

Not required.

2881 Re-Audit of Compliance with MRSA Policy (1.1.1) Management of Sporadic Cases (BHNHST)

Dr Kathryn Lang, F2, Microbiology

MRSA is a national target. Trust guidelines clear on protocol for screening and then management once identified.


19/01/2010 Complete 24/03/2010 Of the 13 cases of MRSA diagnosed in November 2009, 7 fulfilled admission screening criteria and 5 were subsequently screened. The proportion of cases given suppression treatment once identified as MRSA carriers was less (10/13) than compared to our previous audit (22/23) but again we found there was minimal delay in starting therapy. There was generally poor documentation in the medical notes about the patient receiving an MRSA or isolation leaflet.

No changes forthcoming

2882 Outcome of treatment of patients attending Miss Ashworth's Infertility Clinic during 2008-2009.

Dr RamMohan , Dr Alka Halai, GPVTS, SMH

To review all new referrals to the Infertility Cllinic during 2008 and 2009 and review the outcome of their management.

Specialist Services

12/12/2009 Cancelled 30/03/2012 Project cancelled. Project cancelled

2883 Audit of Outpatient Physiotherapy Total Knee Replacement Class PES (SMH)

Tom Barnes, Physiotherapist, Rebecca Edwards, Physiotherapist SMH

To assess the individual patient's perceived level of improvements from the start of their physiotherapy rehab class to the end, a 6 week period.


15/01/2010 Complete 07/07/2010 Positive results for TKR rehabillitation. No results or recommendations.

Not required.

2884 Burns and Plastics Outpatient Physiotherapy - PES (SMH)

Jane Leathwood & Adam Fraser, Physiotherapists SMH

To determine whether patients believe that the service they are receiving is meeting their individual needs. A patient satisfaction survey has not been undertaken for Burns and Plastic Physiotherapy for at least 5 years.


20/01/2010 Complete 01/02/2011 93% of patients were 'very satisfied' with the overall treatment they received from the Burns and Plastics Physiotherapy Outpatients Department and 96% of patients were 'very satisfied' with the overall service. 78% of patients stated it was 'easy' to find the department and 79% of patients stated they were provided with written information. Recommendations: 1) Directions to the Burns and Plastics Physiotherapy Outpatient Department should be made clearer. 2) All patients should be given written information during their period of treatment.

Signage round Stoke Mandeville Hospital is being updated and Physiotherapy have been assured that they are part of this project. Leaflets and written information is being continually updated and handed to patients.

2886 Audit of Newly Spinal Cord Injured, Ventilator Dependent Patients Referred to a SCIC in South of England

Carrie Gardner, AIAU Project Co-ordinator, London Specialised Commissioning Group

To ascertain numbers of ventilator dependent patients waiting to transfer and transferring to a SCIC and to see if guidelines for ventilator weaning are being followed.

Spinal Injuries

21/01/2010 Complete 05/07/2010 There were no recommendations as the audit was carried out through the South East Commissioning board. It wasn’t a local audit but encompassed all 3 spinal units in the South. This will be presented at a National level not at the NSIC audit meeting.

N/A

2885 Side Effects and Compliance Rates in Patients Treated with Dipyridamole and Aspirin (SMH)

Dr Rachel Bate, FY1 and Dr Chris Durkin, Consultant

An audit to evaluate the use of dipyridamole in patients after stroke or TIA, specifically side effects and compliance issues.

Medicine 13/01/2010 Complete 07/07/2010 All patients perceived level of function had improved by a significant amount in 6 weeks and all patients range of movement had significantly increased in 6 weeks. No shortfalls were identified compared to the national standards therefore no specific recommendations are needed at present. This audit was a small sample size - a larger sample size should be considered over a longer period of time for any re-audit undertaken in the future.

No changes required at this time.

2887 Effectiveness of Entonox in Helping with Acute Pain in Interventional Procedures (SMH)

Sophie Alley, Deputy Sister, Radiology, SMH

To ascertain whether Etntonox helps radiology patients with the acute pain sometimes experienced during procedures.


21/01/2010 Complete 26/02/2010 To have Entonox readily available for use. All staff to be trained and competent in use of Entonox. To assess patients suitability prior to use.

Entonox is being used occasionally, as required, for interventional procedures in the Radiology Department. It has not been fully integrated into the whole department as yet.

2888 Chemotherapy Patient Experience Survey (BHNHST)

Annie Richards, Chemotherapy Clinical Nurse Specialist, Cancer Services

Obtain patient feedback regarding the service and information provided.


18/11/2009 Complete 25/11/2010 Results: Lots of positive comments regarding the two Units, their staff and the quality of information provided. However not all patients were aware of the name of their key worker or the purpose of the key worker role. Also patients were not always advsied to bring someone with them to their first consultation appointment. Recommendations: Review the system for advising patients to bring someone with them to their initial appointment. Key worker role needs to be actively promoted. For subsequent audits increase the number of questionnaires distributed and aim for a more equal spread between oncology and haematology patients. Patients need to be educated and awareness raised regarding the use and importance of out of hours contact numbers.

No changes required.

2889 Haematology Cancer Patient Experience Survey (BHNHST)

Asha Mathew and Marie Pennell, Haematology Clinical Nurse Specialists, Cancer Services



12/01/2010 Complete 20/01/2011 1. Patients should be given printed information regarding their diagnosis and details of their key worker. 2. Patients need to be advised to bring someone with them for support when the diagnosis is given. 3. All patients need to be provided with information on support groups and self-help groups by CNS. 4. When the re-audit takes place, it should include a larger sample of patients.

1. All the written information of diagnosis provided to patients is reviewed and the CNS is taking responsibility of making sure that patients receive these documents. It is clearly documented on patients’ notes (in Key worker document). 2. Both CNS in the Haematology Unit have completed an advanced communication course. Regular educational updates are provided for staff within the Haematology/chemotherapy unit and other areas in the hospital. The Cancer and Haematology has Practice development nurse in post to support with all educational needs of the staff. 3. All the changes implemented will be audited again in 8-12 months time.

2890 NICE Audit of Management of Open Abdomen (BHNHST)

Mr Hank Schneider, Locum Emergency Consultant, SMH

Concerns have been raised with the National Institute for Health and Clinical Excellence (NICE) that there may be a link between one of the treatments currently used on patients whose abdomens are left open after surgery or injury, called Negative Pressure Wound Therapy (NPWT), and patients developing intestinal


26/01/2010 Cancelled 29/07/2011 Project cancelled as incomplete data submitted before deadline. Audit Lead left Trust.

Cancelled.

fistulae, a potentially serious condition which can cause infection and bowel leaking. NICE have provided an audit tool to assist in data collection.

2891 Urology Cancer Patient Experience Survey (BHNHST)

Hilary Baker, Joe Kearney, Krystyna Caine, Clinical Nurse Specialists Uro-Oncology



25/01/2010 Complete 20/12/2010 Overall the results of the audit were very positive. The following recommendations were made: Patients should be advised both verbally and in writing to have a relative and/or friend accompany them when receiving their TRUS biopsy results. This advice should also be included in the written information given to patients regarding TRUS biopsies. Urology has three cancer support groups for patients with prostate, bladder and kidney cancer. Staff should ensure these are promoted at diagnosis and as required along the patient’s journey. Develop a leaflet explaining what a Multidisciplinary Team is and what its purpose is. Encourage consultants and associate specialists to attend an advanced communication course. Key worker documentation to include information regarding the stage and grade of disease together with details of the patient’s care plan.

Patients are advised verbally and in the patient information leaflet to have someone with them when receiving their TRUS biopsy results. Details of the three cancer support groups are given to patients at diagnosis. A leaflet explaining the working of MDTs has been produced and is given to patients at diagnosis. Key worker documentation has been revised to include stage and grade of disease together with details of the patient's care plan.

2892 Breast Cancer Patient Experience Survey (BHNHST)

Hilary Hillson, Clinical Nurse Specialist, Breast Cancer



27/01/2010 Complete 25/11/2010 Overall the results of the survey were very positive and patients value the service and support provided by the Breast Care Nurses. Suggestions for improvement: Ensure all patienst are aware of 'out of hours' and emergency contact details. Reduce clinic waiting times by adjusting outpatient appointment times. Ensure all patients undergoing surgery receive a post operation telephone call.

The clinic template has been altered so that ward follow up patients are seen later in the afternoon to reduce their waiting time. All breats cancer patients are phoned post operatively. All patients are made aware of out of hours contact details.

2893 Audit of the Management of Basal Cell Carcinomas (BHNHST)

Dr Katherine Acland, Consultant, Dr Ben Esdaile, SpR, Dermatology

To look specifically at diagnostic accuracy, documentation, complete efusions and clinical and surgical excision margins.

Integrated Medicine

29/01/2010 Complete 20/04/2010 The rate of 87% complete excision rate with narrow margins is unsatisfactory. Reasons for this could be 1) level of operator – large number of juniors performing procedures due to pressure on system. Lesions on head/neck not being removed with sufficient margins. 2) Intent of surgery and triaging of patients in clinic onto correct surgical list. Recommendations: More junior training and supervision. Further dedicated surgical Dermatology Consultant required. Action plan: Review notes of incomplete excisions to ascertain intent of procedure, known diagnosis and then excision. Audit Recurrence and re-excision. Implement standard surgical operation sheet proforma with specific

As a result of the audit a surgical proforma has been implemented which is currently in use. This is to attempt to improve the note taking in the surgical clinics and to ensure that clinical margins of excision are documented and considered. When the audit was presented to the department surgical margins were also discussed. An audit is currently in progress which will show whether the

sections for surgical margins etc. Grading and triaging of surgery to appropriate surgeon – i.e. consultant supervision for large lesions on head/neck. Re-audit.

proformas have improved the record keeping. It is too soon to tell whether rates of complete excision have improved as the numbers are not yet sufficient.

2894 Completion of EMC X-ray Request Forms

Amal Fadal, Radiology A substantial number of EMC forms are completed unsatisfactorily. This audit is to assess the size of the problem and to address it.


15/07/2009 Complete 17/03/2010 76% forms incorrectly filled or ID information missing. Official memo to be sent to EMC staff asking them to fill in form corretly.

EMC will be moving to electronic requests soon. Talks are in progress regarding the need to repeat the audit or whether there is enough information to proceed with electronic ordering of forms.

2895 Analysis of Transfers from Wycombe and Aylesbury Birth Centres to Delivery Suite (BHNHST)

Dr Maria Zammit-Mangion, ST4, Miss Veronica Miller, Consultant

Following the recent closure of WH Delivery Suite and conversion to a Birth Centre, this is an audit to assess the cohort of patients allowed to deliver at the Birth Centre and whether they fulfil the criteria for this. Also, an analysis will be made of the reasons for transfers to SMH Delivery Suite and whether management was appropriate.

Women & Children

29/01/2010 Complete 20/04/2010 The audit showed that the reasons for transfers from Wycombe or Aylesbury Birth Centre to the Delivery Suite, were valid. There were fewer transers from Wycombe Birth Centre (probably due to proximity). Pain relief was the major reason for transfer from Aylesbury Birth Centre. There was a higher Caesarean Section rate for the patients transferred from Wycombe Birth Centre (probably reflective of the differing reasons for transfer).

As no recommendations were made as a result of this audit no changes can be recorded.

2896 National Carotid Interventions Audit Phase 3

Mr Patrick Lintott, Mr Andy Northeast, Consultants, General Surgery, Geraldine Delacy, Surgical Nurse Practitioner

National audit of carotid interventions organised by the RCP. To enter details of all interventions 1st October 2009 to 29th October 2010 onto a web tool. Ongoing from Round 2 Audit 2640.


01/01/2010 Data Collection

Results and Recommendations required Changes required

2897 Airway Assessment in Obstetric Anaesthesia (SMH)

Dr Michelle Walters, ST5, Dr M Okolsor, Dr Willie Sellers, Consultant, Anaesthetics

Assessment of the patient's airway and documentation of this are essential components of anaesthesia. Failed intubation rates are higher in obstetric patients and a pre-op prediction of a difficult airway could reduce the incidence of failed intubations. This is a regional audit involving 5 hospitals in the Oxford Region.


08/02/2010 Complete 05/07/2010 This audit of airway assessment and documentation in obstetric anesthesia was performed in five hospitals of the Oxford region. In each hospital 200 case notes were examined for evidence of documentation including assessment of mouth opening, Mallampati (MP) classification, neck extension, dentition, jaw subluxation or other tests. This is the standard recommended by the Obstetric Anaesthetists' Association (OAA) for airway assessment. The audit revealed that documentation of airway assessment is poor in obstetric anesthesia. Anesthetic charts with specific prompts for airway assessment improve quality of airway assessment. The recommendation was to include an airway proforma on the obstetric anaesthetic chart, to be completed for all anaesthetic obstetric interventions, including epidurals.

No response from audit lead to requests for changes.

2898 National Audit of the Management of Familial Hypercholesterolaemia

Dr Steve Price, Consultant Chemical Pathologist

Web based data collection tool between 1/04/10 and 3/09/10. Organised by Royal College of Physicians.


08/02/2010 Cancelled 26/01/2011 Didn't take part in audit. N/A

2899 National CNS Patient Experience Survey (Breast Screening) (BHNHST)

Hillary Hillson, CNS, Breast Cancer, Cancer Services, Jeanette Tebutt, Lead Cancer Nurse

National patient survey developed by the National Co-ordination Group for Nursing in collaboration with the West Midlands QA Reference Centre to assess the role of the CNS in breast screening.


08/02/2010 Complete 02/11/2010 National and individual site results have been received. No recommendations or action plan have been formulated. The Trust has carried out it's own patient experience survey and recommendations and an action plan will be formulated from this.

Not applicable

2900 Newborn Hearing Screening Programme Satisfaction Survey

Angela Campbell, Newborn Hearing Screening Coordinator

The Newborn Hearing Screening Programme has been running for over 4 years. A satisfaction survey was recommended on a recent visit of the QA.

Women & Children

09/02/2010 Complete 09/09/2010 Screeners should ensure that they follow the format recommended, by the Programme Centre, for talking to the parents, which includes: reiterating what is in the leaflet, so that parents fully understand the need for the test and timing, and asking if the parents have any questions.

New Trust Guideline produced 532.1 February 2011. All screeners have been shadowed either by Angela Campbell or the senior screener to make sure that everybody is adhering to the recommended format.

2901 Audit of Prophylactic Antibiotic Use in Orthopaedic Patients

Lai Ye Cheang, Pharmacist Band 7

Antibiotic prophylaxis in orthopaedic surgery has changed in the last few months and, as infection rates have been higher in the last two years, this audit will check that antibiotic prophylaxis is being given correctly and that the prophylaxis regime is being adhered to.

Medicine 10/02/2010 Complete 30/09/2010 Results: This audit has demonstrated an improvement in adherence to the Trust’s guideline for antibiotic prophylaxis in joint replacement surgery after the introduction of the new regimens around November 2009. The more straightforward regimen with teicoplanin and gentamicin led to a greater degree of compliance than with the previous flucloxacillin/gentamicin combination. Recommendations: 1. Improve documentation surrounding the administration of antibiotic prophylaxis in order to assess more accurately the important timing of antibiotics in relation to the start of surgery. 2. Further improve the actual administration of prophylactic antibiotics as only 63% of patients received their peri-operative doses at the most appropriate time and the timing of post-operative doses also requires attention. 3. Re-audit in 12 months to look for improvement in prophylactic antibiotic prescribing, administration and documentation in elective hip and knee replacement surgery.

No changes supplied.

2902 National Survey of the Impact of Consultant Input into Acute Medical Admissions Management (BHNHST)

Dr David Taylor, Consultant

A study aiming to identify correlations between different levels of physician cover for acute medical admissions and patient outcomes such as length of stay, readmission rate and hospital mortality.

Medicine 25/11/2009 Cancelled 07/07/2011 Cancelled - not applicable

2903 Audit of Electronic Fetal Monitoring (BHNHST)

Dr Vimal Vyas, GPVTS and Mr Tunde Dada, Consultant

An audit of continuous electronic fetal monitoring, against current Trust guidelines.

Women & Children

08/02/2010 Complete 16/03/2010 Areas of non-compiance with the Trust guidelines were: Recording of signatures after initial starting of trace; Not recording date of birth on the trace; Not using Fresh Eyes stickers for interpreting the CTG or second opinions; Recording signature on the second sheet, when the CTG paper is changed. Staff training on correct recording will be provided.

Highlighted at Labour Ward Forum 09/06/2010. Staff training on correct recording being provided.

2904 Audit of Intermittent Fetal Monitoring (BHNHST)

Dr Christina Aye, ST2 and Mr Tunde Dada, Consultant

An audit of intermittent fetal monitoring, against current Trust guidelines.

Women & Children

08/02/2010 Complete 18/03/2010 Presented at academic half day in March 2010. 1st stage monitoring followed guidelines in 90% of cases but improvements are needed for use of the partogram. 2nd stage monitoring followed guidelines in 100% cases but only 4 cases used a 2nd stage partogram. Maternal pulse was recorded in 100% cases at or soon after admission. Maternal pulse was recorded hourly in 85% cases. Continuous electronic fetal monitoring was offered appropriately in all cases. The main recommendation was improved documentation of auscultation.

No changes forthcoming, but topic reaudited (2979) and found Intermittent auscultation always offered appropriately – offered in low risk patients and converted to continuous monitoring when indicated.

2905 Audit of High Dependency Care of Severely Ill Maternity Patients (SMH)

Dr Laura Burkimsher, ST1, Dr Haresh Nagar, ST1, Miss Miller, Consultant, Obs & Gynae. Dr Debosree Majumdar taking over

Audit of the quality of high dependency care received by severely ill maternity patients.

Women & Children

12/02/2010 Complete 01/06/2010 Mews charts are being completed. Documentation of all specialities involved in patient care needs to be improved. The majority of admissions appear appropriate (but there was insufficient data to confirm this). Current guidelines for admission criteria do not define moderate / severe pre-eclampsia. Admission criteria should be more specific about patients with PPH. A re-audit should be carried out in three months.

Reaudit carried out (3141).

2906 Urinary Catheter Care for Elective Caesareans

Jackie Dalton, Infection Control

There is concern that urinary catheters are not being inserted/maintained effectively in patients undergoing elective Caesareans. An observational audit, using the High Impact Intervention Tool used in other Infection Control Urinary Catheter audits, is to be carried out.


15/02/2010 Complete 03/03/2011 Compliance levels for individual elements of the insertion part of the audit were high; 96% (sterile drainage) -100% for all other elements. Sterile drainage was non-compliant on 1 occasion on the Labour Ward. Compliance levels for individual elements of the ongoing management part of the audit were high; 91% (catheter hygiene)-100% for all other individual elements. Catheter hygiene was non-compliant on 2 occasions on the Labour Ward. The area of non participation must produce an action plan to show how they are addressing these issues and how they are monitoring compliance.

Infection Control administer the completion of action plans by individual areas.

2907 DVT Prophylaxis audit

Jane Hegarty, CT2, Haematology

To audit thromboprophylaxis of patients suffering DVT/PE following hospital admissions. To compare current Trust practice with recently updated NICE guidelines.


22/02/2010 Complete 17/06/2010 VTE risk assessment NOT done in 78% of cases.Pharmacological prophylaxis NOT given in 46% of cases .No documentation of mechanical prophylaxis in 71% of cases.6.5% of cases had a contraindication to pharmacological prophylaxis. Recommendations: Implement NICE CG92 guidelines.Incorporate VTE assessment into admission proforma across all specialties.Mandatory junior doctor teaching. Re-audit (prospectively).

All DVT/PEs with hospital admissions and all deaths due to DVT/PE are now automatically registered as SUIs and followed up by Clinical Governance Incident reporting

2908 Service Evaluation following Repair of Chronic Achilles Tendon Ruptures treated with FHL Biotenodesis

Mr Aniruddha Pendse, Trust Registrar, Orthopaedics

To audit results following repair of chronic tendo-achilles ruptures with FHL Biotenodesis. To compare results with existing studies.


25/02/2010 Awaiting Report/Action Plan


2909 Community Infection Control Hand Hygiene Audit

Fiona Simpson, Infection Control Nurse, Quality and Performance Team, PCT

Hand hygiene tool completed for various PCT units. To analyse and report.

26/02/2010 Complete 14/05/2010 When poor practice is witnessed this must be challenged by all staff. If appropriate, actions need to be taken by line managers to ensure compliance to the hand hygiene policy. Improvements are needed with the removal of hand and wrist jewellery, and clinical staff being bare below the elbows, particularly within our community services.Facilities in clinical settings that have been identified as not complying with guidance including HTM 64, need to be refurbished at the earliest opportunity.Financial resources need to be provided in order to achieve these refurbishments. Where this process needs to be supported by capital bids, these bids need to be actioned as a priority.Staff need to be informed that they can order hand hygiene products for their use, including hand sanitiser and hand moisturiser, through the supplies department.

The hand hygiene facilities at Thame and FNH are being addressed with the ongoing estates works currently. All community sites have had a survey and upgrade of hand hygiene dispensers

2910 C Diff Infection Control Policy Audit

Martina Muscat, FY2, Microbiology

The guidelines regarding the management and documentation of C.difficile infections have recently been amended. This audit aims to assess whether these changes are being adhered to.


26/02/2010 Complete 26/02/2010 1. Early isolation of patients into side rooms if they develop diarrhoea. 2. Early submission of stool samples to the lab (the lab offer a same day result if the sample arrives before 2pm). 3. Providing patients or their relatives with leaflets of isolation and C.difficile infection and documenting this on the sticker in the notes. 4. Stool chart monitoring with daily entry, even if there was no bowel movement. 5. Starting treatment on the day of diagnosis. 6. Filling in the C.difficile letters and sending them to the GP and ICT. 7. Indicating on the discharge letter that the patient had C.difficile and was treated for this in the hospital.

All recommendations already in policy, just needed reminding. Re-audit will be carried out. It is a requirement to audit infection control policy.

2911 Community Infection Control Urinary Catheter Audit 2010

Fiona Simpson, Infection Control Nurse

Urinary catheter tool completed for various community units. To analyse and report. Re-audit.


01/03/2010 Complete 26/05/2010 Catheter insertion 100% compliance. Continuing care 99% inpatient, 100% community. Collection of specimens 100%. Actions: Obtain stands that ensure catheter tip does not touch flooring. Although practice is good, need to continue to observe practice and ensure infection control training is updated annually. Staff reminded to check bags more frequently. Staff member encouraged to wear apron when emptying catheter bags.

Was previously community so cannot comment, but I hope the issues raised from the action plan were discussed at ward level following dissemination of the report as they were mainly ward concerns. We have since repeated this audit with acute and community.

2912 Audit of Doctors' Communication and Patient Satisfaction Within Paediatrics (BHNHST)

Dr Tim Brummitt, ST1 and Dr A Dutta, Consultant

An audit to assess communication of doctors with paediatric patients and patient / family satisfaction, compared with the GMC Guidance on communication for 0-18 year olds.

Women & Children

15/02/2010 Cancelled 21/03/2011 Project cancelled as doctor has left the Trust and is not replying to emails.

Project cancelled.

2913 Paediatric A&E Attendance Reports - Information Documented for the Purpose of Paediatric Liaison (BHNHST)

Jane Bremnath, Named Nurse for Child Protection

Working Together to Safeguard Children (2006) and the Climbie Recommendations advise that the relevant GP and appropriate school nurse or health visitor are notified of each attendance to the A&E Department by a child. This is an audit to identify gaps in gathering and recording to enable and promote more effective sharing of information in the safeguarding process.

Women & Children

23/02/2010 Complete 28/02/2011 Clinicians are not completing the Paediatric A&E report forms with as much detail as they are required to do. At Stoke Mandeville the presenting problems are generally recorded under generic headings, whilst at Wycombe this section is completed more thoroughly, with more detail about the nature, location and type of injury. This is also the case for the diagnosis recorded, which the Wycombe forms describe in more detail than the Stoke forms. Recommendations: • To ensure that GP and school attended details are ascertained as correct at each visit to the A&E/EMC Departments. • To maintain, at all times, best practice in record keeping and documentation, using the Remass system of recording, to document accurate and concise information for all attendances. • All nursing and medical personnel should receive training on Remass, to enable and maintain standards of documentation.• To re-audit Paediatric Liaison reports in April 2011. • To ensure information sharing and record keeping is an integral part of all child protection training.

Remass training undertaken. Child protection training updated to include documentation. Re-audit carried out (3259).

However, on both sites, the mechanism of injury, when given, is almost always a generic description, using “other injury”, “unwell/non trauma” or “unwell”, instead of describing the mechanism of injury more accurately. On six occasions at Wycombe, the mechanism of injury was described as “unwell/non

trauma” when the diagnosis recorded had, in fact, been the result of an injury rather than an “unwell” patient.

Results: As a result of inaccurate or inadequate recording of the diagnosis and mechanism of injury, these frequently cannot be considered as being compatible. Unless clinicians complete these categories correctly the form is inadequate as a method of monitoring paediatric attendances at A&E and for the sharing of accurate and adequate information. Recommendations: 1. To ensure that GP and school attended details are ascertained as correct at each visit to the A&E / EMC Departments. 2. To maintain, at all times, best practice in record keeping and documentation, using the Remass system of recording, to document accurate and concise information for all attendances. 3. All nursing and medical personnel should receive training on Remass, to enable and maintain standards of documentation. 4. To re-audit Paediatric Liaison reports in April 2011. 5. To ensure information sharing and record keeping is an integral part of all child protection training.

2914 Audit of Fetal Blood Sampling (BHNHST)

Dr Lucy Young, SHO and Mr Tunde Dada, Consultant

FBS is one of the supplementary investigations to confirm fetal distress when CTG is pathological. The test should only be used when indicated and when facilities and training are available. The aim of this audit is to ensure that there are appropriate indications for taking FBS and to evaluate the documentation after the test.

Women & Children

15/02/2010 Complete 29/03/2010 Presented at academic half day in March 2010. The results showed that on nearly all occasions FBS results are documented in the notes in some format (either handwritten or hard copy). In the majority of situations where FBS is performed, it is indicated and is done at the correct time. Plans stating management following FBS result are always clearly documented. In the majority of situations the consultant is informed at the right time. On the occasions in the sample that they were not it was because delivery was imminent. The following areas could be improved: FBS results are not often recorded on the CTG and rarely recorded on the partogram. In less than half the sample were fresh eye stickers used. To consider 2nd FBS if the delivery is not imminent. To asked for consultant review if not sure whether FBS is indicated. The recommendations will be fed back to the Labour Ward Forum. Future audits on this topic may need to be expanded to include all patients with a pathological CTG trace.

Results taken to LWF. Re-audit carried out (3154). In 50% of cases review of the CTG suggested that FBS was not indicated. This was either the CTG being classified as suspicious at the time or when the trace was reviewed as part of this audit. Timing of samples: 53% were correctly timed. This timing was taken from the decision to perform the sample to the sample being processed. Small sample size for audit. The finding that 47% samples were not indicated was challenged as some felt there were factors other than the CTG that influence the decision to perform an FBS, although others felt that this should not be the case. Re-audit recommmended.

2915 Audit of Perineal Trauma (BHNHST)

Dr Nadia Aisheh and Dr Sarah Barker, SHOs; Mr Tunde Dada, Consultant

An audit of perineal trauma against the current Trust Guidelines.

Women & Children

15/02/2010 Complete 16/03/2010 The audit was presented at the academic half day in March 2010. Positive points were: All tears were classified appropriately; the appropriate technique was used in all cases documented. The correct suture material was used for perineal muscles and skin; all tears were sutured in theatre; in general all appropriate medications were prescribed; Appendix 1 was filled in correctly; For Wycombe patients all 3 were booked to the perineal clinic and appendix 2 was completed. Areas requiring improvement are: There is no perineal clinic for Stoke Mandeville patients; Only 1/11 using 3/0 PDS to IAS + EAS; Appendix 2 not being used when the patient is seen in ANC for follow up.

Re-audit carried out (3152).

2916 Audit of Obstetric Haemorrhage (BHNHST)

Dr Rakhi Sehmi, ST1 and Mr Tunde Dada, Consultant

An audit of obstetric haemorrhage against current Trust Guidelines.

Women & Children

15/02/2010 Complete 18/03/2010 Ongoing data collection – an obstetric haemorrhage proforma should be completed for blood loss greater than 500ml. An initial audit, detailing the results for proformas completed between 11th February and 3rd March 2010, was presented to the department in March. The main finding was that only 13/67 cases of blood loss greater than 500ml, had a proforma completed. Staff were unclear as to the volume of blood loss at which the proforma needs to be completed. The proformas which were completed had poor documentation of timings. The volume of blood loss at which the profoma needs to be completed has been reviewed and changed to 1litre. This will be confirmed with staff. There will be ongoing staff education regarding the location and use of the proformas.

The obstetric haemorrhage proforma has been changed and has to be completed for cases of blood loss greater than 500ml.

2917 Emergency Caesarean Section Audit (BHNHST)

Dr Christine Gan and Dr Robert Parsons, SHOs; Mr Tunde Dada, Consultant

An ongoing audit of Caesarean Section against NICE and CNST standards.

Women & Children

15/02/2010 Complete 22/03/2010 Ongoing data collection. An initial audit, detailing the results for 45 consecutive emergency Caesarean Sections from 8th February 2010 (when the audit was initiated) was presented to the department in March. The main results were: The audit proforma was completed in 36% notes; 50% had the NICE grading of CS recorded at the time of the decision; 79% had the reason for CS documented at the time of the decision; 55% had a delay in decision to section time (the reason for this was not recorded in most cases); there was evidence of a post-surgical discussion of events with the mother prior to discharge, in 33% cases. Areas of good practice included antibiotic / thromboprophylaxis, consultant liaison and antiemetics / antacids. Improvement is required in completing the EMCS prospective data collection proforma. A process has been put in place to raise awareness of the need to complete the form and complete missing forms retrospectively.

Recommendations referred to completion of the EMLCS documentation and the audit proforma. Ongoing audit, no changes forthcoming.

2918 Oxytocin Audit (BHNHST)

Dr Clare Conroy, SHO and Mr Tunde Dada, Consultant

An audit of the use of Oxytocin for induction of labour, against current Trust Guidelines.

Women & Children

15/02/2010 Cancelled 31/03/2010 N/A project cancelled N/A project cancelled

2919 Management of Hyperosmolar Nonketotic Patients

Dr Alireza Mohammadi, SpR (ST3), Endocrinology

To determine if hospital guideline relating to HONK is adhered to.

Medicine 03/03/2010 Cancelled 30/07/2010 Cancelled Cancelled

2920 Effect of Velcade on Platelet Counts

John Willan, FY1, Haematology

Velcade is a chemotherapy agent which is known to suppress platelet numbers. Currently given on certain days of chemotherapy cycle. Patients must have platelet levels measured before drug given. Audit aims to understand if platelets reduce in a particular way and thus determine if it is necessary to measure platelet levels before each dose.


03/03/2010 Complete 15/10/2010 Platelets fall in a very predictable way during administration of Velcade. Our results appear to match results from large scale published studies.We may be being overly cautious in withholding Velcade until that days platelet count is available. It was decided to implement the following option. At start of each cycle delay day 1 administration of Velcade until count received. If above 70 then rest of cycle can be administered without awaiting counts. Blood should still be taken pre-Velcade in case patient is in the <1% who needs a platelet infusion.

The option detailed was implemented.

2921 Community Nutrition and Dietetic Service Patient Satisfaction Survey

Renu Bansil, Dietetic Team Lead

A patient satisfaction survey to be carried out to assess the effectiveness of the service as part of the quality improvement programme.


03/03/2010 Complete 15/02/2011 The majority of patients are happy with the service provided. Long waiting times for referral appointments are being addressed; the integration into Bucks Healthcare and the hospital dietetic service may help. RIO may also help with inequalities in the service. Areas should be identified in which to extend provision – initially look at more rural areas e.g. Thame.

Waiting times have been addressed by providing additional clinics as and when required, however additional clinics in other areas have not been initiated.

2922 Management of Empyema in the Chest Department (WH)

Dr Lynne Curry, ST4, Chest Medicine, Dr Shahidi, Consultant, Chest Medicine, WH

Empyema is a serious medical condition affecting a number of patients each year. The purpose of this audit is to identify: whether antibiotics used are in keeping with local guidelines, the proportion of patients requiring surgery, whether BTS guidelines are being adhered to and whether there are certain organisms grown in our population of patients.

Medicine 05/03/2010 Complete 10/11/2010 On average the respiratory department manages one patient with empyema per month, and in most cases diagnostic tap and drain insertion were done promptly. Our use of ultrasound was low, and nutritional assessment could also improve. It is worth noting that part of the audit group predates the release of both the NPSA and BTS guidance (published 2008), and we now have a departmental ultrasound machine for pleural procedures. Surgical rates within our patient group appear to be comparable to that found in the literature.

A departmental ultrasound machine is now available for pleural procedures, no other changes made.

2923 Annual Hand Hygiene Report

Amanda Adkins, Infection Control Nurse

Infection Control have their own set of Excel spreadsheets on which they record all hand hygiene observational data each month by ward. They want an overall report, based on this data, for the period April 2009/March 2010.


08/03/2010 Complete 18/05/2010 The overall compliance level has improved from 90% in 2008/09 to 94%.‘Bare below the Elbows’ compliance has also improved from 92% to 95%. There has been a great increase in the number of observations recorded from 11999 in 2008/09 to 110213. The hand hygiene compliance per division ranged from 90% to 99%.

Report issued. Areas with low compliance required to carry out extra audits. Audit ongoing monthly.

2924 Routine Breast Screening Patient Experience Survey

Gareth Jowett, QMS Co-ordinator, Breast Screening

Breast screening patient experience survey to meet the requirements of the NHS Breast Screening Programme.


08/03/2010 Complete 04/10/2010 98% felt they were definitely treated with dignity and respect. 95% thought the breast screening service was very good. No-one thought it poor. RECOMMENDATIONSDiscuss the possibility of longer opening hours once digital equipment has been installed. Look into redirecting incoming client calls to a phone that is not used for any other purpose.Review the directions to the Wycombe static unit to see if they can be made clearer.Review staff attitude.

Research is being conducted into longer opening hours. Incoming client calls have been redirected if phone busy. New site signage has improved directions to static unit. Comments boks have been introduced and staff attitude is discussed regularly.

2925 National Maternity Survey 2010 (BHNHST)

Audrey Warren National Maternity Survey to be conducted on all mothers giving birth in February 2010.

Women & Children

08/03/2010 Complete 03/03/2011 Results for antenatal and postnatal care were considerably worse than in previous years.Care during labour and birth, although in some areas it was not as good as in the 2009 survey, was still an improvement on the 2007 survey. The CQC looked at responses from 19 of the survey questions and scored them. The scores for our Trust were compared with scores from all 142 acute hospital trusts that took part in the survey. For all 19 questions our Trust scored in the middle 60% of trusts, i.e. no better and no worse than other trusts.

Actions taken to ensure as much as possible that expectant mothers see the same midwife or doctor antenatally, so women are always involved with their antenatal care and have continuity. Developed literature and improved website to try to ensure mothers have choice about where to have baby. Birth place options to be discussed with mother. Launch of DVD and virtual tour. Review of all written information given to mothers. The normal birth pathway re-launched, focusing on improved antenatal education, reducing postnatal care in the community and using “drop ins”, ensuring the community midwife is the first point of contact. Ensured that the debriefing and reflections of childbirth service are fully available to all women across the area. Results from the debriefings are fed back to all staff. Notice boards in clinical areas to highlight the Reflections, PALS and Complaints services. Steps taken to ensure all mothers are sutured within one hour post-delivery. Remodelled the organisation of various roles required during inpatient admissions. Active birth classes to inform on pain relief, labour positions. Many

other changes ongoing.2926 Is There a Need

for a Bladder Cancer Support Group at BHNHST? (BHNHST)

Krystyna Caine, MacMillan Urology Nurse Specialist

A survey to find out whether there is a need for a support group for patients (and their families) who have been diagnosed with bladder cancer.


09/03/2010 Complete 01/07/2011 1. Currently there is no great need for a support group for patients with superficial bladder cancer however further information is required about patients with invasive disease. 2.We have obtained some useful information on the possible structure of a support group, if this is developed in the future. It is encouraging to know that the structure of our longstanding Prostate Cancer Support Group is of a similar nature.3. Patients are given written information on their disease and further management when seen in the Nurse-led Results Clinic. They are also given the contact details of the Uro-oncology CNS (Keyworker) if they have any questions/queries. We have recently amended the Keyworker document (which is sent to the GP and given to the patient at diagnosis) and are considering undertaking an audit of the patient information given out at diagnosis to find out how useful patients find this. We could also consider evaluating the support given by the Keyworker during the patient pathway. 4. We are planning to organise a meeting with the other cancer support groups in Urology to discuss merging the three support groups together.

Changes required. Emailed Krystyna Caine for changes 11/1/2012. Reply from KC 4/9/12. Review of support group structure; regularity of meetings and suggested speakers has taken place. Written information currently with Patient Education Group for review. Meeting held – decision made to keep support groups as individual groups but invite/meet up with other groups as required.

2927 Audit of the Use of the AMT 10 Assessment on Admission in Medical Patients aged over 65 (SMH)

Dr Lee Aye, FY1, Medicine, Dr C Yau, Consultant, MFOP

National and local guidelines recommend that all older patents should be screened for cognitive impairment on admission to hospital, using a tool such as the Abbreviated Mental Test - (AMT - 10).

Medicine 11/03/2010 Complete 08/11/2010 Currently not identifying all older patients (over 65 years) with cognitive impairment using the AMT on admission. Rates of AMT use of admission in the over 65s can be improved by the modified medical admissions booklet and continued physician education. Rates of use were highest in junior doctors; when the presenting complaint was confusion; PMHx of dementia; or when the post-take consultant specialised in elderly care.

The medical admission proforma has been permanently modified to indicate that the AMT should be performed in all patients over 65.

2928 Audit of the use of Oral Supplements for patients in care homes

Gbonyefa Samani, Community Dietitian

To measure current practice of the management of oral nutritional supplements against standards.

15/02/2010 Cancelled 08/02/2011 Cancelled Cancelled

2929 Drinks Audit Liz Evan, Nutrition Nurse Specialist

To identify how, what and when patients are offered drinks. Concern that nurses and housekeepers provide drinks at WH and Sodexho at SMH, to ensure that patients are not dehydrated. 02/02/2011 spk to Liz Evans - she has been very busy with other things and will hopefully get back to this audit in the next month.

Specialist Services


2930 Paediatric Oncology Patient Experience Survey

Jo Davison, Lead Nurse for Oncology, Paediatrics

Survey to obtain patient feedback on self-assessment in accordance with paediatric cancer measures.

Women & Children

17/03/2010 Complete 01/06/2010 It is recommended that this pilot study be followed up later in the year with a larger study to include all oncology families, past and present, under the care of Buckinghamshire Hospitals NHS Trust. Some of the questions should be expanded slightly to elicit more information about the service these families have received. Action plan: Key worker documentation needs reviewing and highlighting for parents who are unclear. Information on the service provided at Wycombe needs highlighting, as parents are receiving information from Oxford. Facilities for teenagers need reviewing in the future (also referral to TYA in Oxford). A larger questionnaire sample will be needed later on in the year. This will also be added to the work plan to take place in Autumn 2010.

We decided not to do our own expanded survey of all the oncology patients as they are already being surveyed by the John Radcliffe. We intend to see what we can draw from their responses rather than burden parents with a second questionnaire.We have improved our key worker policy and each child is allocated a key worker.TYA is not yet established at Oxford so there is centre to refer them to, however there is a TYA MDT at which they would be discussed. Facilities for teenagers have not yet been improved.

2931 Gynae-Oncology Patient Experience

Francesca Lis, Gynae-Oncology Nurse Practitioner

A patient experience survey of patients receiving care and

Women & Children

18/03/2010 Complete 12/04/2011 Overall the results of the survey were very positive. The following recommendations were made: improve the communication pathway so all patients are able

Changes made: dedicated phone line with ansa-phone in CCHU; patients/relatives ring

Survey treatment for a gynaecological cancer.

to contact their Specialist Nurse; ensure all patients can discuss their diagnosis, treatment and on-going care at any time with their Specialist Nurse; offer all patients copies of correspondence and a summary of their treatment plan; discuss available national support groups with patients.

Specialist Nurse at any time for clarification of their diagnosis, treatment and on-going care; GPs also contact Specialist Nurse on work mobile for similar issues; patients are offered copies of correspondence in all of the clinics: Gynaecology and Gynae-oncology; national support groups are discussed at any time along the patient pathway, and especially at diagnosis; we have started using a Distress Thermometer in the clinics/Wards and issues/problems are highlighted, discussed and an action plan put into place; a nurse led clinic is currently in the process of being set up.

2932 Bronchoscopy Patient Experience Survey (BHNHST)

Dr Helen Davies, SpR, Respiratory Medicine

A patient experience survey of patients having a bronchoscopy.

Medicine 18/03/2010 Complete 15/07/2010 Overall feedback was positive. No difference between hospital sites. Areas for improvement: Clarity of information given. Explanation of risks and benefits. Mention dressing gown, slippers etc. Plan to introduce a new patient information sheet and provide training for nursing/medical staff.

The patient information leaflet has been revised in line with the recommendations made following the audit.

2933 NCEPOD Peri-Operative Care (BHNHST)

Dr Richard Bunsell, Consultant, John Abbott, Theatre Manager

An NCEPOD study looking at peri-operative care.


01/03/2010 Complete 09/12/2011 There is a need to introduce a UK wide system that allows rapid and easy identification of patients who are at high risk of postoperative mortality and morbidity. (Departments of Health in England, Wales & Northern Ireland). All elective high risk patients should be seen and fully investigated in pre-assessment clinics. Arrangements should be in place to ensure more urgent surgical patients have the same robust work up. (Clinical Directors and Consultants). An assessment of mortality risk should be made explicit to the patient and recorded clearly on the consent form and in the medical record. (Consultants). Better intra-operative monitoring for high risk patients is required (Clinical Directors). The postoperative care of the high risk surgical patient needs to be improved. Each Trust must make provision for sufficient critical care beds or pathways of care to provide appropriate support in the postoperative period. (Medical Directors). To aid planning for provision of facilities for high risk

From the pre-operative aspects, the Trust currently falls short on a number of the recommendations. Anaesthetic clinics are available in the pre-assessment clinic at WH; there are no current anaesthetic clincs at SMH. Consultant anaesthetists see high risk patients on an ad hoc basis when required. Urgent cancer patients are fast tracked through; there are some capacity issues currently. MUST screening is not currently undertaken in pre-assessment clinic. Starvation guidelines are given in pre-assessment; there is no

patients, each Trust should analyse the volume of work considered to be high risk and quantify the critical care requirements of this cohort. This assessment and plan should be reported to the Trust Board on an annual basis. (Medical Directors)

cohesive Trust policy re: carbohydrate pre-op loading. An assessment of mortality risk is made for those patients who are reviewed but not all high risk patients are seen currently. Invasive monitoring is utilised as required during the peri-operative period; the availability of esophageal dopplers / lidco is to be discussed by the anaesthetic consultant body. There is no formal recovery pathway solely for high risk patients; however, there is lots of good practice: pre-op physio classes for all hip and knee patients; DM control guidelines about to be approved; Hb optimisation in process; regional anaesthesia utilised.

2934 Audit of Laparoscopic Fundoplication Surgery (BHNHST)

Dr Hanish Nagar, FY2, General Surgery, Mr Farouk, General Surgery, Consultant

Audit of the follow up of patients post laparoscopic vissel fundoplication.


23/03/2010 Complete (no changes reported)

18/04/2011 Recommendations were: generation of database to log cases of anti-reflux surgery; review long term outcomes for patients receiving anti-reflux surgery; identify predictors of success; re-audit.

Changes required

2935 Audit of the Post Operative Complication Rate following Carotid Endarterectomy (BHNHST)

Dr Edward Choke, SpR, Vascular Surgery, Dr Vimmie Shriyan, Clinical Attachment, Mr Lintott, Consultant, Vascular Surgery, Dr Patel

To asses the rate and type of post operative complications within 12 to 24 hours of carotid endarterectomy.


26/03/2010 Cancelled 30/09/2010 Cancelled Not applicable project cancelled

2936 Community Infection Control Environment Audit 2010

Fiona Simpson, Infection Control Nurse

Environment tool completed for various PCT units. To analyse and report. Re-audit.

27/03/2010 Complete 14/05/2010 Where hand hygiene facilities do not meet the requirements work needs to be done as a priority to correct this. Furniture and fixtures that are damaged or that do not have washable surfaces, need to be repaired or condemned and replaced as appropriate. All carpets in clinical areas need to be removed and replaced with washable floor surface. Cleaning in some areas was not up to standard on the day of the audit. Floors that were not clean were identified. The audit highlighted the need to provide a change of curtains on a pre-planned programme for clinical areas. Floors need to be kept clear in order to enable cleaning staff to clean them effectively. Storing items on the floor, results in them being contaminated. No items should be stored on the floor.

Carpets are being removed as part of the estates work at FNH & Thame. All furniture and equipment has been assessed during visits and torn/ripped kit removed and or replaced Wing unit and Rayners Hedge are not inpatient units anymore

2937 Urology Consent PES (WH)

Dr T Cibulskas, FY1, Dr M Lumb, FY1, Mr N Halder, Consultant Urologist

Assess whether or not our consenting doctors are adhering to GMC guidelines.


30/03/2010 Complete 25/10/2010 Overall an extremely positive response with excellent coverage of GMC guidance. Recommendations: ensure that side effects have been discussed, and that the patient has taken these on board; clearly state that the patient always has the option to refuse treatment; consent patients for the use of their anonymised images/samples; ensure patients are given a copy of completed consent form; carry out a re-audit (see audit 3085).

Further training has taken place and a re-audit is being carried out.

2938 Audit to Assess the Adequacy of the Documentation of Whiplash Patients in WH EMC (WH)

Dr S Hameed, Dr O Duprez, Dr Mike Kazer, Consultant, EMC

To assess the adequacy of documentation in whiplash patients presenting at Wycombe EMC, highlight areas of strength and weakness and implement guidelines/ checklist for assessing patients with neck injury.

Medicine 01/07/2009 Complete 31/03/2010 C-spine tenderness was well documented, however there was room for improvement in documenting neuro findings, GCS and intoxication status. X-rays were being requested appropriately. A checklist should be put up in EMU to remind clinicians of the NEXUS criteria. Re-audit to be carried out in 6 months.

Plans to include audit results on the departmental document store so information is easily accessible and there as a reference source. The NEXUS criteria will be included in this.

2939 Audit of the Documentation of Respiratory Rate at Triage in EMC (WH)

Dr Peter Kizito, SHO, Dr Mike Kazer, Consultant, EMC, WH.

Audit of patients presenting to the EMC at WH with respiraory related conditons to see whether their respiratory rate was documented.

Medicine 01/07/2009 Complete 31/03/2010 Respiratory rate is an important tool for monitoring and assessing patients in a clinical setting and should be recorded at triage and every time other observations (e.g. pulse, BP, etc) are monitored and recorded. Clinical staff need to be reminded of the importance of monitoring and recording respiratory rate. Will be re-audited when the CEM vital signs audit is carried out.

Though not directly as a result of this audit, vital signs documentation for acutely ill patients - 'modified early warning score' (MEWS) has been introduced which incorporates measurement of respiratory rate. The Trust is also taking part in the CEM vital signs audit.

2940 Audit Rehabilitation Referrals (SMH)

Dr Yesa Yang, FY1, MFOP, Dr Rachel Fisken, FY1, Haematology, Dr Yau, Consultant MFOP

There is no formal handover of patients to the rehab team which has led to delay in investigations and loss of outpatient follow up which could compromise patient sfaety.

Medicine 01/04/2010 Complete 30/09/2010 Audit showed that there is often a lack of a formal structured medical handover when patients, especially the elderly, transfers from Acute care to Rehab. Patients are being transferred without proper physio and OT review and some with outstanding acute medical problems. Propose the introduction of a medical handover proforma to address these problems.

A new handover proforma was designed and introduced for use on the Rehabilitation Ward. This did lead to better handover of follow up plans, however the Rehabilitation Ward has since closed.

2941 Medical Readmissions Audit (BHNHST)

Dr Graz Luzzi on behalf of the Healthcare Governance Committee; Dr Mitra Shahidi, Respiratory Consultant

A review of medical readmissions, requested by the Healthcare Governance Committee.

Medicine 01/04/2010 Complete 28/01/2011 A significant proportion of `re-admissions` are due to planned follow up appointments i.e. DVT Clinic, cystoscopy, colonoscopy. Of those `legitimate` medical admissions, 11% were due to acopia following discharge (equal to our misdiagnosis, COPD & LRTI re-admission rates). Re-admissions at the end of life (known terminal disease) is the single largest contributor at 15%. Clarify the CRS search criteria to select only `legitimate` re-admissions. Repeat the audit with a larger sample.

coded DVT re-attenders differently so they are no longer showing as readmissions. Faith Button to comment on additional changes.

2942 January 2010 Mortality Review (BHNHST)

Dr Graz Luzzi on behalf of the Healthcare Governance Committee

A review of January 2010 deaths, requested by the Healthcare Governance Committee following an increase in mortality rate for this period.

Trustwide 01/04/2010 Complete 19/11/2010 Recommendations were to: continue to improve the recognition of the deteriorating patient - the use of Early Warning Scores should be an integral part of this process; redesign the Emergency Care pathway for medicine to ensure early review by a senior clinician; implement the action plan resulting from the NCEPOD report into Acute Kidney Injury; continued scrutiny of hospital deaths at all levels of the organisation, including committee review of clinical outcome data, Service Delivery Unit review of every death and involvement in a review of 50 case notes every 6 months as part of the South Central Patient Safety Federation ‘Reducing Needless Deaths’ workstream.

Increased scrutiny of deaths in the organisation; assurance provided to the Board with regard to clinical care of patients prior to death; links with the Mortality Task Force work around reducing HSMR.

2943 Day Hospitals Service Patient Experience Survey (Pilot) (BHNHST)

Todd Kaye, Physiotherapist, MFOP, Dr Simmie Manchanda, Consultant, MFOP

To investigate patients' overall satisfaction with the service provided by the Day Hospitals and including their reactions to and experiences of using the Nintendo Wii as part of their treatment.

Medicine 07/04/2010 Complete 23/09/2010 Pilot showed that questionnaire is too long and complicated for elderly patients to complete. A new method of collecting data is to be devised together with physiotherapy staff and a re-audit carried out.

Pilot, no changes required.

2944 Investigation of Iron Deficiency Anaemia in Men Under the Age of 50 (BHNHST)

Dr Kapil Sahnan, FY1, General Surgery, WH, Dr McIntyre, Consultant Gastroenterologist, WH

Currently the national guidelines indicate 'top & tail' scopes for all men under the age of 50 with iron deficiency anaemia. The question is do these cases really warrant endoscopy?

Medicine 01/04/2010 Complete (no changes reported)

19/05/2011 Microcytic anaemia is uncommon in men less than 50 & GI malignancy is rarely a cause especially in those less than 45. Chronic disease & haematological causes, usually apparent from the clinical picture and simple tests, accounted for more than half of the abnormal FBCs when one was identified. Not investigating these patients further would seem appropriate and would not miss GI malignancy. We would suggest that in men under 45 GI investigation with endoscopy and colonoscopy should generally be considered only after obvious disease (haematological, chronic disease, coeliac, etc) has been excluded or in those whose anaemia worsens or fails to respond to treatment of known disease.

Changes required

2945 DIEP Breast Reconstruction

Dr Jonathan Cubitt, SHO, Plastics

To analyse all DIEP breast reconstructions performed and


07/04/2010 Complete 05/08/2011 This was a retrospective analysis of all DIEP breast reconstructions performed within the Trust from 2003 to 2010. There are many publications about preoperative perforator mapping using CT or MRI

No recommendations for change were made.

compare outcomes from 2003 to 2010. Focusing on length of operation, complications, post-op analgesia and length of stay. Aiming to publish results.

scans and the benefit on outcomes. This series of 159 flaps, with no flap loss, only had Duplex ultrasound for perforator mapping. This technique is cheap and readily available. It gives a real time image of the perforators and the route through the muscle and also allows visualization of the internal mammary vessels. In response to 3 pulmonary emboli DVT prophylaxis was revised to LWMH and there were no further Pes. Our partial flap necrosis rates were much higher at the beginning of the series when the flap was shaped on the abdomen. Now that the shaping occurs on the chest the rates are significantly lower. There is not much written about perioperative analgesia in the literature. Our combination of intrapleural block and post operative morphine PCA gives an acceptable analgeisa. As with any new technique there is a learning curve. Several factors were compared through the series: the length of operation, the ischaemic time, the post operative haemoglobin and the incidence of complications. The most significant changes observed were in the increase in post operative haemoglobin and the reduction in number of complications as the series progressed.

2946 Excision of Cutaneous Squamous Cell Carcinoma

Dr Sameer Gujral, CT2, Plastics DrAadil Khan, ST3, Plastics Dr Jonathan Cubitt, CT2, Plastics

To determine clinical and histological findings of excisions for squamous cell carcinomas, 2008-2009. To evaluate findings to determine outcomes, need for re-excisions and whether there is a need for change in practice.


07/04/2010 Complete 31/12/2010 This was a regional audit involving the Oxford and Wessex Training Region. It was the largest European study of SCC excisions and involved larger and deeper tumours. It was presented at BAPRAS in London in December 2010. Results: Overall, the incomplete excision rate (8%) was higher than predicted; national guidelines for radial excision margins were exceeded; radial incomplete excision rate was 2.5%; deep margin involved in 92% of incomplete excisions.

The audit was a regional audit and compared practice at Stoke Mandeville Hospital with that at other hospitals. Overall our practice was good and no changes were needed. Other hospitals needed to make changes.

2947 NSIC Orthotics Dot Tussler, Kirsten Hart, Physiotherapists, NSIC

To review those patients provided with orthotics, which orthotics cointinue to be used, which are abandoned. Review all patients not seen for over a year to identify reasons why, in particular which orthotics are most likely to continue to be used.


13/04/2010 Complete 09/02/2011 Results: 49% orthoses are still being used regularly and another 20% are used, but not used as often as they should be. 31% orthoses are no longer used. Reasons for not using the orthosis or not using it often enough were most commonly discomfort (29%), ineffectiveness (19%) and impracticality (18%). 13% of orthoses were no longer needed. Of those orthoses no longer used, 39% were no longer used within 6 months of receiving them. 32% feel they need a review of their orthotics provision. Recommendations: It is recommended that a prospective audit through follow up questionnaires is initiated 6 months after the provision or completion of any orthotic intervention, in association with dissemination of the NSIC Orthotic service user information.

Follow up audit being designed.

2948 Management of Meconium Liquor (BHNHST)

Dr Ralph Robertson, ST1 and Dr Cathy Noone, Consultant

An audit to assess whether we are following the standards for meconium observations in neonates, outlined in the NICE Guideline on Intrapartum Care.

Women & Children

14/04/2010 Complete 01/04/2011 Only one baby had meconium aspiration syndrome. This baby was immediately recognised as being unwell and taken directly from Labour Ward to NICU. Seven babies had abnormal meconium observations and had paediatric review. Of these, three were managed conservatively and four were started on IVABx. All were discharged home with negative cultures at 48 hours. Can we safely discharge babies who have had meconium stained liquor, but are clinically well, without 12 hrs of Meconium Observations?

No changes will be forthcoming for this audit. No recommendations were made.

2949 Review of the use of HPV testing in Colposcopy Clinic (BHNHST)

Miss Deborah Sumner, Consultant (Tunde Solebo)

HPV testing has been introduced to try and help the management of colposcopy patients and hopefully allow discharge of patients from clinic. This is an audit to determine whether HPV testing has helped management and whether patients have been discharged from clinic.

Women & Children

19/04/2010 Complete 13/01/2011 Results: 54% of patients tested were HPV positive. (95% of these with a HR-HPV). 11 HPV negative patients were discharged back to their GP. 13 more HPV negative patients theoretically could have been sent back to their GPs . Of these 11 had low grade smears.The majority of patients over 40 with HR-HPV were not Types 16 or 18.The majority of the older women positive for HR-HPV had low grade smears (61%). Department continuing to use HPV testing to try and aid in management of difficult cases.

There were no recommendations made as a result of this audit and therefore no changes are forthcoming.

2950 Audit of Isolation Precautions

Yesa Yang, Rachel Fisken, FY1, Gen Medicine, Haematology

Signs outside side rooms are sometimes not maintained correctly which can lead to confusion. This audit is to confirm whether side rooms are maintained according to hospital guidelines.


27/03/2010 Complete 02/08/2010 Results: Maintenance of isolation notices generally poor.Availability of PPE & usable sharps bins in each side room generally good. Inconsistent maintenance of isolation notices may lead to confusion and perhaps reduction in compliance to barrier nursing precautions by staff. Some patients unaware of why in isolation. Recommendations: Proposed intervention – alert infection control link nurses on each ward; notice in email bulletins; consider putting up posters in hospital temporarily to increase awareness. Re-audit.

Doesn't look as though any changes made or recommendations actioned. It will be re-audited.

2951 Gonorrhoea Treatment Audit (WH)

Dr Amanda Roberts, Associate Specialist, GU Medicine, Dr G Luzzi, Consultant GU Medicine

Ascertain current resistance levels of GC and assess whether current BASHH guidelines are being met.

Medicine 22/04/2010 Complete 05/07/2010 Using ceftriaxone as first line treatment for gonorrhoea infections follows national guidelines and has a 100% success rate. More patients are seeing a health advisor, but more care needs to be taken to ensure patients are receiving written information and that this is documented. Consider providing patients with details of links to relevant websites as well as written information. Consider changing responsibility for administrating ceftriaxone to health advisors to ensure all gonorrhoea positive patients are seen by a health advisor. Consider a reduction in ‘test of cure’ appointments for symptomatic male patients who have been given ceftriaxone, they would be advised to return only if their symptoms did not settle.

Greater care is now taken to ensure all patients receive written information about their diagnosis and treatment. Health advisors are administering ceftriaxone injections, when time and staffing levels allow, thus ensuring the patients see a health advisor. There has been no change yet in seeing male patients for test of cure as national guidelines indicate there may be some ceftriaxone resistance emerging. For this reason we continue to see all patients for test of cure.

2952 Colorectal Cancer Patient Experience Survey (BHNHST)

Robin Radley, Clinical Nurse Specialist Colorectal Cancer, Jeanette Tebbutt, Lead Cancer Nurse



19/04/2010 Complete 31/08/2010 On the whole this is a very favourable report and for the most consistently high scoring. There are a few areas where some improvement could be made such as information about Multidisciplinary Teams. We also appreciate that some of the written post operative information is not always up to standard, but this should improve when we implement the Enhanced Recovery Programme (ERP). Recommendations: Ensure it is explained to all patients that their treatment will be co-ordinated by a Multidisciplinary Team (MDT) and that they receive written information explaining what an MDT is. Improve the quality of the post operative information which is provided to patients.

There has been an initial change in the literature to include reference to MDT working. A completed review of all literature is taking place with a view to producing a comprehensive information pack for all patients. Which will include a leaflet explaining MDT working.

2953 National Sentinel Audit of Stroke - Organisational Audit 2010

Dr M Burn and Dr C Durkin, Consultant

To measure the rate of changes in stroke service organisation within BHNHST, with benchmarking against National provision.

Medicine 19/04/2010 Complete 05/10/2011 The report produced by the RCP has been reviewed and discussed. Since this audit was completed there has been a complete review of stroke services within the Trust and a Hyper Acute Stroke Unit has been established at Wycombe Hospital.

No changes required

2954 National Sentinel Audit of Stroke 2010 - Clinical Audit (BHNHST)

Dr M Burn and Dr C Durkin, Consultant, Stroke Leads

To measure the quality of care for stroke patients, including National benchmarking, and the extent to which the recommendations made in the 2008 audit have been implemented within BHNHST.

Medicine 19/04/2010 Complete 05/10/2011 The report produced by the RCP has been reviewed and discussed. Since this audit was completed there has been a complete review of stroke services within the Trust and a Hyper Acute Stroke Unit has been established at Wycombe Hospital.

No changes required

2955 WHO Surgical Safety Checklist (BHNHST)

John Abbott, Operations Manager, Critical Care, Jo Eldridge, Acting Matron, Wycombe Theatres, Jackie Benson, Debra Panikkar, Theatres Stoke Mandeville

To monitor compliance with the WHO Surgical Safety Checklist, which must be completed for all surgical procedures, and that a record has been kept of the pre-brief for theatre teams' listings on a daily basis.


22/04/2010 Complete 01/04/2011 1. Redesign of day surgery booklet to include WHO Time Out checklist. 2. Standard intra-operative booklet to be used in all admission areas. 3. All integrated care pathway (ICP) booklets to include WHO Time Out checklist. 4. Clinicians encourage junior doctors to fully complete all sections of the WHO surgical checklist. 5. Surgeon/scrub nurse to lead Time Out just prior to knife to skin with all team present and paused.

1. Booklet was redesigned and has been put out in all admission areas i.e. Mandeville Wing at SMH, A&E, Day Ward at Wycombe etc. 2. Standardised in-patient booklet containing WHO time-out checklist already in all admission areas. 3. Only applies to Fractured Neck of Femur pathway. 4. This will be included as part of team/audit/governance meetings as well as training sessions so that all grades of doctors receive ‘training’/reminder. As evidence, we will be asking the SDU lead to send us copies of agendas/minutes demonstrating this was discussed. 5. Rachel Young

met with all SDU leads to confirm that this means the surgeon and scrub nurse need to vocalise the WHO Time out so that all staff present in the theatre pause and are aware it is taking place so that they can hear the questions and the respondent’s reply. Rachel Young will follow this up with observational audits as part of on-going TPOT work. Any non-compliance will be reported to both the theatre matron and SDU lead for that speciality.

2956 Audit of submissions to the National Joint Registry

Mr Geoffrey Taylor, Consultant, Dr Sameer Gujral, CT2, Plastics

To look at which patients undergoing hip, knee and ankle replacements have been submitted to the National Joint Registry and to check that the BHNHST coding, used by HES to calculate compliance, is correct.


22/04/2010 Complete 04/04/2011 Discrepancies exist between the compliance rates the NJR quote for BHNHST against those calculated by the Trust. Improve compliance rates. Recommendations: 1. Ensure all trainees are NJR registered and trained. 2. Ensure surgeons are logging procedures at corrected hospitals. 3. Further analysis of figure so far by consultant. 4. More regular review of our stats – re-audit. Ensure accurate data consent rates: 1. Provide a form in the POD to consent for data at same time as procedural consent. Alternatively patient completes form in clinic or via post prior to op.

Not much has changed so far. The issure of one surgeon logging the wrong hospital has been corrected. All trainees are asked to register with the NJR but this always takes time and not all do this.

2957 Audit of Indications for Hartmann's Procedure

Ashley Ridout, CT2, General Surgery

To assess the indications for Hartmann's procedure, including reason for procedure, grade of surgeon, outcome and reversal.


26/04/2010 Cancelled 30/09/2010 Project cancelled NA - project cancelled.

2958 Child Death Management Protocol (BHNHST)

Dr Shailendra Rajput, ST5 and Dr A Dutta, Consultant

There is no current Trust guideline for the management of child death. National guidelines have been published by the Royal College. This audit is being undertaken to review whether we are managing child death in line with national standards and to propose a guideline for use locally.

Women & Children

20/04/2010 Complete 06/12/2010 Results: The guideline is not being followed. There is poor documentation of procedures around child death. There is poor note keeping, no uniformity in collecting investigations and no explanation of why the investigations were not done. No consistency in recording the involvement of other agencies. Recommendations: Need for a robust local trust guideline – has been prepared. Detailed action checklist - has been prepared. Documentation of Post mortem reports and results of multiagency discussions. Documentation of final outcome. Re-audit in 2 years.

A new Trust Guideline (Policy in the event of a sudden unexpected death of a child or young person 773.1) was uploaded onto the intranet in June 2011.

2959 National Comparative Audit of the Use of Group O Negative RhD Red Blood Cells

Donna Beckford-Smith, Transfusion Specialist

To start in June 2010. Clinical Support Services

01/06/2010 Complete 25/08/2010 National audit, data submitted. National report received.


2960 Shoulder Dystocia Audit (continuous) (BHNHST)

Miss Veronica Miller and Mr Tunde Dada

A continuous audit of the management of shoulder dystocia. Required for CNST.

Women & Children

01/02/2010 Complete 10/01/2011 Results of audit April 2008-April 2009 (six months either side of merger of midwifery services 19/10/2009). 1. 7/37 (19%) of the women had no antenatal risk for shoulder dystocia. The most common risk was BMI>30 (30% ). Only one patient had previous shoulder dystocia. 2. 20/37(54%) of the women had no intrapartum risk. The most common risk was augmentation of labour 27%. 3. Times, and whether staff were already present or called, were poorly documented. Where times were recorded staff arrived very quickly after diagnosis. 4. 18/37 (49%) of patients required only Macrobert’s to resolve shoulder dystocia. 5. The mean time between head and body delivery was 2 minutes. 6. 50% of shoulder dystocia sheets were fully completed after merge compared to 35% before. 7. 86% of babies went straight to postnatal ward after delivery (90% after merge compared to 82% before). 8. No baby had either brachial plexus injury or another complication that required follow up after delivery. Recommendations: 1. Documentation sheets need to be fully completed. 2. Details of

CNST requirement to complete continuous audit of all cases. Audit proformas and Datix forms should be completed in all cases and this will be raised at each 8 a.m. safety briefing. New procedures have come into place since this audit and in the six months following this compliance is now 78%.

timings need to be well documented.2961 Audit of Operative

Vaginal Delivery (continuous) (BHNHST)

Miss Veronica Miller and Mr Tunde Dada.

A continuous audit of operative vaginal deliveries. Required for CNST.

Women & Children

01/02/2010 Complete 18/08/2010 47 patient notes audited. Results of first audit showed lack of documentation. Indication was appropriate for all 47 patients. 89% patients had documented consent. On 2 occasions there were 4 pulls but all delivered. 2 patients did not have analgesia. Recommendations included improving documentation; always administer analgesia; debrief on post-op care by obstetrician; always record cord gases.

CNST requirement to complete continuous audit of all cases, year on year report written with no changes. 21/2/13 CP

2962 Audit of Obstetric Haemorrhage (continuous) (BHNHST)


A continuous audit of the management of obstetric haemorrhage. Required for CNST.

Women & Children

01/02/2010 Complete 28/02/2011 Interim results of ongoing audit. More than 70% of transfusions are based on low Hb or clinical signs. Pre-transfusion Hb in 85% patients is less than 8gms/dl. Consent was documented in only 25% of patients.

CNST requirement to complete continuous audit of all cases, year on year report written with no changes. 21/2/13 CP

2963 Audit of Severe Pre-Eclampsia / Eclampsia (continuous) (BHNHST)


A continuous audit of the management of severe pre-eclampsia / eclampsia. Required for CNST.

Women & Children

01/02/2010 Complete 10/01/2011 During March 2010, 47% of patients with pre-eclampsia were not examined for clonus, therefore potentially missed out on optimum management for severe pre-eclampsia. MEWS recorded 80%; urine output recorded 60%; fluid balance recorded 60%; fluid restriction 30%; corticosteroids 2 out of 3. Recommendations: Improved documentation to enable monitoring of compliance with protocol; magnesium sulphate prophylaxis; improved monitoring of fluid balance and restriction.

2964 Maternity Record Keeping Audit (BHNHST)


An audit of maternity record keeping, carried out by

Women & Children

01/06/2010 Complete 07/05/2010 1. Results to be circulated to all midwives requesting they examine their own practice against the audited standards. 2. Audit report to be covered during SoM

1. Email sent with audit tool and audit results attached. 2. Initiated 26/05/2011 - ongoing.

supervisors of midwives and senior midwives. Required for CNST.

session on mandatory day B, session to include discussion of problems and solutions associated with record keeping to increase compliance. 3. Liaise with consultant audit leads to plan their involvement and revise monitoring section of guideline to reflect this when finalised. 4. On-call SoM and band 7 midwives co-ordinating shifts to conduct ad-hoc quick reviews of records pertinent to their area, offering advice and pointing out good and bad practice. 5. Workplace teaching sessions regarding risk assessments at booking and throughout pregnancy. 6. Introduction of detailed sticker to gather this information. 7. New format should lead to more organised notes; introduced to midwives on mandatory training during SoM session and support staff using these in practice. 8. Revision of these documents to complement other components of the maternity records and encourage compliance with specific areas. 9. Informal canvassing of midwives comments regarding use of the tool in conjunction with Audit Department. 10. Remind midwives of the correct use and completion of CTGs, MEWS, VTE assessment, prescription chart, epidural and suturing records in relevant training sessions. 11. Previous audit two years ago soon after introduction; to be repeated to monitor compliance and highlight deficiencies.

More SoM volunteers needed for Day B sessions. 3. All new medical staff to complete 2 audits. This plan now agreed and written into maternity record keeping guideline. 4. Quick audit tools now devised "TIFIs" and in use on the wards. 5. On-going but progress slow at present as MPDT awaiting new team member. 7. New notes demonstrated during record keeping session on Day B. Work being developed with FA. 8. Work 50% completed. Dischrge form out to midwives for consultation. 11. MEWS chart is now audited monthly by productive ward team and senior midwives on Rothchilds. Charts that "trigger" to be audited by MPDT when identified by above audit or during notes reviews. This plan now written into Observations guideline.

2965 A Comparison of Detection Rates for Urinary Tract Calcification in Patients with a Spinal Cord Injury

Justine Osborne, Sonographer

A Comparison of Detection Rates for Urinary Tract Calcification in Patients with a Spinal Cord Injury. Project being carried out for MSc dissertation; registration only.

Specialist Services


01/09/2011 The conclusions of the study were that UTUS is a significantly superior imaging tool for UTC than AXR. Also thatassessment by AXR did not seem justified in the routine urological assessment of SCI patients with the ability to fill their bladder for UTUS. Based on the results of this study alone, it is hard to justify the exposure to ionising radiation by AXR to this group of SCI patient. Furthermore, the continued follow-up by routine AXR would appear to be inappropriate.

Changes required

2966 National Audit of Falls and Bone Health in Older People (BHNHST)

Dr Syed Hasan, MFOP, Consultant

Clinical audit component of National Falls & Bone Health inOlder People Audit.

Medicine 01/05/2010 Complete 10/11/2011 Recommendations: Multifactorial falls risk assessment clinical proforma to include osteoporosis, vision and routine ECG. Develop a measure so inpatient falls rate and injurious falls rate can be presented at board level. Appoint a specialist pharmacist in falls & bone health. Consider adopting and priorities the key indicators. Consider ways of identifying patients for whom OT assessment for potential hazards at home would beneficial. For non hip fracture patients ensure lying/standing BP, exercise programme after fall and osteoporosis treatment happen. Document that written falls prevention information has been given to patients.

Changes required

2967 Retrospective Audit of Pharmacist Intervention Reports

Roisin Kavanagh, Pharmacy

As part of a regional intervention reporting scheme, pharmacists record interventions over a fixed time period once a year. The investigator audited the intervention reports for trends.


31/03/2010 Complete 31/03/2010 1. The audit findings should facilitate continuous medical education, CME activities and training programmes to address gaps in medication-related issues. 2. These CME activities and training programmes must be extended to the other healthcare providers, i.e., physicians, nurses and pharmacists. 3. To successfully address medication error incidents, pharmacists require sufficient clinical knowledge, adequate set of skills and the suitable technicalities to negotiate with other clinicians. 4. Documenting and analysing interventions should be performed routinely. 5. Feedback reports about the medication errors detected, and the proper methods to eradicate, them should be sent to the other healthcare providers on a monthly basis. This will increase the level of awareness amongst all healthcare providers..

Data on medication errors received more recently has superceded the intervention data from this audit and therefore is used to inform medicines management training. Nurses were already receiving medicines management training and medication incidents are discussed via this training. We already have training and assessment programmes in place to ensure pharmacists have appropriate skills and knowledge. We have just repeated the intervention study at the beginning of December and now need to analyse the data. Mechanisms already exist for discussing error reports within SDUs, Trust governance and DTC. There are no plans to change the current system.

2968 Outpatient Parenteral Antibiotic Therapy


Retrospective audit of OPAT service examining infections managed, antibiotics used and the cost in comparison to inpatient management of those infections.

31/03/2010 Complete 31/03/2010 The OPAT service in BHNHST has shown a favourable clinical and safety outcome in the study population with significant cost-savings generated in the OPAT management of bone and joint infections.


2969 A Study of Patients' Information Needs Regarding Discharge Medicines


Study of Patients' Information Needs Regarding Discharge Medicines

31/03/2010 Complete 31/03/2010 Patients greatly valued information on their discharge medicines and it is important to make sure all relevant information is communicated to patients. However, it is not possible to generalise information needs for individual patients and ways to assess individual patients’ needs should be investigated. Further research is needed to uncover the reasons for nurses’ low preference as the source of information.

No funding to carry out this research at the moment.

2970 Availability of MRSA Suppression Kits on Wards

Breda Cronnolly, Pharmacy

Prospective study of use and availability of newly designed MRSA suppression kits at ward level to identify if problems around timely supply and use have been resolved by provision of the kits as ward stock.

31/03/2010 Complete 31/03/2010 There has been a significant improvement in the speed of provision of MRSA suppression therapy. Although the standard of 100% of patients receiving suppression therapy was not attained on the day of the results, this could be related to the timing of the results being made available. The recommendation of this audit is to encourage clinical staff to prioritise the treatment of patients identified as MRSA positive to minimise the transmission of MRSA to other patients.

There is no problem with patients receiving the MRSA suppression packs in a timely manner.

2971 Maternity Record Keeping Audit Pilot (BHNHST)

Hannah Hunter and Lucy Duncan

A pilot of the maternity notes record keeping audit tool. 42 audit tools

Women & Children

Complete 26/05/2010 1. General improvement in record keeping standards throughout the maternity unit. 2. Raise awareness of current areas of particular problem with record keeping. 3. Correct completion of pregnancy

All band 7 midwives to audit 3 sets of notes in one year. Individual record keeping booklets circulated. Circulated

received in total of notes audited by Band 7 midwives and supervisors of midwives. Report to be done every 6 months.

booklet. 4. Correct completion of Waterlow score. 5. Full documentation on CTG as per NICE and CNST. 6. Completion of VTE assessment. 7. Correct completion and interpretation of MEWS charts.

results of the audit to all midwives via email to identify points of concern regarding record keeping. Meet with the community midwives on both sites to discuss minimum requirements. Raise awareness and outline requirements in baseline newsletter. Design a poster to publicise minimum requirements. Discuss at annual supervisory review. Continue to include in mandatory training. Continue to cover in mandatory training.

2972 CEFM Electronic Fetal Monitoring

Dr L Hawxwell, ST1 A reaudit of continuous electonic fetal monitoring, against the current Trust Guidelines.

Women & Children

13/05/2010 Complete 30/09/2010 30 sets of notes were audited for February/March/April 2010. Results showed that indications for CEFM were documented in 96% cases. Documentation of date and time had improved from 63% in last audit to 80%. The standard overall was similar to thre previous audit, but none of the CTGs met all requirements. Re-audit recommendations (September 2010) 1. Improve the use of fresh eyes stickers hourly, through education of staff. 2. Senior midwives and doctors to remember to sign the CTG and use a fresh eyes sticker when the trace is reviewed by them. 3. Introduction of checklist for things to be documented on a CTG to be put on each monitor.

Hannah Hunter has created the checklist referred to in point 3 of the recommendations. Staff education is being carried out at morning meetings.

2973 Perineal Trauma Dr Nighat Arif, ST1 Reaudit of the classification and treatment of perineal trauma, against the current Trust Guidelines.

Women & Children

13/05/2010 Complete 10/10/2010 1. Equity in service provision between SMH and WH with the introduction of a midwife-led perineal clinic on the SMH site (there is no funding for this so this recommendation will remain just that). 2. Introduction of a leaflet on perineal trauma. 3. Greater awareness of the guideline and the need to complete Appendix 2 when the patient is reviewed and that it is available in the clinic setting.

2974 Audit of Screening Test for Diabetes in Pregnancy

Dr Olufemi Dina, Registrar

Re-audit of guidelines on screening test for diabetes in pregnancy.

Women & Children

13/05/2010 Complete 10/10/2010 1. Ensure that all women have a RBS at booking - CMW education. 2. Documentation of results and hard copy filing. 3. Documentation of the need for GTT at 28/40 when risk factors are identified and documentation of the reason if omitted.

To Audrey Warren for discussion with Diabetes Specialist Nurse.

2975 Analysis of Axillary Clearances - Comparing Sentinel Node Biopsy and Primary Clearance (WH)

Dr Vimmie Shriyan, F1, Surgery, Mr Cunnick, General Surgery, Consultant

Audit to compare primary clearances and clearances after sentinel node biopsy.


17/05/2010 Cancelled 30/09/2010 Cancelled due to lack of activity. Cancelled - not required.

2976 Audit of Oxygen Prescribing in Acute General Medical Wards (SMH)

Dr Senthil Rajasekaran, SpR, Dr Stephen Gardner, Consultant

An audit to evaluate current practice at SMH with regards to oxygen prescribing and monitoring.

Medicine 18/05/2010 Cancelled 25/10/2010 Cancelled - Doctor left the Trust without completing the audit.

Cancelled - not required.

2977 Audit of Venous Thromboembolism Prophylaxis in Medical Inpatients (SMH)

Dr Senthil Rajasekaran, SpR, Dr Stephen Gardner, Consultant

An observational study to assess current practice with regards to VTE prophylaxis in medical inpatients.

Medicine 18/05/2010 Cancelled 25/10/2010 Cancelled - Doctor left the Trust without completing the audit.

Cancelled - not required.

2978 The Implementation of a Single Assessment Process in Day Hospitals (WH)

Patricia Gettings, Staff Nurse, Dr Simmie Manchanda, Consultant

Project being completed for Master's Dissertation. Aim to implement a single assessment process in the Day Hospital, in line with NSF recommendations.

Integrated Medicine

19/05/2010 Cancelled 16/09/2011 Not applicable Changes required

2979 Intermittent Fetal Monitoring (SMH)

Dr Alice Bristow, ST1, Miss Veronica Miller and Mr Tunde Dada, Consultants

A reaudit of intermittent fetal monitoring, against the current Trust Guidelines.

Women & Children

19/05/2010 Complete 18/08/2010 Intermittent auscultation always offered appropriately – offered in low risk patients and converted to continuous monitoring when indicated. Recommendations were: 1. Clear guidance needed on when monitoring should be commenced. 2. Partogram could be used instead of notes to prevent duplication and help pattern recognition. 3. Importance of recording FHR as single figure to be emphasised. 4. Inclusion of knowledge of local guidelines in birth plan (including intention to auscultate immediately after a contraction for 60 seconds).

No changes forthcoming.

2980 Audit of Paediatric Diabetes Care Following the Introduction of a Paediatric Diabetes Specialist Nurse (BHNHST)

Dr Wendy Bailey, ST4 and Dr Dutta, Consultant

An audit of paediatric diabetes care (frequency of hospital admission and length of stay, glycaemic control and follow up) pre and post introduction of a diabetes specialist nurse.

Women & Children

19/05/2010 Cancelled 16/09/2010 Cancelled. Audit cancelled - never started.

2981 Fetal Fibronectin Audit (SMH)

Dr Francisco Garcia, Dr Lorna Lamb and Dr Hamdulay, SHOs. Miss Veronica Miller and Mr Tunde Dada, Consultants

An audit of adherence to the hospital protocol for fetal fibronectin testing and documentation of this.

Women & Children

01/01/2010 Complete 20/04/2010 A sample of 20 patients undergoing fetal fibronectin tests between August 2009 and February 2010 were included in the audit. The main results were: admissions were high in negative test results (57%); 28% of those with negative results were given steroids; 75% of PV bleeds had negative results, all were discharged with no steroids. In 3 cases tests were performed outside the gestational age marked by guideline. There was no record of intercourse prior to the test in any of the 20 cases.

No recommendations were made and thus no changes are forthcoming. Audit of New Clinical Procedure.

2982 Peri-operative Paediatric Temperature Control (WH)

Dr Bianca Tingle, CT1, Tessa, Greenslade, Anaesthetics, WH, Dr S Snyders, Consultant Anaesthetist, SMH

Children are more prone to heat loss during surgery due to the large body surface area to volume ratio. Therefore RCOA guidelines recommend a strict post op temperature of 36 to 37oC. The aim of this audit is to assess whether all children have a post op temperature in this range and to evaluate what warming techniques are used intraoperatively.


19/05/2010 Cancelled 13/01/2011 NA - audit was not carried out. NA - audit was not carried out.

2983 Infection Control Kitchen Audit 2010

Niamh Whittome, Infection Control Nurse

Kitchen tool completed for various community health units and BHT areas. To analyse and report. Re-audit.


19/05/2010 Complete 28/07/2010 Overall compliance 90%. The elements least likely to be complied with were: 1) No fabric tea towels or dish cloths in use (community only) 57%. 2) The cleaning schedule for the kitchen is displayed (community only) 57%. 3) Inaccessible areas (edges, corners and around furniture) free of dust and dirt 62%. 4) Waste bins clean (community & acute) and labelled "for general waste"? (acute) 72%. 5) Shelves, cupboards and drawers clean inside and out, free from damage, dust, litter or stains and in a good state of repair 74%.

Applicable wards informed of results and the need to improve. Relevant wards have produced action plans. For re-audit next year.

2984 Infection Control Patient Equipment Audit 2010

Niamh Whittome, Infection Control Nurse

Patient equipment tool completed for various community health units and BHT areas. To analyse and report. Re-audit.


19/05/2010 Complete 28/07/2010 Overall compliance 97%. Areas with lowest compliance were: 1) Daily/weekly department schedule available for equipment such as blood pressure machines, drugs trolleys etc. (84%). 2) “I am clean” stickers being used appropriately (88%). 3) Washers/disinfectors tested according to HTM 2030 standards (86%).

Applicable wards informed of results and that they must improve. Relevant wards have produced action plans. For re-audit next year.

2985 Interventional Radiology Nursing Documentation

Maggie Rees, Radiology Sister

Audit of nursing documentation for interventional radiology. Aim to improve or change as necessary.


27/04/2010 Complete 01/06/2010 Action plan drawn up by Maggie Rees. 1. Ensure relevant staff are aware of results of 2010 audit. 2. Ensure line manager is supporting action plan. 3. Re-audit to check for improvements.

Changes required. Emailed Maggie Rees 20/10/11. Emailed again 11/1/2012. No longer on global. May have left Trust, so unable to chase.

2986 Intravesical Chemotherapy Patient Experience Survey (BHNHST)

Hilary Baker, Uro-oncology CNS

A survey to assess patient satisfaction with the intra-vesical chemotherapy service at Stoke Mandeville and Wycombe Hospitals.


12/05/2010 Complete 12/03/2012 This is the first audit of patient experience of Intravesical Chemotherapy. The findings were that overall the patients were very satisfied with the care and treatment they received. 1. The audit does show that the nursing team do need to emphasise to patients who are undergoing maintenance treatment, or a second course of treatment, that they may suffer more side effects than their first course of BCG. 2. Consent forms must be signed prior to treatment and a copy of the consent given to the patient for them to refer to prior to treatment. 3. The nursing team need to examine cross cover and flexibility in the service when staff are away on annual leave etc. so that patients can be treated within six weeks of commencing treatment. In general, a good report with some interesting findings where objectives have been set with review dates.

1) New patient information sheets produced by the Trust are now available for patients at the time of their treatment. 2) All trained Nurses who give IVC chemotherapy are competent at consenting patient and obtain consent on starting treatment. 3) The introduction of Mito in is still ongoing.

2987 Nurse-led Surveillance Flexible Cystoscopy - Patient Experience Survey (BHNHST)

Hilary Baker, Uro-oncology CNS

A survey to assess patient satisfaction with the nurse-led surveillance (flexible cystoscopy) service.


12/05/2010 Complete 01/06/2011 1. To try and offer appointments at either Wycombe or Stoke Mandeville hospitals. 2. To consider whether same gender patients could be grouped together for flexi appointments. 3. To enquire as to whether the department can obtain gowns in larger sizes.

1. The urology teams discuss with patients their choice of hospital when booking investigations. 2. The clinic is booked in blocks for female and male patients or there are all female/male lists. 3. Larger sized gowns are now available in the clinic.

2988 Speech And Language Therapy Survey

Debbie Begent, Adult Speech & language Therapy Service manager

A survey amongst consultants and other healthcare professionals to assess the service provided by the Speech & Language Therapy Department.


24/05/2010 Complete 21/09/2010 Generally the respondents’ feedback was positive with the acute SLT team at Wycombe viewed as reliable and professional. The service provided was seen as valuable and helpful. The issue which was commented on most was that of weekend cover. Recommendations: Design a decision making tool to support nursing staff with weekend admissions requiring swallowing assessment.SLT to carry out a proactive ward round on Friday afternoons to identify inpatients requiring swallowing assessment before the weekend.For patients on restricted amounts for safety a member of the SLT team will ensure the relevant medical team has been contacted prior to the weekend to explain the assessment process and rationale for this decision.For palliative patients who may be made nil by mouth over the weekend SLT team will ensure the ‘At Risk’ feeding sign has been agreed and explained to the nurse in charge of the ward.SLT Team to complete regular Monday morning audits to identify the number of weekend admissions

Tool has been designed for weekend working and will be presented soon. SLT are carrying out proactive Friday afternoon ward rounds. SLT team are aware they need to discuss patients on limited oral intake over weekend. An "at risk" feeding sign is now in use and has been agreed with Nutrition Committee. An audit has been designed for identifying relevant weekend admissions - it is dependent on decision making tool being actioned. DTN programme awaiting agreement from Midwifery Board.

that could not be managed by using the decision making tool.New Dysphagia Trained Nurse (DTN) guidelines have been developed and a further programme of training will be planned to enable DTNs to cover out of hours and weekends.

2989 Audit of the Use of Imipenem on the General Medicine, Haematology and Spinal Wards at BHNST

Breda Connolly, Senior Pharmacist, Dr David Waghorn, Consultant Microbiologist

The prescribing of imipenem has increased over the last year. The purpose of this audit is to ensure that prescriptions for imipenem are appropriate and are used for an appropriate duration of therapy.


26/05/2010 Complete 01/09/2010 No action required. No changes required.

2990 Pressure Ulcer Audit (BHNHST)

Janine Ashton and Julie Sturgess, Tissue Viability Nurses

An audit of pressure ulcers to be carried out on 28th and 29th April 2010, to determine the level of reporting.

Trustwide 15/04/2010 Complete 31/05/2010 In October 2009 it was agreed by the Trust that all pressure ulcers Category 2 and above would be reported as a clinical incident via the DATIX System. This includes both patients admitted into the hospital with pressure ulcers and pressure ulcers that have developed whilst the patient is in hospital.A pressure ulcer prevalence audit conducted in October 2009 identified that of the 72 patients found to have pressure ulcers, only 11 had been reported via DATIX, a percentage of 15%.Following heightened awareness by both Tissue Viability and Risk Management it was thought that the level of reporting had significantly increased. An audit was performed on 28th & 29th April 2010 to establish if this was the case. The results are far from optimistic, of the 53 patients found with ulcers only 16 had been reported via DATIX, a percentage of 30%. The information from the DATIX records will be used to prepare reports for the commissioners, the Strategic Health Authority and the High Impact Actions. The quality of reporting at present is not adequate to provide a true reflection of the numbers of pressure ulcers in our Trust. We have been set targets to reduce our pressure ulcers by 25% and 30% but we are still unable to establish a baseline and consequently demonstrate a reduction. The percentage of reporting would need to improve to a minimum of 80% for this to be achieved.We feel as a team that we are constantly promoting the reporting system, but believe that in order to meet this target, direction needs to be provided from top management to ensure that all pressure ulcers are reported.

We are auditing every 2 weeks in the acute trust to still try and increase reporting levels. There is now a pressure ulcer group which is chaired by Celina Eaves and involves divisional leads, matrons, nutrition etc and also involves acute and community.

2991 Postural Hypotension Measurement in Orthogeriatric Patients (SMH)

Rachel Thompson, FY1, General Medicine, Dr Syed Hasan, Consultant, Medicine for Older People

Audit of the measurement of lying and standing blood pressure to diagnose postural hypertension in elderly patients, with a fracture, following a fall.

Medicine 04/06/2010 Complete 16/08/2010 Orthogeriatric rehab ward compares favourably with national average for postural bp measurements. However, still a way off achieving ideal target of 100%. Hip fracture proforma extremely comprehensive and never fully completed. Proposed changes: Introduce teaching sessions for rehab nurses, stickers on obs charts, reminders written on obs charts, posters displayed on rehab ward. Results of re-audit carried out following these changes. 57% patients had lying and standing bp measured after intervention (compared with 28% previously). Postural hypotension picked up in 14% patients (compared with 5% previously).

Teaching sessions for rehab nurses, stickers on obs charts, reminders written on obs charts, posters displayed on rehab ward.

2992 Audit to Assess the Need for an Outpatient Parenteral Antibiotic Delivery Service

Jesuloba Abiola, FY1, General Medicine, Dr Cann, Consultant, Microbiology

To assess current adhoc parenteral antibiotic provision and compare how this compares to standards set by OPAT.

Integrated Medicine

09/06/2010 Cancelled 18/07/2011 Not aplicable - cancelled. Not applicable

2993 Audit of the Use of Emergency Contraception (EC)

Dr Jackie Moncur, Specialty Doctor, GU Medicine

Audit of the use of EC to ascertain whether this, especially the IUD, is being use appropriately, whether women are being offered a choice of EC and to determine how many women present for EC within 72 to 120 hours.

Medicine 03/06/2010 Complete 03/06/2011 1.All women should be offered all available methods of EC. 2.Notes need to document that all methods, i.e. Levonelle, Ella One and IUD, have been offered. 3.Notes need to document reasons behind recommended method of EC. 4.Notes need to document the woman’s decline/acceptance of each method and subsequent action taken.5. The introduction information leaflet ‘Advice for Patients taking the EC’ (Levonelle) needs to include a section on drug history detailing if the patient is on any enzyme-inducer drugs and should include the ‘effective rates’ of each EC in more detail. 6. Re-audit notes to ensure full and accurate records are being kept.

Emailed Jackie Moncur 11/1/2012 also asked if she was currently re-auditing as we need to register the re-audit if she is. Changes reported - Proforma for emergency contraception has been changed a year ago to prompt staff to ask and document all the options/decisions/actions. A re-audit has taken place and report drafted - much better record keeping this time.

2994 Paediatric Early Warning Score

Jo Davison, Practice development nurse, Paeds

A new EWS form was introduced in September 2009. The audit will assess whether it is being used properly by wards and by A&E. A staff questionnaire will also be used to see what they think of the form.

Women & Children

09/06/2010 Cancelled 06/12/2010 Cancelled. Project cancelled.

2995 Are SEND Discharge Summaries Being Completed Appropriately? (SMH)

Dr Sumedha Bird, ST4, Paeds

Record keeping audit of SEND discharge letters used by the NICU at SMH. Compare the information in the SEND discharge letters with the information in the notes to see how up to date/complete the information in the SEND discharge letter is.

Women & Children

14/06/2010 Complete 18/01/2011 Training for juniors to update SEND weekly. Use in notes instead of weekly sheets. All SEND letters need to be counter signed by registrar. Notes for babies that are discharged to postnatal wards need to come back to unit for letter to be completed.

Paediatric Department has confirmed that these changes have been implemented.

2996 An Investigation into Patient Satisfaction and Preferred Appointment Times for Outpatient Physiotherapy in BHT.

Ian Springall, Physiotherapy, WH

a patient satisfaction survey which includes asking patients when they would like to be treated. This coincides with the move to 7 day working, which is currently under consultation.


09/06/2010 Complete 28/07/2010 Overall there is a very high patient satisfaction in all areas with the physiotherapy service across all three sites. Patient satisfaction with the quality of written information whilst still high is not as high as verbal communication. Written information may be an area to improve in the future. Patient satisfaction with reception staff is very high in terms of speed of service and attitude although WGH suffered from poor response when there was no receptionist present. Patients are very satisfied with the comfort and cleanliness of the departments. 15%-25% of patients found direction to AGH or SMH physio departments (respectively) poor or fair. This may be an area that needs to be improved. Car parking is considered fair or poor by 53% of patients across all three sites. Overall approx 10% of all patients would prefer to be seen at some time other than what is currently offered. The same people asked for sat am, or very early weekday am, or late pm. This does not support opening at weekends but may support more flexible weekday hours to meet demand. The most popular time for appointments was weekdays

As a result of this audit some patient handouts for common conditions have been updated or are in the process of being updated. There are also plans to print patient information in conjunction with the nationwide exercise referral scheme to give patients information as to where they can go to exercise post discharge from physiotherapy. As for the flexible working, physiotherapy has now started 7 day working on the wards. This has reduced the number of staff working during the week, but we have managed to maintain our 8am-5pm opening times. There is not capacity to run the service any earlier or later at this time.

between 8am and 12pm.2997 Audit of

Effectiveness of Paediatric Admission Proformas

Dr Meena Shamuganathan, ST2 GP VT2, Paediatrics

To look at the effectiveness of current paediatric admission proformas. As they are legal, medical documents, we would like to see if they are filled out appropriately and if they are designed to meet the needs of doctors and nurses in an on-call setting.

Women & Children

15/06/2010 Cancelled 23/05/2011 Project cancelled as doctor has left Trust without completing audit.

Project cancelled.

2998 FIM / FAM (Functional Independence Measure) Reaudit

Karen Earp, Advanced Physiotherapist

A re-audit of FIM/FAM (functional independence measure) to evaluate stroke outcome.


21/06/2010 Complete 14/02/2011 1. To encourage use of this outcome tool in the new Neuro-Rehabilitation Unit for use in acquired brain injury. 2. Train and update new staff in its use. 3. To use tool to develop skills in outcome prediction, treatment planning and to facilitate team working. 4. Resurrect the idea that consultants in neuro-rehab consider its use in their outpatients clinics.

Changes required. Emailed Karen Earp 7/11/2011. Karen has emailed about re-auditing FIMFAM. Will need to get changes first.

2999 Allergies Documentation

Dr Rebecca Evans, FY2 and Dr Yau, Consultant

An audit of the documentation of allergies in patient notes.

Medicine 14/06/2010 Complete 03/09/2010 Conclusion: record keeping standards are not being met. Recommendations: introduce mandatory teaching, stickers on clerking sheets, allergy section on PMS and an, allergy section on TTOs (pharmacy will not dispense drugs unless section is filled out).

Teaching on therapeutics and safe prescribing is now included as part of the medicine teaching programme.

3000 Obstetrics and Gynaecology Presentations at

Dr Sonali Dassanaike, ST1, Mr Tunde Dada, Consultant

An audit of the assessment / admission of obstetric

Women & Children

14/06/2010 Complete 18/08/2010 70 sets of patient notes were audited. 29% of patients were seen and managed by A&E with no discussion or referral. Is it appropriate and practical

Guideline being reviewed by consultants; will be amended to introduce more robust

the Emergency Department

patients attending the emergency department.

for all cases to be discussed with the oncall Gynae SpR? As EPAU is a valuable resource is it acceptable for an A&E SHO to see and discharge a patient without discussing with Gynae team or A&E SpR. In terms of patients being admitted under other specialities, it is imperative that the O&G team are made aware of this admission. Recommendations: 1) To discuss with other specialties that although patient may not present with O&G problem that it is important that they let the oncall Cons/SpR know that there is a pregnant patient in the hospital and to devise a central list of these patients which should be regularly updated. 2) A&E doctors should do speculums where needed and when patient is not going to be referred to O&G team therefore, increase education and training for the A&E juniors on speculum examination and swabs. 3) Establish a proper pathway for patients going to Ward 9 for review. 4) Revise the guidelines for pregnant women (<20/40) presenting to A&E. 5) Need to split the audit up into mini audits looking specifically into trauma and pregnancy/Acute medicine and pregnancy. 6) Re audit to assess if changes implemented have made a difference.

practices.

3001 Oxytocin Audit Dr Misbah Ali, ST1, Mr Tunde Dada, Consultant

An audit of the use of Oxytocin, against current Trust guidelines.

Women & Children

14/06/2010 Cancelled 18/08/2010 30 sets of notes were audited for the 3 month period March to May 2010. 97% women assessed before monitoring commenced. 80% women did not have an individual management plan when oxytocin commenced. It was not documented when oxytocin should be stopped for any of the women. The main recommendation was for an improvement in documentation, with individual management plans and the time that oxytocin should be stopped being a priority.

A study is in progress looking at how women are managed. Education has been given on carrying out a VE before starting oxytocin. Veronica Miller and Audrey Warren taking to STAG.

3002 Laparoscopic Hartmann's Procedure for Bowel Evacuatory Disorders in Spinal Injury Patients

Dr Alex Tzivanakis, CT3, General Surgery

A case series report to describe the Trust's experience of Laparoscopic Hartmann's procedure for bowel dysmotility disorder in spinal injury patients.


22/06/2010 Complete 29/07/2011 Results: Laparoscopic Hartmann’s procedure is an effective option for spinal cord injury patients with bowel dysfunction where conservative methods of bowel care have failed. It has an acceptably low incidence of post-operative complications and it has a reduced incidence of diversion proctitis compared to similar published series where stoma formation alone was performed. These findings were presented to the Association of Surgeons in Training in 2011.

No changes to practice required.

3003 HQIP Inpatient Audit of Children with Diabetes

Dr A Dutta, Consultant, SMH, Dr M Russell-Taylor, Consultant, WH, Diabetes & Endocrinology

A regional multi-centre audit of inpatient care for children with diabetes. This audit, which has been approved and funded by HQIP, is in 3 parts: organisational data collection, clinical data collection, including patient feedback, and implementation of the action plans based on the findings of the audit.

Integrated Medicine

22/06/2010 Complete 28/09/2012 National results showed that over 85% of all infants, children and young people diagnosed before 2011 had their HbA1c measured, however only 16.4% of males and 15.1% of females achieved the NICE recommended HbA1C target of <7.5% this has increased from 14.5% in 2009/10 to 15.8% in 2010/11. There has been an increase in the incidence of diabetic ketoacidosis emergency admissions from 2005-6 to 2010-11. Stoke Mandeville patients had 6.3% of missing HbA1C results with 29.1% of those surveyd having all key care processes missing. Wycombe patients had 2.4% of missing HbA1C results with 30.7% having all key care processes missing. Conclusions - The development of regional networks and the inroduction of the best practice tariff in England should help deliver high quality service. Further analysis is taking place concerning diabetic ketoacidosis but this should also be addressed at local level.

National report for 2010/11 - further audits have superceeded any action plans.

3004 Evaluation of the Physiotherapy Led Back Group

Lynn Bath, Clinical Specialist, Physiotherapy

An evidence based back group is run at all 3 hospitals. The audit will obtain patients' views on how it has affected their perceived disability, timing and content, in order to improve the service.

Specialist Services

23/06/2010 Complete 10/06/2011 Results: The Back group was designed to address patients’ fears of exercising and taking part in physical activity and to improve their confidence and fitness when they have back pain. The responses to the questionnaire indicate that the back group is achieving this aim with 67% reporting improved fitness and 60% increasing the range of activities they could do, which often exceeded their expectations.The area where some people were disappointed was in the continuation of their pain, although 47% reported a reduction in pain and 68% reported the effect on pain was about what they expected or better.Using the Roland Morris questionnaire as an outcome measure we can see that 38% of patients had a statistically significant reduction in their level of back related disability. All patients rated the Back Group as very good or good. Patients particularly praised the physiotherapists that ran the groups. Recommendations: Explore in more detail those that

Results presented to Pain Consultants and their teams where it was well received and has resulted in them referring patients for this type of approach. The Rheumatology department were also very enthusiastic about it and agree that this is a useful way of dealing with people with chronic pain. Has been presented to physio departments and has boosted morale.The other recommendations will require a further audit which has not yet been done.

increased their RM score. Look at how we influence psychosocial yellow flags by using a suitable outcome measure. We have not collected data on how many patients did not complete the 6 sessions and we should explore how many drop out and their reasons for doing so.The results of this audit should be presented to the musculoskeletal physio service and those referring patients to the physio departments.

3005 Care of Ventilated Patients May 2010


To evaluate results of High Impact Intervention (HII) 4 tool used in Saving Lives Infection Control programme.


25/06/2010 Complete 30/07/2010 Overall compliance for all applicable elements performed was 69%. This is considerably worse than in 2009. However, different wards have taken part so overall compliance is not directly comparable.

Applicable wards informed of results and that they must improve, particularly with regard to hand hygiene prior to ventilation. For re-audit next year.

3006 Urinary Catheter Care May 2010



Trustwide 25/06/2010 Complete 15/10/2010 Compliance levels for individual elements in the insertion part of the audit was of a consistently high standard. With the exception of the personal protective equipment element (99% compliance), all other elements achieved 100%. Compliance levels for the individual elements in the continuing care part of the audit ranged from 94% to 100%. The compliance level for the hand hygiene element was 100%. The other results were catheter hygiene (98%), aseptic sampling (95%), drainage bag position (98%), catheter manipulation (94%) and catheter needed (94%). A review of the continuing need for a catheter should be an integral part of catheter management. As there is a significant increase in the number of observations from the 2008/2009 audits, direct comparisons can not be made. However the overall compliance level for all applicable elements for the on going care of catheters has dropped from 100% in 2009 to 88%. It is not possible to tell from the audit whether the individuals being audited are Doctors or Nurses. Future audits should record the staff group of the individual carrying out the urinary catheter insertion.

All recommendations actioned. To be re-audited.

3007 Epilepsy 12 Kamal Sawhney, C G Rastogi

A national audit looking at the quality and delivery of care for children and young people with suspected and diagnosed epilepsy.

Specialist Services

01/05/2011 Complete 16/10/2012 24 eligible patients included in audit. Investigations obtained at the audit unit were 12 lead ECG; 'awake MRI'; MRI with sedation; MRI with GA. 6/24 children (25%) had a diagnosis of epilepsy (two or more episodes of epileptic seizures) by the first paediatric assessment and 10/24 children (41.7%) at 12 months after the first paediatric assessment. 9 children commenced on AEDs. Of 10 children with epilepsy, there were 5 children with input by a

Changes required

‘consultant paediatrician with expertise in epilepsies’ or a paediatric neurologist by 1 year (50%). Of all 24 children, there were 12 children with evidence of appropriate first paediatric clinical assessment (50%). Of 10 children diagnosed with epilepsy, there were 10 children who still had that diagnosis at 1 year (100%). Of 2 children meeting defined criteria for paediatric neurology referral, there was 1 child who had input of tertiary care by 1 year (50%). Of all 24 children, there were 12 children with evidence of appropriate first paediatric clinical assessment (50%).

3008 CMACE Head Injury in Children Study

Dr Rastogi, SDU Lead, Dr Subramanian, Associate Specialist

A CEMACE study into head injury in children. The aim of the head injury in children study is to build up the evidence base concerning how early management of head injury in children affects health outcomes and to identify avoidable factors associated with adverse outcomes.

Women & Children

01/09/2009 Cancelled Audit suspended. Cancelled

3009 Re-Audit of CSSD and Trays returned to CSSD

John Abbott, Critical Care Operations Manager, Jill Hathaway, CSSD Manager

Re-audit of 2008 audit to record problems with cleanliness of equipment/instruments cleaned by CSSD and also to re-audit incorrect and incomplete paperwork being returned to CSSD by theatres.


25/06/2010 Complete 07/11/2011 1. Storage in theatre area to be reviewed to help limit damage to trays. Theatre Matrons to assess all equipment no longer used. Storage is still a huge issue in New Wing and Loakes. Still to be addressed.2. Knowledge of job roles between units. Visits to be arranged between Sterile Services and Theatres to allow staff the opportunity to understand each others roles. April 2012.

Theatre Storage - New Wing has been addressed with new racking being purchased. Concerns over handling in WGH addressed and all theatre sets are now returned directly to Theatres. Faulty/old equipment - Where possible new instruments/sets have been purchased and repair/replacement is an ongoing issue monitored from Sterile Services.

3010 Audit of Comprehensiveness of Consenting for Dynamic Hip Screws

Dr Bradley Porter, FY1, Orthopaedics, Mr Alistair Graham, Consultant, T&O

To compare comprehensiveness of consenting for dynamic hip screws with the recommendations of the British Orthopaedic Association.


24/06/2010 Complete 22/08/2011 Recommendations included: meeting with Registrars and Senior House Officers; handout demonstrating BOA recommendations and results from the 1st audit cycle; referred to Orthoconsent.com; re-audit in 3 months.

A re-audit has been carried out and it is planned to produce guidance for inclusion in the SHO Truama and Orthopaedic induction pack.

3011 National Diabetes Audit 2009 to 2010 Paeds (BHNHST)

Dr Atanu Dutta, Consultant, SMH, Dr M Russell-Taylor, Consultant, WH

A national system for routine data collection, analysis and feedback of diabetes related data.

Medicine 01/03/2010 Complete 28/01/2013 SMH summary results - based on 111 children with type 1 diabetes. Percentage of patients receiving care processes - national framework is that all children should ahve HbA1c measured every year and all children aged 12 and above should receive all care processes - completion rate for HbA1C was 89.2%, percentage receiving all care processes was 35.3%. NICE target for HbA1c is 7.5% or less, percentage of patients achieving the set treatment target (N= 99) was 9.1%.Incidents of patients admitted for ketoacidosis was 8.8 per 100 patients (9 patients excluded due to diagnosis within the audit year)

WH summary results - based on 166 children with type 1 diabetes. Percentage of patients receiving care processes - national framework is that all children should have HbA1c measured every year and all children aged 12 and above should receive all care processes - completion rate for HbA1C was 98.8%, percentage receiving all care processes was 4.2%. NICE target for HbA1c is 7.5% or less, percentage of patients achieving the set treatment target (N= 164) was 9.8%.Incidents of patients admitted for ketoacidosis was 16.7 per 100 patients (10 patients excluded due to diagnosis within the audit year)

No changes received as now working on 2011- 2012 audit.

3012 National Diabetes Audit 2009 to 2010 (BHNHST)

Dr Stephen Gardener, Consultant, SMH and Dr Ian Gallen, Consultant, WH


Medicine 28/06/2010 Complete Ongoing educational support to improve the quality of diabetes management within Primary Care.

Data collected relates to GP practices and Primary Care, so no changes to be made.

3013 Stroke Improvement National Audit Programme (BHNHST)

Dr M Burn, Stroke Consultant, WH

A national stroke audit which focuses on the first 72 hours of stroke care and requires every stroke patient to be entered onto an audit tool.

Integrated Medicine

11/06/2010 Not yet started


3014 Use of Faecal Occult Blood Testing in an Acute General Hospital (WH)

Dr Victoria Morrell, FY1, Gastroenterology, WH. Dr Fisken taken over audit in August 2010.

To investigate the use of FOB testing in acute hospitals - is its use appropriate, if inappropriate what is the impact of inappropriate testing? Should FOB testing be available in an acute hospital.

Medicine 17/06/2010 Cancelled 14/06/2011 Cancelled doctors failed to complete theis audit. Not applicable

3015 Timing to First Dose of Antibiotics in Sepsis

Dr Vishalli Ghai, FY1, Anaesthetics

An audit of antibiotic prescription for patients with sepsis. Looking at mortality and timing of antibiotics from presentation.


06/07/2010 Cancelled 30/09/2011 Project cancelled. Project cancelled.

3016 UK National IBD Audit 3rd Round 2010

Dr Sue Cullen, Consultant Gastroenterologist WH, Dr R Sekhar, Consultant Gastroeneterologist SMH

A national audit to examine the organisation and structure of IBD services and clinical care throughout the UK.

Integrated Medicine

07/07/2010 Complete 21/02/2012 Key recommendations from national report: Sites should work to establish an identifiable IBD team with a named clinical lead. Clinical pharmacy support for the IBD team should be strengthened given the high cost and complexity of the drug regimes that are often used. Colorectal surgeons should be encouraged to enter the data on pouch operations onto the ACPGBI Ileal Pouch Registry: tp://www.acpgbi.org.uk/research/ilealSites should work to engage psychology and counselling services. IBD Team meetings and multidisciplinary working should remain a focus of the IBD team in the face of opposing pressures. Any opportunity to improve the bed to toilet ratio should be grasped and IBD teams should seek to create solutions within a defined timescale.

Changes required

3017 Complications Following Laparoscopic Cholecystectomy

Kapil Sahnan, FY1, General Surgery, Project Sponsor Mr Wasantha Hiddalachchi, Trust Registrar

Follow up audit on elective laparoscopic cholecystectomy. Compare post op complications between the two audits. (We don't seem to have previous audit registered) Audit 2515?


07/07/2010 Cancelled 08/12/2010 Project cancelled - audit was not carried out. Project cancelled.

3018 Audit Grade 4 Pressure Ulcers (BHNHST)

Alison Brandon, Divisional Lead Nurse, Division of Medicine

Audit of all grade 4 pressure ulcers reported via Datix between 1/10/2009 and 31/103/2010.

Medicine 08/07/2010 Cancelled 28/02/2011 Cancelled Cancelled

3019 An Audit of Inpatient Endoscopy Referrals (SMH)

Dr Helen Cordey, FY1, Gastroenterology, Dr Ravi Sekhar, Consultant Gastroenterologist, SMH

To audit how adequate and appropriate inpatient endoscopy referrals are and how soon after referral endoscopies are carried out.

Medicine 09/07/2010 Complete 22/10/2010 Conclusion: Referral forms are still not being correctly used and completed. Recommendations: Clinicians can to help improve the service provided by endoscopy by: using the correct form, filling in all sections of the forms, checking the pt is happy to have the procedure prior to booking it and letting Endoscopy know if pt is to be discharged or is otherwise unable to have their booked endoscopy.

During departmental induction junior doctors are educated in the correct way to complete endoscopy referral forms and reminded of the need to submit them in a timley manner. This is also discussed during medical meetings.

3020 Peripheral Line Insertion and Continuing Care Audit June 2010

Amanda Adkins, Infection Control, SMH

Patients with Iv cannula device in situ should have VIP form properly completed.


28/07/2010 Complete 04/11/2010 Results: Insertion: Overall compliance for the different elements of the tool were as follows: Insertion using aseptic technique 98%. Skin preparation performed 99%. Dressing in situ 100%. Insertion of device documented 93%. All applicable elements complied with 91%. If theatres are excluded compliances for all divisions are worse than in 2009. Continuing care: VIP forms were completed for 84% patients with IV lines, a considerable reduction on the 2009 compliance of 95%. Insertion documentation is particularly badly completed, particularly the name of the person inserting the IV device and the date/time of insertion.Aseptic access is performed in 99% cases. Compliances for presence of a VIP form, insertion documentation and continuing clinical indication are worse than in 2009. Compliances for removal documentation, access documentation, aseptic access and labelling of admin sets have improved.


3021 Surgical Site Infection Audit Plastics June 2010


High Impact Intervention preventing surgical site infection for Plastics only.


28/07/2010 Complete 13/09/2010 Pre-operative component. Only 57% screened for MRSA. None tested positive so further action cannot be audited. Peri-operative component. Only 54% received prophylactic antibacterial 60 minutes prior to incision. Normothermia monitored and maintained for 94% patients. All applicable elements complied with in 55% cases.


3022 To Establish the Long-term Compliance of AIS A SCI Individuals with Standing Post Discharge from NSIC

Kara Hoskins, Sara Edmondson, Physios

Questionnaire to patients discharged 1998-2008 to establish compliance with standing.

Specialist Services

28/07/2010 Complete 03/01/2012 Results: 74% patients’ standing devices were available when they were discharged from hospital. 4 patients waited more than 6 months for their standing device to be available. 1 patient never received their device. Whilst waiting for their devices 4 patients did not use an alternative to standing. 4 patients used stretches, either by themselves or with assistance from a carer. 69% of patients were recommended the Oswestry standing frame by their treating physiotherapist. 30% patients stated that they no longer stand on a regular basis.10/12 patients stated that they stopped standing over one year ago. Patients reported that they stopped standing for a number of reasons; the most common were ‘lack of time’ and ‘no one available to assist’.9/14 patients still have their standing device, but do not stand.78% patients were still using their original standing device. 22% of those who still stand do not stand for the recommended length of time. Recommendations: Patient advice leaflet/ patient educationRe-audit in SPOP – larger sample, shorter questionnaire. Provide contact details in e-shot for those unhappy with current standing provision. Standing promotion day. Increased number and variety of standing frames in unit. Search of alternative frames on the marketDemonstrations of various products to staff. Some trialled with patients.‘Problem solving sessions’ with current suppliers.

1. Various different Reps have provided staff with in-service training on new standing devices. 2. Different frames have been loned to the unit for trial with patients. 3. Therapists have been encouraged to inform patients regarding the reasons for standing. 4. A database has been compiled of people to approach in commissioning at various PCTs throughout the country.

3023 Endoscopy Staff Satisfaction Survey 2010 (BHNHST)

Sue Kenny, Sister, Endoscopy Unit SMH, Deborah Dobree-Carey, Sister, Endoscopy Unit WH

To asses levels of staff satisfaction and identify any areas for improvement.

Medicine 14/07/2010 Complete 19/11/2010 Recommendations: Improve staffing levels (both sites). Greater opportunities for staff training, including specialist training (both sites). More visible input from Trust management (SMH). Review of the facilities and layout of Unit given the recent increase in activity (both site). Ensure staff appraisal are carried out on an annual basis (WH). Discuss future plans for the Unit (both sites).

New staff have been appointed at WH. A working party was set up but suggested changes to facilities/ layout were vetooed by management because of lack of funds. More training with specialist outside agancies is being undertaken. Staff appraisals are up to date. A re-audit is planned for September 2011.

3024 Community Head Injury Service - Audit of Initial Assessment Process

Dr Andy Tyerman, Consultant Clinical Neuropsychologist, Head of Service CHIS

The initial assessment process used by the Community Head Injury Service is essential to the effective provision of the service. This audit will check whether the initial assessment process provides the background information required in order to provide an effective service, and check how well the process operates from a clinical/administrative perspective.

Integrated Medicine

29/06/2010 Complete 24/08/2011 Draft revisions to be made to the; Initial Assessment Checklists, Background Interview Schedule, Head Injury, Problem Schedule & Relatives Screening Interview for discussion at CHIS Service Management Group (12/09/11) Final amendments to be made to forms by 30/09/11 with a view to revised forms being ready for implementation from 01/10/11. Changes to be outlined to all staff at next staff meeting on 13/10/11. Revised form to be reviewed at Service Management Meeting in April 2012.

Changes required

3025 Audit of Manual handling Documentation in Therapy Notes of Spinal Patients July 2010 onwards

Dot Tussler, Superintendent Physiotherapist, NSIC

A manual handling assessment should be carried out before physiotherapy and updated regularly. Audit to see if this is being carried out.. Audit repeated monthly until sufficient compliance.


01/07/2010 Complete 30/07/2010 Recommend that re-audit is completed monthly until a completion rate of over 90% is obtained. Manual handling forms present (July 75%, August 90%, October 100%, November 90%), manual handling forms completed (July 65%, August 85%, October 80%, November 90%), risk assessment form present (July 65%, August 45%, October 80%, November 60%), risk assessment form completed (July 25%, August 45%, October 50%, November 45%)

Re-audited.

3026 Audit of Manual handling Documentation in Therapy Notes of Spinal Patients - Oct 2010

Dot Tussler, Superintendent Physiotherapist, NSIC

A manual handling assessment should be carried out before physiotherapy and updated regularly. Audit to see if this is being carried out. Also done in July 2010 and August 2010. August results presented in this audit.


01/10/2010 Complete 25/10/2010 Results: Now 20/20 (100%) had manual handling forms present. 16/20 completed, 14/16 updated once. 16/20 risk assessment forms present. 10/20 completed. Improvement on August and July but still not good enough. Recommendations: Completed risk assessment and manual handling forms to be kept at front or rear of notes. Re-audit monthly until 90% achieved for each form. Consideration of manual handling and risk assessment documentation with implementation of IMS needs to be considered.

Now have electronic record keeping (IMS), paperforms no longer required. Too early to assess IMS documentation. Re-audit will be done.

3027 Laparoscopic Surgery - Information, Counselling and Consent

Dr Hooman Soleymani, Dr Dawn Brittain, ST1

An audit to assess the performance of the gynaecology department against the RCOG greentop guidelines for consent for operative laparoscopy.

Women & Children

01/10/2010 Complete 16/11/2010 Results: Documentation of discussion, major and common complications was well completed. However, the common minor complications such as wound bruising 4%, shoulder- tip pain 10%, & wound gaping 0% were not well documented. Also the RCOG recommend that women who are obese, have significant pathology, previous surgery or pre-existing medical conditions are informed that they are at increased risk of complications. The verbal information given to patients was supplemented by a leaflet in only 60% of cases. 18% were consented in clinic prior to admission and the remainder on the day of surgery. Recommendations: information should be given, preferably in a written format, in the clinic prior to admission, but consent should be gained on the day of surgery by the surgeon. The use of a sticker to make the general consent form specific to the procedure, and therefore act as a memory aid, was considered a positive suggestion, along with the suggestion for those at greater risks.

A dedicated laparoscopic surgery patient information leaflet was ratified Mr Dada has been distributing this. He has also completed a ‘ post laparoscopic surgery’ pt info leaflet which is going through the system (August 2011) and will be available in due course for further info sharing and good practice. Consent is also currently being addressed for all gynaecological surgery. No junior should consent for an operation that he/she cannot carry out. We are meeting as a consultant body to consider if we agree templates for minor ops and standard ones ie TAH etc. Laparoscopic surgery consent will probably remain the domain of the surgeon.

3028 Laparoscopic Surgery - Techniques and Outcomes

Dr Laura Creasy, GPST1, Mr Tunde Dada

An audit of gynaecological laparoscopic surgery against national guidelines: to ensure the guidellines are being adhered to; to compare the performance of different operating surgeons; to determine length of stay.

Women & Children

01/10/2010 Complete 01/11/2010 As complications with laparoscopic surgery are relatively rare the small sample size limited the information that could be collected with this audit. It was felt that a larger sample over a longer period would be a greater benefit. It was also felt that an audit which focuses on one reason for the laparoscopy rather than the range sampled in this audit would give more useful data.

No changes will be provided as the results were not conclusive. Re-audit suggested with larger sample over a longer period and focusing on only one reason for laparoscopy.

3029 Audit of Fast Track Physiotherapy Service for Staff referred from Occupational Health

Kate Glover, Physiotherapist

An audit of staff members referred by Occupational Health to the Fast Track Physiotherapy Service to assess the speed of service, number of days on sick leave and outcome of treatment. Survey being carried out as part of compliance with recommendations in the Boorman Report published 2009.

Specialist Services

01/12/2010 Complete 25/05/2012 Figures were used to support bid for further funding of fast track service so not really an audit as such. No recommendations or action plan or report.

Not applicable

3030 Thromboprophylaxis in Gynaecology

Mayurika Wimalaranta, Memoona Kan

Audit against Trust guideline 539.1.

Women & Children

01/11/2010 Complete 01/11/2010 The audit found that there was better compliance with the guideline in elective patients, but in general documentation was poor and that Fragmin was being under prescribed. Recommendations and discussion:1. Fragmin should be initiated as part of the WHO check list in theatre. 2. Responsibility for prescribing or recording the reason for omitting should sit with the surgeon. 3. Reformatting the operation record to have a check box for Fragmin. 4. VTE form should be completed as part of the clerking procedure. 5. Training to increase awareness of the guideline. 6. Re-format the prescription chart to have fragmin pre-printed on it requiring only the dosage and signature to be added. 7. To design a Gynae admission proforma with VTE/Fragmin check boxes. NICE guidance advises that all Gynae patients should have TED stockings. It was felt that there is a need for a change in practice to ensure that best practice becomes the normal culture. While flowtron boots are used in the Gynae theatres, when the patient returns to the ward they are not used because the ward doesn’t have the required pumps. Action issue

Discussed at the Academic Half Day. Will also be discussed at Risk Monitoring meeting - part of the ongoing raising of awareness.

to be raised at O&G business meeting. The use of the VTE form in A&E this should be included in the emergency paperwork. Action Audrey Warren to ensure that there is a supply available.

3031 Thromboprophylaxis in Obstetrics

Vishalli Ghai, Lorna Evans


Women & Children

01/11/2010 Complete 01/11/2010 Results: Risk assessment is not being correctly performed, and treatment is not being correctly prescribed. Postnatally, 100% of LSCS patients received prophylaxis but other patients sometimes had multiple risk factors that had been identified. Recommendations: There is a need for greater awareness of this guideline and training for staff. The booking assessment should be performed by the community midwife but after this point any practitioner seeing the patient should check that it has been completed and complete it as required. As part of this discussion the possibility of changing the colour of the form so that it is more easily identifiable in the notes was raised. The form will be changing format when the new guideline is published. Staff should remember that mechanical methods of prophylaxis are indicated for some patients. The need for an assessment to be completed in the postnatal period should be stressed.

New VTE forms introduced.

3032 Vaginal Birth with Uterine Scar

Sangeetha Pelly, Naomi Jeffery


Women & Children

01/11/2010 Complete 01/11/2010 Recommendations and discussion: Documentation of the audit requirements in the antenatal period were found in a variety of places which made the audit more difficult. Wider use of the sticker introduced in the VBAC clinic will make this easier for future audits and should increase compliance with the guideline. Regarding review of the requirement for all VBAC patients to be seen at 36 weeks: could the guideline be amended to remove this requirement for those women who have already made a decision about proceeding with a VBAC? When these patients are reviewed at 20 weeks could the GP letter be tailored to fulfil the audit requirements? Ensure that women who miss the 36 week appointment are followed up.

Documentation and use of the sticker has improved.

3033 LMA and ETT Intracuff Pressures Audit

Dr Bartosz Swiech, FY2, Anaesthetics

To measure the intracuff pressures of Laryngeal mask airways (LMAs) and Endotracheal tubes (ETTs) in theatre. To assess the relationship between intracuff pressures and post operative sore throats.


01/11/2010 Complete 12/11/2009 LMAs: Out of 109 patients, 30 (27.5%) reported having a sore throat post operatively. Out of these 30 patients, 93% of patients had an intracuff pressure greater than 60cmH2O. ETTs: Out of 60 patients 39 (65%) reported a sore throat. Out of these patients, 59% had an intracuff pressure greater than 32cmH2O. In both the LMA and ETT groups it was found that the intensity of sore throat experienced by a patient was directly linked to increased intracuff pressure. Recommendations: Handheld intracuff manometers should be available in all anaesthetic rooms. Intracuff pressures should be routinely monitored during surgery. The correct size of LMA should be used based on weight as this may cause an increase in cuff pressure for adequate seal.

Appropriate size of LMA cuff is now being chosen.

3034 Monthly Survey of PALS Clients

Sue Ball, Patient Experience Manager, Nick Bigwood, Head of PALS

To regularly survey a random selection of PALS clients to measure satisfaction in the service and identify any areas for improvement.

Trustwide 05/08/2010 On-going Results and Recommendations required Changes required

3035 Audit of the Incidence of VTE in Stroke Patients

Dr Nihal Fernando, Associate Specialist, MfOP, WH

Audit to investigate the incidence of VTE (PE) in stroke patients and the effectiveness of prevention strategies. Have there been any changes since the CLOTTS trial?

Integrated Medicine

05/08/2010 Cancelled 14/11/2011 Not applicable Not applicable.

3036 Audit of Cutaneous Squamous Cell Cancer Excisions

Dr Rubeta Matin, SpR, Dr Katharine Acland, Consultant, Dermatology, AH

Squamous cell carcinoma is the second commonest form of non-melanoma skin cancer diagnosed. Recent guidelines have been drawn regarding the management of patients with SCC and this audit will determine whether these are being adhered to.

Integrated Medicine

05/08/2010 Complete 18/03/2011 Results: Documentation at time of diagnosis is poor. Recommendations: Design and implement use of a proforma for skin lesions presenting at the Triage Clinic. Need to document the size and site of the lesion so an appropriately skilled surgeon and appropriate time-slot can be allocated.

A surgical proforma has been introduced.

3037 Audit of Methotrexate prescribing in Dermatology

Dr Rubeta Matin, SpR, Dr Sophie Grabczynska, Consultant, Dermatology, AH

An audit was undertaken in November 2007 to determine prescribing of methotrexate in the Dermatology Department. Suggestions were made and the audit increased awareness of the prescribing guidelines. The re-audit is therefore being undertaken to determine if these standards are being met and to close the audit loop. (Original audit 2027)

Integrated Medicine

05/08/2010 Complete 04/07/2011 This re audit highlights that we need to continue assessing the F/U patients for risk factors to MTX such as alcohol intake and drug interactions. Contraceptive advice must be improved in F/U patients. To continue to improve our blood monitoring including P3NP levels (which will partly involve the GPs). Ensure all patients have documented co prescription of folic acid with MTX.

A check list has now been introduced for use at all clinics. Agreed at the Dermatology Clinical Governance Meeting.

3038 Measuring the Surgical Management of Otitis Media with Effusion in Children against NICE Guidelines

Jane Lambie, Lead Research Nurse, Genetics of Otitis Media Study, Nuffield Department Surgical Sciences, Mr Ian Bottrill, Consultant, ENT, SMH

The NICE guideline for the surgical management of Otitis Media with Effusion in children, introduced in February 2008, places a 3-month period of active observation at the centre of the care pathway and provides guidance on when surgery is most appropriate. This audit aims to measure the degree of compliance with NICE guideline CG60.


06/08/2010 Cancelled 10/08/2011 Project never started. Not applicable - project cancelled.

3039 National Comparative Re-Audit of the Use of Platelets 2010

Donna Beckford, Transfusion Nurse, Terry Perry, Transfusion Nurse

Audit to examine the use of platelets in a haematology setting.


09/08/2010 Complete 01/08/2011 Platelet usage is within normal range. Nothing unusual.

Main points circulated to haematology consultants.

3040 Baseline Audit of Putting Feet First

Erin Lee, Band 7, Podiatry, Jane Coles, Band 7, Podiatry

A one-day audit of all diabetic inpatients, looking at the number of patients, their risk rating according to NICE guidelines and the current inpatient care. The audit aims to draw up specifications for the proper management of the diabetic foot in secondary care. Left message 3/12/2010 on answerphone - no response. Sent emails on 7/1/2011 with list of questions and also asking for a meeting. 18/1/2011, 24/1/2011, 2/2/2011 emails sent requesting a meeting to discuss data as cannot proceed without their input.

Medicine 11/08/2010 Complete 20/06/2011 Results: Only 14% of patients over the 3 hospital sites had their feet screened on admission. However, only 6% of these screened patients had been referred to the specialist team. When screening all diabetic inpatients on 9th November 2010, we actually identified that - 32% patients were low risk; 45% were increased risk; 12% were high risk and 12% were ulcerated. This would indicate 24% of these patients should have been referred to the specialist team. This demonstrates that putting feet first report and NICE clinical guideline 119 (2011) key priorities are not being met. Recommendations: 1) Develop a programme of education, awareness and practical training for healthcare professionals to highlight the risk of complications of the diabetic foot. 2) Standardize a foot screening tool. 3) Referral pathway. 4) re-Audit Inpatient foot screening. 5) More time and staff.

This audit has now been superceded by audit number 3349.

3041 Audit of Investigations & Outcomes for Patients with Presumed Lower GI Bleed (SMH)

Dr Ben Wildblood, FY1, Dr Ben McNeillis, Dr Wei Liong, Consultant, Radiology, SMH

Audit to assess whether SIGN & BSG guidelines are being followed and whether CT angios are being requested appropriately. How do the different investigations compare regarding diagnosis and outcomes?

Medicine 17/08/2010 Cancelled 07/10/2010 Not applicable project cancelled Not applicable

3042 Evaluation of MCU Antibody Testing as Serological Marker in Early Diagnosis of Rheumatoid Arthritis

Aleksandra Sryntar-Jarocka, Biomedical Scientist, Jacqui Wozniack, Lead Biological Scientist, Virology & Immunolgy

Use of results of MCU Antibody Testing to improve diagnosis and monitoring of treatment for rheumatoid arthritis.

Specialist Services

25/08/2010 Complete 27/04/2011 When considering the diagnosis and monitoring, statistical analysis proved that the MCV test can and should be used as a screening test. This was more of a research project than an audit and there were no recommendations relating to the Trust.

None indicated.

3043 Evaluation of New In-house PCR Method for Diagnosis of Herpes Simplex Virus

Tate Watson, Trainee Biomedical Scientist, Jacqui Wozniack, Lead Biological Scientist, Virology & Immunolgy

Samples for PCR diagnosis for herpes simplex virus had previously been sent to a referral laboratory but are now dealt with in-house. This audit will compare the two methods.


25/08/2010 Complete 15/02/2012 This is almost certainly research. Report very very technical.

Not applicable

3044 Personal Protective Equipment audit July 2010


Use of personal protective equipment tool in all wards to evaluate if infection control guidelines are being followed.


24/08/2010 Complete 29/11/2010 To achieve the target compliance level the score must be 85% or above as set by the Infection Prevention Society. The overall score for all areas of this audit was 97%. 48 areas achieved a compliance level of 100%. 4 areas were below the 85%, with scores ranging from 62% to 78%. Scores by question varied from 90% to 100%.


3045 National Inpatient Survey 2010

Medical Director, Chief Nurse

National Inpatient Survey to 850 inpatients discharged from hospital in July 2010.

Trustwide 25/08/2010 Complete 03/06/2011 Improvement of >=5% in following areas since 2009: Were offered a choice of hospital, cleanliness of ward and bathrooms, hospital food, help to eat, hand hygiene, confidence in nurses, enough nurses, patient involvement in decisions, pain control, answering call button, discharge information, medication information, copies of GP letters, treated with respect and dignity, very good or excellent care.There was a decline of at least 5% in explanations of procedures. We were amongst the 20% worst performing trusts for wait to be admitted, sharing a sleeping area with patients of the opposite sex, time to answer call button, explanation of operations, information on discharge medication, clarity of letters to GPs, asking for patient views, info on how to complain. We were in best performing 20% trusts for offering a choice of food.

Medicine Division are: Monitoring waiting lists. Urgent care pathway being implemented. Single sex policy implemented. Auditing patient experience through Matron's walkabouts. Attendance at medicines management training being monitored. Patient representative on service redesign group. All wards have a sign stating how patients/famililies can access doctors and when ward rounds are. Ensuring all areas have discharge leaflets. Community Hospitals have implemented inpatient referral management system to enable improved access to community beds.

3046 Gentamicin Prescribing

Denys Gibbons, Pharmacist

Re-audit to compare the results with those of a previous audit and to assess the implementation and use of a new gentamicin chart.


25/08/2010 Complete 25/08/2010 Reason for initiating recorded in only 37% cases. Of those where indication recorded, all were prescribed in line with Trust guidelines (75% in last audit). Weight recorded in 33% cases (10% improvement on last audit). If weight recorded improvement of 5% in correct dose prescribed. Only 1 made checks on renal function before prescribing. Improvement of 1% in gentamicin level monitoring. Charts should be monitored by pharmacists but only 16% were. 90% used gentamicin chart but old charts still being used at WH. Recommend awareness and education campaign, revision of chart to include pharmacist's signature.

Ensured that the new chart was in use on every ward as great deal of the old charts were still in use in the trust and the supplier was using up old stock.

3047 Seretide Prescribing

Shu Yi Tan, Pre-reg Pharmacist

Audit to identify Seretide prescribing trends (used for asthma and COPD).

Medicine 25/08/2010 Complete 25/08/2010 Only 73% prescriptions written according to licensed doses and frequencies (most rectified by ward pharmacist). 51% used off license, cost savings if switched to equivalent medication. Recommend education sessions, cost comparisons, re-audit.

Pharmacists assist new doctors to review so inhalers are reviewed. Inhaler technique review partially achieved. Prescribers constantly reminded by pharmacists of different dosing regimes. Seretide 500 Accuhaler now on Trust's formulary. A new clinical guideline for COPD has been created which uses most cost-effective inhalers. This has been circulated Trustwide including PCTs. Pharmacists aware and intervene where appropriate. No future audits carried out as yet.

3048 Audit of 'Place of Death' Outcome from Palliative Care Team Caseload

Carol Hobson, Palliative Care Cancer Nurse Specialist

To reassess current practice with regard to recording patient's preferred place of death and exploring reasons for discrepancies between actual place of death and recorded place of death.

Specialist Services

26/08/2010 Complete 20/10/2011 1.The results of this audit should be presented at the EOLC steering group. 2.The results should be presented at the Palliative Care Management Meeting. 3.Re-audit should take place in 2012.

Re-Audit took place in 2012 after introduction of new EOLC pathway in February 2012.

3049 BTS National Pleural Procedures Audit 2010

Dr Rachel Ayers, SHO, General Medicine, Dr Charlotte Campbell, Consultant, Respiratory Medicine, WH

National audit looking at pleural procedures - diagnosis, treatment and outcomes.

Medicine 03/09/2010 Awaiting Report/Action Plan


3050 Health Visitors Client Experience Survey

Rosemarie Finley/Jenny Chapman, Clinical Manager/Head of Children & Young People's Community Services

A client experience survey of the Health Visitors service.

Women & Children

16/08/2010 Cancelled 19/10/2011 Failed to supply recommendations and action plan report still in draft format

Not applicable

3051 Seasonal and Swine Flu Vaccination Survey

Dr Kathryn Campion, Consultant Occupational Health Physician

Survey of doctors' and nurses' perceptions of flu vaccination to identify why uptake is low.


10/09/2010 Complete 04/05/2011 The results of the audit were well received and it is hoped that some of the observations may shape this year's flu campaign e.g. highlighting the benefits of the flu vaccine both from a work and a personal perspective.

Not applicable

3052 Cardiac Day Unit PES (WH)

Ghazala Yasin, Sister, Nicola Bowers, Sister, Cardiology, WH

Survey to ensure a high quality service is being provided to patients within the Cardiac Day Unit and to highlight any areas for improvement.

Medicine 20/09/2010 Complete 18/05/2011 1. Ensure an appointment letter is always sent to the patient with clear instructions showing how to get to the hospital from the centre of High Wycombe town and also how to get to the Unit from within the hospital. 2. Ensure information sheets explain fully what will happen during the patients time in the Unit, e.g. include the fact that procedure could take place through the wrist and what this means in terms of being able to drive and work etc, likely waiting times, items of clothing to bring, drugs lists to bring and likely recovery times. 3. Ensure patients are met as they arrive at the Unit and all staff introduce themselves. 4. Maintain the patients privacy at all times and keep them informed of progress through the procedure. 5. Avoid situations where patients in recovery have to move from their bed to a chair to free up their bed for another patient.6. Continue to improve standards of cleanliness in the Department, particularly toilets.

1. Staff are making a conscious effort to introduce themselves to all patients and are also wearing name badges, clearly showing name and position. 2. Deputy Sister Abbey is working on uploading information about the cardiac day unit on the new Swan website. 3. Chairs at the end of the unit have been clearly labeled as recovery chairs for patients to sit in whilst recovering from angiograms. 4. Staff have been informed that the coordinator of each shift needs to inform patients of likely waiting times and cath lab activities, which is being undertaken on each shift. 5. Cleaners have been asked to check the toilets at around

lunch time everyday, which is being monitored and has been accomplished. 6. Planning to work on the letters with the secretary and hoping to do that when the website is active and uploaded, as we can put a lot of information about the procedure on the website and patients are able to access this information from home.

3053 Comparison of Long Term Results of Bilateral Congenital Cataract Treated with Early Cataract Surgery, Aphakic Glasses and Secondary Intraocular Lens Implantation

Tahmina Islam, Registrar, Ophthalmology

To evaluate the long term visual outcome after early surgery of bilateral dense congenital cataracts, aphakic correction with glasses and secondary intraocular lens (IOL) implantation.


01/10/2010 Complete 21/02/2011 Presentation received, contained a discussion section but no recommendations. Numbers were small (22) despite collection over 12 year time period. Very difficult to draw conclusions but enabled a discussion of current practice.

Changes not required

3054 Diagnosis & Treatment of UTIs

Dr Zac Etheridge, F2, Microbiology, Dr K Cann, Consultant Microbiologist, SMH

UTI may be over diagnosed in SMH with the result that antibiotics are unnecessarily prescribed or there is a delay in reaching the correct diagnosis.


21/09/2010 Complete 22/11/2010 Urinary tract infection is poorly diagnosed at SMH, and the current guidelines may not be applicable to older people. In this audit, only 6% of patients were treated appropriately according to current guidelines. In an era of increasingly resistant bacteria and Clostridium difficile associated diarrhoea, accurate diagnosis and avoidance of unnecessary courses of antibiotics is essential, and UTI should not be used as an easy “get out” diagnosis when presented with a non-specifically unwell older adult. Recommendations: i) Establish a consensus between MFoP physicians and microbiologists at SMH for correct diagnosis of UTI. ii) Consider recommending an in-out catheter for obtaining a urine specimen in patients who are unable to provide one. iii) Educate doctors as to the correct use and interpretation of urine dipstick testing. iv) Educate nursing staff regarding the correct procedures for dipstick testing via infection control study days. v) Produce an updated clinical guideline for assessment of UTI.

The Trust guideline regarding Urinary Tract Infections has been up dated to include the suggestions made. The results of this audit were presented to nurses at the Infection Control Study Days at WH & SMH in November 2010. Junior doctors are continually reminded regarding the correct procedure for interpretation of dipsticks.

3055 Audit of Renal Growth in Children with SCI (SMH)

Dr Claire Atkins, FY1, General Surgery, Dr Alison Graham, Consultant, NSIC

Children with SCI are at risk of renal disease due to loss of bladder function as a result of their inury. These children require regular assessment of upper tract anatomy and renal growth for optimal urological management.

Spinal Injuries

21/09/2010 Complete 26/04/2011 This study has shown preliminary evidence that spinal cord injury in childhood impacts on renal growth. The study has also shown that renal growth patterns differ in children with spinal cord injury compared to uninjured children and renal growth charts used need to be specific to this patient population. Regular renal length measurement has an important role in identifying early, a child who is at increased risk of developing renal disease. The NSIC should be performing renal ultrasounds on their paediatric population. By using some small measures, improvements in care for children with spinal cord injuries can be achieved.

Renal growth and size will continue to be measured and recorded as both are useful clinical indicators of healthy development.

3056 Audit of Outcome of Outpatient Hysteroscopy in comparison with national data

Dr Gemma Brierley, ST2, Gynaecology, Dr Shalmali Karnard, ST1, Mr Tunde Dada, Consultant

To audit the outcome of outpatient hysteroscopy in comparison with national data and Trust guideline 644.2.

Women & Children

21/09/2010 Complete 17/03/2011 Results: Hysteroscopy is an easy, relatively safe method for investigating women with a thickened endometrium. Hysteroscopy with the indication as raised endometrial thickness alone appears justified as it identifies 48.5% benign pathology and 9.5% potentially sinister pathology. Incomplete documentation may be skewing analysis of data. Hysteroscopists are now going to enter data directly onto database at time of procedure. Do rates of identification of pathology differ between OPH and inpatient/ DSU hysteroscopy? Is it any different using TVUS rather than abdominal USS? Discussion around performing hysteroscopy for raised endometrial thickness found on USS in the absence of other symptoms, audit showed the majority were found to have benign pathology. Recommendations: It was felt that there was a need for a guideline on the treatment of women found to have raised endometrial thickness on USS. Possible randomised controlled trial on conservative management /hysteroscopy.

The management of the inadvertent finding of a thickened endometrial lining in postmenopausal women who have not had any bleeding is contentious. There is no national or indeed international agreement on what should be done in these circumstances – a reason for initiating the audit in the first place. Now that we have our own data however we are able to counsell our patients as to what we have found in our own unit, which is invaluable

3057 Radical Cystectomy Audit

Mr John Kelleher, Consultant, Urology

To compare complications and outcome of radical cystectomy over 3 periods during last 15 years.


27/09/2010 Complete 07/10/2010 Lessons learned: reduction in LOS over the years; enhanced recovery programme; extraperitoneal cystectomy; combined approach to neobladder surgery; radical prostatectomy experience invaluable especially for nerve sparing; cystectomy for G3pT3B and G3pT4 cancer is palliative.

No response from audit lead to requests for changes.

3058 A Survey of Dr Sarah Martin, A survey to assess Specialist 28/09/2010 Complete 05/04/2011 Results and Recommendations for menorraghia Second part of the audit

Patient Satisfaction following Outpatient Endometrial Ablation

GPST1, Mr Chris Wayne, Consultant, Obs & Gynae

patient satisfaction following outpatient endometrial ablation through written patient feedback, and to assess adherence to NICE guideline TA78 for the management of menorrhagia.

Services component of audit: Investigations completed as part of patient assessment: FBC (71%); USS (94%); Swabs (52%); Hysteroscopy/biopsy (94%). 52% of patients presented to clinic without any prior treatment from their GP. Of the treatment options discussed with patients, most commonly discussed were medical and ablative therapies. The most common treatments offered were the Mirena coil and ablation. 68% of patients were discharged with no further follow up. There is a need for documentation to be more thorough, and further conclusions can not be made until the second part of the audit is completed. It was felt that the small sample size and the multitude of variables made this a difficult audit to complete and obtain useful data. There are different pathways on the twin sites. However, it was a positive finding that hysterectomy is no longer the first line of treatment.

should be carried out, i.e. follow-up, in order to complete the cycle before changes can be made.

3059 BTS Emergency Use of Oxygen 2010

Jennifer Ricketts, ICU Outreach Lead Nurse, Dr Simon Barnes, SpR, Respiratory Medicine, Dr Chris Wathen, Consultant Respiratory Medicine

National British Thoracic Society (BTS) audit to establish the practice of oxygen presribing and delivery throughout the Trust.

Medicine 16/10/2010 Complete 14/06/2011 Recommendations: Further training required regarding the requirements of the British Thoracic Society (BTS) Guideline for Emergency Oxygen Use in Adult Patients, particularly: need for a written prescription with a stated target saturation range, signing for oxygen on the drug chart at each drug round, adjusting delivery devices and/or flow rates when the oxygen saturation falls outside the target range, recording details of the oxygen delivery system on the observation chart. Re-audit to be carried out - participation in the BTS Emergency Oxygen Audit 2011.

F1s & F2s receive training in oxygen prescribing. The correct procedure for oxygen prescribing is taught on staff induction days, BEACH course and the ALERT course. Pharmacy & Radiology have received training and are helping with prescribing issues on the ward. The Trust Oxygen Policy has been updated and is available on the intranet. Working is being done on an e-learning programme.

3060 VTE Prophylaxis in Orthopaedic Patients Post TKR and THR

Dr Siobhan Williams, FY2, Orthopaedics, Nik Bakti, CT1, Surgery, Project Sponsor, Mr Biring, Consultant, Orthopaedics

An audit of VTE prophylaxis in elective TKR and THR patients pre and post introduction of dabigatran, a new oral anti-coagulant.


30/09/2010 Complete 28/09/2011 The outcome of the study was not conclusive. It will be followed up with a possible audit with the Haematology Department to correlate dabigatran levels and post op wound oozing.

The outcome of the study was not conclusive. It will be followed up with a possible audit with the Haematology Department to correlate dabigatran levels and post op wound oozing.

3061 Medications and Fasting: Up To What Point Can Oral Medication

Dr Jonathan Chambers, FY1, General Surgery, Mr Akinwale, Consultant,

To assess whether there is a need to clarify the guidelines on oral medication


04/10/2010 Complete 15/04/2011 Results: This audit set out to assess how frequently doses of oral medications are being omitted whilst patients were ‘nil by mouth’ for theatre. It found that 17% of doses prescribed were omitted due to

Following the report, the following action has been taken: a) Several copies of the same poster have been

Be Given General Surgery when patients are nil by mouth. Is confusion regarding which oral medications can be given and up to what point, when patients are nil by mouth, leading to significant incidences of omitted medications?

patients being ‘nil by mouth’. However, of this percentage, only 3% of these were clearly not contra-indicated by the underlying disorder and surgical indication and should have been administrated unless two hours prior to the operation. Therefore, the majority of omissions documented as ‘nil by mouth’ were justified. This audit concludes in finding that when oral medications were being omitted, this was done so appropriately. It has not shown any objective evidence to suggest that confusion exists on the wards regarding fasting guidelines and so causing significant amounts of unnecessary omission.Recommendations: introduce and display posters on specific pre-operative fasting guidelines for ward staff; encourage clearer documentation by doctors regarding their requirements for fasting e.g. “Nil by Mouth from 0000, but clear fluids and regular oral medications up to 2 hours before theatre"; consider introducing a ‘Six is Safe’ scheme, ensuring early morning doses of regular medications are administered; consider providing theatre lists by 0200 hrs for nursing staff of patients on the General Surgical theatre list for later in the day.

distributed around the General Surgical Ward (6) in SMH which presents the Trust Guidelines for Pre-operative Fasting, both for elective and emergency surgical cases; b) The audit was presented to the General Surgical Academic Half Day, with points made to encourage clearer documentation by doctors regarding their requirements for fasting (included explanation for why this was necessary) and discussion on the ‘Six is Safe’ scheme and provision of theatre lists.

3062 Audit of Delirium in ICU Patients

Dr Joyee Basu, FY1, Anaesthetics/ITU, Project sponsor Paul Wong, Consultant, Anaesthetics/ITU

Delirium contributes to prolonged mortality and morbidity and has been shown to be common on ICU. It is often poorly recorded and assessed. This audit aims to determine if every patient is being assessed daily and to look at the risk and management of delirium.


05/10/2010 Complete 12/01/2011 Results: Patients admitted to ICU have multiple risk factors for the development of delirium; assessment of delirium is not routinely performed and/or recorded; treatment is often not administered to CAM ICU positive patients. Recommendations: Education programmes, incorporation of a flow sheet onto ICU charts and clear clinical guidelines may help to improve detection, documentation and management of delirium.

The RASS scale assessment tool has been incorporated on to the ITU chart. The SMH ITU Acting Matron set up teaching sessions for the nurses to raise awareness and assess the delirium on a daily basis. The Confusion Assessment Method (CAM) ITU tool is now attached at the bedsides to facilitate the assessment process which will be on a daily basis. These actions will be cross site. Work is in progress on the ICU daily assessment chart for doctors incorporating delirium check. The treatment will depend on the findings and patient’s clinical state.

3063 Audit of Process of Discharging MGUS patients to Primary Care

Dr Robin Aitchison, Consultant Haematologist, Timothy Lim, F1 Haematology

Assess compliance with BCSH MGUS guideline on issue of information given to patients and GP when patients discharged to primary care.

Specialist Services

05/10/2010 Complete 02/09/2011 All 10 GPs surveyed had received written information of some sort, whereas this figure was only 2 out of 10 in the patient group. Recommendations: Create a template clinic letter/leaflet for our clinic to send to GPs and patients on MGUS, including all relevant information.Ensure copies of GP letters are sent to patients.Ensure leaflets on MGUS are readily available in our clinic.Emphasise the importance of follow-up.Encourage patients to have a reminder system for themselves to pursue follow-up.Action PlanMGUS information leaflets designed with the BCSH guidelines in mind will be given to newly-diagnosed MGUS patients in our CCHU from now onwards,

Patient information booklets have been produced and agreed.

prior to being discharged to primary care. Related leaflets will also be sent out to their respective GPs. The importance of follow-up will also be emphasised more heavily to patients with a new diagnosis of MGUS.

3064 Audit of the Daily Checking of Defibrillators WH

Dr Anne Beh, FY2, General Medicine, WH, Jenny Wright, Resuscitation Manager

Trust policy says all defibrillators should be checked daily by a clinical member of staff. This audit will look at whether checks have been made daily, who by, any problems identified and any action taken.


08/10/2010 Cancelled 05/05/2011 Project cancelled - no information provided. NA - Project cancelled

3065 Audit of Adherence to the Guideline for Management of Reduced Fetal Movements in Pregnancy (SMH)

Dr Gemma Brierley, ST2, Obs & Gynae, Miss A Reddy, Consultant

Audit of adherence to Trust Guideline 419.3 Management of Reduced Fetal Movements.

Specialist Services

17/10/2010 Complete 01/06/2011 Audit 111 patients 86 sets of notes obtained and reviewed (77%). These patients had 118 encounters between them. Appropriate decisions were made but 13 scans were not performed when indicated. 100% of scans detected appropriate findings. 7 incidences of detected IUGR. 7 incidences of unexpected birth of baby <10th customised centile. A re-audit was suggested.

No changes required - re-audit taking place January 2012.

3066 An Audit to Review the Effectiveness and Accuracy of Discharge Documentation in Communication with GP's

Dr Jessica Gale, FY2, Rheumatology, Dr Samantha Scammell, FY1, Rheumatology, Dr Stevens, Consultant, Rheumatology

An audit to see whether discharge documentation is being accurately completed.

Medicine 06/10/2010 Complete (no changes reported)

04/02/2011 The following criteria all with a 90% standard were measured by this audit, details of the standard achieved are included after each criteria: all summaries should detail diagnosis or presenting symptoms 100%, all summaries should be clearly legible 35.7%, associated medical conditions should be accurately completed 50%, discontinued medication should be clearly documented 75% and follow up plans should be clearly stated 60.7%. Conclusion: Current handwritten discharge documentation is significantly below the standard expected. Recommendations: Typed summaries should be implemented and considered mandatory. A structured format for completing electronic discharges should be made available to all juniors. Importance of correct completion of discharge summaries should be reinforced at Trust induction meetings. Re-audit in 6 months.

No changes have been made.

3067 IV Antibiotics Missed Doses Audit

Dr Zac Etheridge, F2 , Microbiology, Dr Xin Hui Chan, F1, Diabetes, Dr K Cann, Consultant Microbiologist

It is important patients with serious infections do not miss iv antibiotic doses, as this can lead to a prolonged hospital stay and a poorer outcome. This audit looks at why doses of iv antibiotics are missed.


19/10/2010 Complete 31/05/2011 Results: This audit demonstrates that not all doses of intravenous antibiotics prescribed are administered. The reason for omission was unknown in 48.8% of cases despite the existence of medicines not administered codes. The next most common reasons – 7% each – were the patient being off the ward, lack of intravenous access and medicines not being on the ward. Recommendations: Appropriate training and support should be provided to doctors, nurses, pharmacists and patients to improve prescription, supply, administration, compliance and documentation. This should include encouraging the use of medicines not administered codes. Also suggest changes to the Buckinghamshire Healthcare Trust prescription chart. Re-audit in 3 months.

Training for doctors, nurses, pharmacists and patients to improve prescription, supply, administration, compliance and documentation has taken place. Changes have been made to the Buckinghamshire Healthcare Prescription chart. A re-audit is being carried out.

3068 Audit of Malnutrition in Surgical Patients

Dr Claire Atkins, FY1, Dr Nisha Sriram, FY1, General Surgery, Mr Schneider, Consultant, General Surgery, SMH

Nutrition is known to affect surgical outcomes and length of stay in hospital. This audit is based on a NICE guideline published in 2006 on the implications and assessment of malnutrition in hospital.


19/10/2010 Cancelled 28/11/2011 Not applicable - cancelled. Not applicable - cancelled.

3069 Is the Management of Early Inflammatory Arthritis in Line with EULAR/ACR Guidance? (SMH)

Dr Ben Wildblood, FY1, Rheumatology, Dr Sally Edmonds, Consultant Rheumatologist, SMH

Audit to investigate whether current practice is in line with the new criteria published by the EULAR/ACR and suggest areas for improvement.

Medicine 19/10/2010 Complete 31/12/2010 Results of the audit compared favourably to the new criteria introduced by the EULAR/ACR. The audit helped to introduce clinicians to the new guidelines and highlighted the need for faster referral from primary care to the Rheumatology Dept.

No changes required - results of the audit show the guideline is already being followed.

3070 NCEPOD Cardiac Arrest Procedures Study

Dr Graz Luzzi, Medical Director, Jackie Smith, NCEPOD Reporter, Jenny Wright, Resuscitation Services Manager

The aim of the NCEPOD study is to identify areas where the care for adult patients who receive resuscitation in an inpatient setting may be improved.


12/10/2010 Complete 01/07/2012 NCEPOD report published June 2012. http://www.ncepod.org.uk/2012report1/downloads/CAP_fullreport.pdf

Changes required

3071 Audit of Urodynamic Practices in Spinal Unit

Dr C A Thiyagarajan, Associate Specialist, Spinal

Audit of current practice of filling cystometry. Filling cystometry is started as a baseline investigation to all newly injured spinal patients since Jan 2009. To compare current practice against ICS "Good Urodynamic Practices" report.

Specialist Services

25/10/2010 Complete 09/09/2011 Recommendations: Referrer’s feed back on the value of baseline filling cysometry and report system. Integrate Urodynamic report to Patient’s e-record. “PILL” need to be issued prior to the urodynamic.

We have successfully integrated the urodynamic report to patient’s e-record.Patient information leaflet is designed and waiting for approval. Referrer’s feedback is collected and waiting to be analysed.

3072 An Audit into Bed Positioning of Spinal Patients at Night

Hannah Proctor, Michelle Clarke, Physios

To identify how patients positioned, what equipment used, identify if nursing staff adhere to positioning charts. A "24 hour positioning" working party has been set up.

Specialist Services

25/10/2010 Complete 18/05/2011 Results: Patients are asked how they want to be positioned BUT – patients not always educated in all options, which best meets their clinical needs. Positioning charts were not being used. Pressure requirements not always met. No postural requirements met. Not always access to water/ECU Recommendations: Need to consider patients positioning at all times (24hrs!) when back in bed not just when going to sleep. Review & Utilise 24 hour positioning charts already in place with nursing staff. Incorporate education to patients on postural needs in bed as well as skin – patient education lecture. Ensure access to ECU & water at all times. Ensure increased involvement of nursing staff in 24 hr positioning – on the ward and in working party. Re-audit in 4 months – consider evening positioning and night positioning.

We are continuing to do 24hr posture assessments in gym and ward for rehab patients. We carried out our first ever MDT assessment on a patient and are due to do another. The actual awareness of 24 hr positioning is increasing. Discussed patient talk with the Patient information officer.

3073 Long line Venous Catheter October 2010


To evaluate the results of the High Impact Intervention (HII) Central Venous Catheter tool used in the Saving Lives Infection Control programme. ITU and St Andrews only.


25/10/2010 Complete 10/01/2011 Results: There was 100% compliance for hand hygiene, catheter site inspection, catheter injection ports and catheter access. Overall compliances for dressing, admin set replacement and avoid routine catheter replacement varied from 95% to 99%. All applicable elements were complied with for 93% observations. There were 12 non-compliant elements in total from the 160 observations. Action Plan: All areas with non participation must produce an action plan on how they are monitoring their compliance with this audit. Areas who did not produce an action plan and return an action plan at the time of completing the audit must produce an action plan to show how areas of non-compliance have been addressed.All areas with ‘No’ answers are required to sign off this action plan to confirm all actions have been completed and then return to the IPC.


3074 Audit of Service User Opinion of Speech & Language Therapy Outpatient Service

Debbie Begent, Service Manager, S&LT

One to one questionnaire with 12 users.



3075 Oncology/Haematology Research Patient Experience Survey (SMH)

Tracey Stammers, Cancer & Haematology Research Nurse, CCHU, SMH

The research team has been through many changes over the last 18 months and now that they have achieved stability they want to review and optimise their practice regarding recruitment of patients into clinical trials.

Specialist Services

27/10/2010 Complete 22/12/2011 Results: 76% patients stated they had heard the term 'clinical trials'. 65% patients stated they found the explanation given to them about clinical trials 'very easy' to understand. 94% patients were provided with written information. 98% stated the written information was clear. 96% patients stated they were given enough time to consider whether they wanted to participate in a trial. All patients felt that their dignity and privacy was respected at all times. 80% patients decided to participate in a trial. 31% stated they were aware that Buckinghamshire Healthcare NHS Trust particpates in clinical trials. Recommendations: 1) Promote trial awareness for professional colleagues. 2) Promote trial awareness for the public, potential trial participants and their carers. 3) Ensure that the correct patient groups are selected for participation in the Patient Experience Survey to obtain clearer results.

An Abstract from the result of the audit was submitted to the National Cancer Research Institute ‘NCRI’ .Cancer Conference 2012. The Abstract title: Enhancing recruitment into clinical trials by promoting understanding and awareness of a comprehensive portfolio of research studies available in a local NHS Trust was selected for inclusion in a poster session at the Conference. A piece relating the clinical trials has been incorporated on the Trust website.

3076 Acuity/Dependency Scores

Celina Eves, Lynn Swiatczak, Chief Nurse

Dependency level recorded for each patient on each ward for 20 days every 6 months. Used to calculate nursing requirement.

Trustwide 27/10/2010 Complete 28/07/2011 No action plan No action plan

3077 Do Not Attempt Resuscitation (DNAR) Re-Audit

Graz Luzzi, Medical Director & Jeanette Tebbutt??

Audit of DNAR process/paperwork against Trust guidelines. This is a re-audit from 2008.

Trustwide 08/10/2010 Not yet started


3078 Outpatient Hysteroscopy Patient Experience Survey

Tunde Dada, Consultant, Obs & Gynae

Patient experience survey of outpatient hysteroscopy for service review and development.

Specialist Services

01/10/2010 Complete 14/03/2012 1. Patients should be reviewed by the consultant if possible in recovery after the procedure. 2. Analgesia should be offered in the form of NSAID or PCM. (Both disseminated through staff at hysteroscopy meeting). 3. The post-hysteroscopy information sheet should be revised and always given to the patient after the procedure. 4. Ensure written communication of histopathology results to appropriate patients.(To be passed through hysteroscopy guidelines).

Mr Dada now reviews patient in Recovery after the procedure.

3079 Lymphadenectomy Audit

Miss Sally Jay ST5, Audit Lead, Consultant Sudip J Ghosh

Following a recent change in guidelines as to who can perform lymphadenectomies, this audit aims to review clinical and histological outcomes pre and post the change in the guidelines.


03/11/2010 Complete 23/05/2011 In this audit of practice at Stoke Mandeville, Oxford and Salisbury Hospitals, compliance with the guidelines as to who can perform lymphadenectomies made no significant difference to the outcome of the operation in terms of complications and recurrence. Oxford data (bigger cohort) suggests significant reduction in regional recurrence. Indirect effect of guideline is that all patients get discussed/treated in MDT.


3080 Neonatal Heart Murmur Audit

Peter Sidgewick, ST1, Paediatrics

Compare practice with neonatal heart murmurs against guidelines with aim of updating local guideline.

Women & Children

03/11/2010 Complete 01/03/2011 Overall the current protocol was followed in its entirety in only 2 cases. An apparently high proportion of pansystolic murmurs was found on first assessment, which were later felt to be innocent; although we were unable to find any published data on the comparative incidences of ejection and pansysolic murmurs, intuitively this would seem to be unlikely to be a correct representation. The likeliest cause would be misunderstanding of the descriptors used for murmurs by the staff performing the newborn examinations. Solutions would include either more training of junior staff, or insistence upon middle grade review of all of these babies. Senior review is required by the current protocol, but did not occur in a quarter of cases. All these cases had been initially described as pansystolic murmurs - potentially pathological and so review should have been mandatory. Currently re-auditing to check whether the new proforma started after the March Audit has improved our practice. The new audit was started in August using exactly the same audit proforma as the one in March, and aiming to

Re-audit taking place.

compare the results.3081 Audit of

Percutaneous Biliary Drainage and Stent Insertion

Dr Zishan Sheikh, CT2, Gastroenterology, Dr Sekhar, Consultant Gastroenterologist, SMH

Audit against British Institue of Radiology standard.

Integrated Medicine

03/11/2010 Cancelled 17/06/2011 Cancelled Not applicable cancelled.

3082 Retrospective Audit of Neonatal Chest X-rays

Michelle Sugrue, Radiography Student, Pam Sangster, Radiology Manager

Retrospective audit of neonatal chest radiographs performed with respect to image quality and evaluation, with a view to making recommendations for improvement in radiographic technique.


03/11/2010 Cancelled 01/08/2011 Not carried out Not carried out

3083 Monitoring of Length of Stay for Primary Elective THR & TKR 2010 (BHNHST)

Jane Eastman, Jenny Grievson, Senior Physiotherapists

To monitor length of stay for THR and TKR and to identify reasons for delays in discharge.


12/11/2010 Cancelled 12/04/2011 Not applicable - cancelled. Not applicable - cancelled.

3084 Specialist Clinic for Diabetes and Sport Patient

Dr Alistair Lumb, SpR, Diabetes

The Trust has been running a specialist clinic for the

Integrated Medicine

12/11/2010 Complete (no changes

03/04/2012 Recommendations were to: improve follow-up access; provide information sheet to patients prior to clinic visit.

Changes required

Experience Survey

management of diabetes for sport and exercise for 3 years. Before that, appointments were offered on a more ad hoc basis. The aim of this audit is to examine the effectiveness of the clinic in terms of its effectiveness in improving blood glucose control and to assess the patient experience of the clinic.

reported)

3085 Re-audit of Urology Consent PES (WH)

Rebecca Nicholas, FY1, Urology, Tom Rees, FY1, Urology, Mr Haldar , Consultant, Urology

Following audit 2937, this is a re-audit to assess whether or not our consenting doctors are adhering to GMC guidelines.


12/11/2010 Complete 28/07/2011 Results: Overall: positive responses, good coverage of GMC guidance; improvement in explaining possible side effects since original audit but re-audit highlighted need for clearer discussion of potential complications including patient wishes.Recommendations: clearly state that the patient always has the option to refuse treatment +/- statement in leaflet; consent patients for use of their anonymised images/samples; offer patients copy of completed consent form.

The results were presented to us at one of our departmental monthly audit meetings and we agreed to make changes to offer patients a copy of the consent and request their consent for use of their images. By definition by requesting consent the patient is made aware that they have the option to refuse consent and decline treatment.

3086 Audit on the Management of Respiratory Distress in Children under One Year of Age (WH)

Dr Anne Beh, FY2 Respiratory distress in children under one is generally poorly managed by non-paediatric staff and it is thought that the protocol is not followed, with patients often receiving unnecessary treatment. Audit will contribute to changes in practice which will improve compliance with the protocol.

Integrated Medicine

15/11/2010 Cancelled 01/12/2011 Project cancelled as doctor has left Trust and did not have time to do the audit.

Project cancelled.

3087 Management of Hyperglycaemia in Patients admitted with MI

Dr Howell Williams, Dr Henrietta Brain, Consultant, Diabetes

To compare management of diabetic patients with MI with Bucks protocol.

Medicine 16/11/2010 Complete 20/05/2011 Results: Lab glucose measured in most but not all patients. Sliding scales not used in the majority of cases. BM control the same, and within safe range. Most patients not referred to DM team. S/c insulin not commenced in anyone. Recommendations:

Draft guidelines incorporating the new recommendations have been circulated to cardiology consultants. We were holding off finalising

Guideline change: Hypoglycaemia and hyperglycaemia should be avoided. Aim for BM 5 – 11 mmol/l. Sliding scale is not necessary in all cases. Consider using sliding scale to control hyperglycaemia at BM = 10 – 11. Start sliding scale if BM > 11. Treat for hypoglycaemia if BM < 5. Other recommendations: It is essential to measure admission lab glucose in patients with confirmed or suspected MI. Capillary BM monitoring – 4 or more in first 24hrs. All patients should be referred to DM team (diabetic specialist nurses) DM team will commence s/c insulin in suitable patients. Publicise recommendations by presentation at Academic half-day and presentation to cardiology / medical juniors.

guidelines as we were awaiting NICE guidance which was published last month. The new NICE guidance is very similar to our new recommendations so we are in the process of combining the 2 into a new guideline. The new guideline will be highlighted at the next F1 and F2 teaching given by a Diabetologist. Howell Williams plans to re-audit in the new year.

3088 DVT/PEs with Hospital Admission in previous 100 days

Jonathan Pattinson, Consultant Haematologist

Every 3 months we produce list of DVT/PES with previous hospital admission using information from DVT clinics and cause of death lists received from the ONS. Dr Pattinson needs to examine notes of these patients. These must now be reported as a SUI.

Specialist Services

17/11/2010 On-going Not required. Just used to check notes to ensure incident reported.

Changes required

3089 Questionnaire for Dysphagia Trained Nurses

Elizabeth Fraser, Speech & language Therapy Clinical Lead

S&LT are planning to introduce new guidelines and training for dysphagia trained nurses (DTNs). Initially need to identify current practice and numbers of nurses requiring training so can design training effectively.

Specialist Services

22/11/2010 Complete 10/05/2011 Results: It was clear from respondents that their initial 1:1 contact with SLT for training / refreshing training varied dramatically with some staff having received 1:1 SLT training over 7 years ago. Despite this there is a large number of swallow screens being undertaken by DTNs across the Trust. The majority of respondents reported they were completing documentation in the medical notes for all swallow screens however this cannot be confirmed.Recommendations: In order to maintain competencies by carrying out regular swallow screens – use of DTNs should be restricted to a smaller number of wards most likely to receive Stroke patients – Stroke Wards, MAU & AMU and A&E/EMC.All DTNs that responded and currently work on the above target wards will require refresher training delivered by an SLT and where appropriate 1:1 supervision to ensure that competencies are up-to-date.All DTNs will be trained using the guidelines compiled by the SLT team and invited to annual refresher sessions. These refresher sessions will be mandatory in order to continue carrying out swallowing screens.DTNs will need to complete swallow screen flow chart for all screens and return to the SLT dept so

Swallow screening has now been limited to the Stroke Unit only. Staff have been identified for update training and this commenced last week. Annual refresher will be initiated by SLTs and completed on the wards with a ward based practical. Part of the update training includes requesting that staff complete a handover sheet listing any screening assessments completed, which is kept on the stroke unit, so that SLT can track screening assessments. The Training and Development Department will be keeping an updated list of those trained to screen swallowing. SLT have requested that senior nurses write to nurses who are not on the stroke unit and have not had updated training, this has not been completed.

that the team can monitor and audit the efficacy of the DTN programme. There was a suggestion made that SLT could provide a drop-box on the ward where staff could leave screens to be collected by a member of the SLT team on a weekly basis. A list of all current DTNs can now be kept and DTNs will be asked to keep the SLT team informed if they move wards or leave the Trust. This will be updated on an annual basis.DTNs that did not respond to the questionnaire and those not working in the above target wards will be informed in writing that they are no longer able to carry out swallow screens.

3090 Venous Thromboembolism Prophylaxis Medicine


As a follow up to audit 2907 which showed patients were not being assessed for DVT and to comply with NICE guideline 92, a rolling audit of venous thromboembolism prophylaxis. Each division audited once a year (about one division every 2 months). 50 sets of notes audited (notes from ward) and proforma completed and sent to CA&E for analysis and report. First audit for Medicine Division.


22/11/2010 Complete 10/01/2011 Patients should be assessed using the appropriate BHNHST VTE assessment tool and appropriate prophylaxis should be given if necessary. SMH Medicine Jan/Feb 11: 80% fully compliant and another 10% were given the appropriate prophylaxis although the assessment form was not completed. 5 patients (10%) were not given appropriate prophylaxis. WH Medicine Dec 2010: 47% were fully compliant and another 44% were given the appropriate prophylaxis although the assessment form was not completed. 9 patients (9%) were not given appropriate prophylaxis.

Results reported back to divisions. To be re-audited next year.

3092 Physiotherapy Staff Survey regarding 7 Day Working

Charlotte Moss, Service manager, Physiotherapy

Weekend working for physio and OT staff introduced in September 2010. Survey to assess staff views and suggestions.

Specialist Services

22/11/2010 Complete 01/09/2011 Recommendations: A training update for respiratory skills will be continued on an annual basis. Training updates/refreshers for equipment and focusing on orthopaedics will be established for both sites.The rota to continue as present rota with the ability to exchange dates. Bank holidays and weekend days associated with bank holidays to become volunteered rota. All staff must volunteer for the appropriate quota per year. Taking NWD time back – to extend the time period to a maximum of 6 weeks within which NWD should be taken.Recording of working hours and NWD time taken back to be changed to assist in better logging and recording at the end of the month.Working hours to be adjusted (OT 9.00 – 2.00; CSW 9.30 – 1.30; PT 8.30 start for resp PT’s, 8.30 or 9.00 start for cat 2/3 PT’s) - the impact of this change will be monitored for adverse effects. Working sheets to be modified for Physio to enable more consistent data collection.

A training update for respiratory skills is continued on an annual basis. Training updates/refreshers for equipment and focusing on orthopaedics in progress.The rota continued as present rota with the ability to exchange dates. Bank holidays and weekend days associated with bank holidays have become volunteered rota. All staff must volunteer for the appropriate quota per year. Taking NWD time back – time period extended.Recording of working hours and NWD time taken back changed to assist in better logging and recording at the end of the month.Working hours adjusted - the impact of this change will be monitored for adverse effects. Working sheets modified for

Physio to enable more consistent data collection.

3093 Mortality Review April - September 2010


A review of 50 deaths requested by the Healthcare Governance Committee as part of an ongoing review of mortality within the Trust.

Trustwide 24/11/2010 Complete (no changes reported)

21/04/2011 Recommendations were: Medical Director and Associate Director Healthcare Governance (ADHG) to review the 3 potentially avoidable deaths; independent consultant to confirm the assessment that death was probably avoidable in the cases identified - if the final assessment is probably avoidable then these should be investigated as Serious Incidents; Medical Director to remind all consultants about appropriate supervision of junior doctors and documentation; Associate Director Healthcare Governance to discuss with Associate Directors of Nursing (ADNs) what actions are being put in place to improve the use of the Early Warning Score and fluid balance management; continued focus on reducing harm from falls and pressure ulcers as part of the Safety Express programme.

The 3 potentially avoidable deaths were reviewed and the final assessment was that death was not avoidable.

3094 The Quality of Speech & Language Therapy Case Notes

Michelle Holmes, Deputy Manager, S&LT

Audit undertaken each quarter to identify quality of S&LT notes, some quarters concentrating on quality, some on organisation etc. Each Clinical Team Leader accesses random sets of case notes and assess using checklists for a range of criteria. Comparisons made with previous quarters to assess improvement.


24/11/2010 Complete 17/01/2011 Oct-Dec 2010. 25% of standards were achieved in more than 96% of case notes. 16% of the identified standards were adhered to in 86% to 95% of case notes. 50% of standards were not followed in 85% or less of the case notes. Six standards were achieved with 100% adherence. Comparisons will be made when the areas specifically targeted in this audit are reviewed in the same quarter next year. Recommendations: Summary of the casenote audit be emailed to staff where the following areas would be identified as requiring immediate attention: Statistical front sheet filed. Appointment time and time session started. Written information re Service given. Preferred name and title noted. Client’s name, ID number/date of birth on each sheet of notes. Long term aims recorded. Short term aims recorded. Record of outcome given. Date of discharge and code used noted. Copy of discharge report included if appropriate. All entries signed.

Emailed staff re areas requiring immediate attention and have provided training at a recent departmental meeting. Will be reauditing the casenotes in December.

3095 Assessment & Management of Wheeze in Children Under 1 Year Presenting at A&E/PDU

Dr Liza Waldegrave, FY2, Paediatrics, Dr Michelle Russell-Taylor, Consultant Paediatrics

During the winter months bronchiolitis is the commonest cause of wheeze in under 1s presenting at hospital. This audit aims to see if these children are appropriately assessed on admission and treated in line with Trust guidelines.

Specialist Services

25/11/2010 Complete 21/06/2011 Maintain the current good clinical standards by including awareness of this guideline in the induction day for new A&E and PDU doctors. Other measures to increase awareness of the guideline; posters in both departments, ensuring doctors know where to access guidelines and presenting the results of this audit to both departments.

Changes required

3096 Prolonged SROM (SMH)

Dr Radha Karnad, ST1, Dr Bindu Annamraju, ST4, Dr Shalimali Karnad

Audit of the management of patients with prolonged spontaneous rupture of membranes, September and October 2010.

Specialist Services

02/11/2010 Complete 17/05/2011 Looked at 90 sets of notes - Gestation at SROM; Method of diagnosis; Onset of labour; Mode of delivery. Discussion around diagnosis of SROM which can be very difficult, use of syntocinon versus prostin for an unfavourable cervix. Evidence currently does not support the use of prostin as method to improve outcome. The diagnosis of intact forewaters is important. The discussion also covered whether evidence suggested it was best to perform induction immediately SROM is diagnosed or delay for 24 hours.

No recommendations given, junior Doctor audit unable to contact CP 21/2/13

3097 Audit on Completion of the ISCOS Neurocheck Chart in NCIS

Vimmi Shriyan, FY2, Spinal

Neurocheck charts are normally completed on the first admission of a patient to NSIC. This audit looks at whether all elements of the chart are completed.

Spinal Injuries

30/11/2010 Complete 30/11/2010 Of 30 patients the following elements were completed. Patient identity 14/30, sensory check 22/30, sensory total 17/30, motor check 24/30, motor total 9/30, AIS score 11/30, date examination 16/30, ward 22/30. To be re-audited in 6 months.

Computerised system now in place so some of the issues are prefilled. The recommendations were to improve and recheck and the use of the ims system should help this. Should be able to re-audit by using data on systems.

3098 Audit on use of antirhinitis treatment in the management of pseudonasolacrimal duct obstruction

Sally Painter, ST4, Ophthalmology

To review the notes of the patients who have been treated with steroid medication and to assess the success of the treatment.


01/12/2010 Complete 29/02/2012 This small study showed that use of topical steroids and nasal decongestants can treat patients with patent nasolacrimal systems. Patients can be maintained symptom free on beclometasone nasal spray alone. This treatment regime is recommended as first line management for these patients. An abstract of this audit has been accepted for publication at the Royal College of Ophthalmologists Annual Congress and Oxford Ophthalmology Congress.

The use of topical steroids and nasal decongestants to treat patients with patent nasolacrimal systems is now routine practice.

3099 On-call Commitments have no Effect on BMI

Lorna Lamb, ST1 (GPVTS), Tunde Dada, Obs & Gynae

On-call commitments predispose to sedentary behaviour and increased calorie

Specialist Services


intake through unsocial hours, altered food consumption and preference for unhealthy snacks. Conversely activity may be limited by request to stay on site. To assess whether on-call duties affect calorie intake. To assess whether on-call duties predispose to sedentary behaviour. Are on-call duties unhealthy activities?

3100 National Audit of Heavy Menstrual Bleeding

Tunde Dada, Obs & Gynae

An audit of patient outcomes and experience of treatment for women with heavy menstrual bleeding. Joint project with RCOG, London School of Hygiene & Tropical Medicine, and Ipsos MORI. Two part audit: 1. to evaluate current referral patterns, protocols and practice in the management of HMB. (May to September 2010) and 2. A study of symptoms and health-related quality of life among women who attend outpatient gynaecology clinics with complaints of HMB.

Specialist Services



3101 Antibiotic Prophylaxis & Post-operative Infection following Spinal Surgery

Dr Vimmi Shriyan, SpR, Spinal, Dr Jamous, Consultant, Spinal

To assess compliance within Trust guidleines regarding the use of prophylaxis antiobiotics in spinal surgery. Assess the post-operative rates of wound infection in spinal surgery.

Spinal Injuries

30/11/2010 Complete 04/05/2011 This audit has highlighted that in spite of not complying with the Trust Guidance Protocol regarding antibiotic prophylaxis, there has not been any evidence of post-operative wound infection following spinal surgery in spinal cord injured patients.

No recommendations

3102 National Audit of NICE Public Health Guidance Relevant to the Workplace

Dr Kathryn Campion, Consultant

Organisational audit of the implementation of NICE public health guidance relevant to the workplace.

Trustwide 01/10/2010 Complete 09/04/2012 Trust does prioritise some health promotion topics for staff. Valuing staff days, health awareness no smoking, national stress day. Stress workshops don’t meet the requirements of action 43 as workshops not mandatory. More managers need to be targeted. Need to review the health and well being strategy and update this and ensure it includes obesity.

Action plan put into place. Service review of workplace health is currently taking place. Out of this reivew there will be a rolling programme of effective preventative measures which will be developed and promoted across the organisation. Stress workshops have been provided for 65 managers so far. New intranet due to be launched in May 2012 will give easier access to all health and well being and the proposal is to have well being at work as the main umbrella to all Occupational health services etc. Awareness events incorporated into existing training programme for managers and supervisors - core module on engagement and wellbeing to recognise the link between engagement and health and wellbeing and performance/productivity.

3103 Breast Cancer Service Pledge

Hilary Hillson, Breast Cancer Nurse

The Trust are taking part in a patient survey organised by Breakthrough Breast Cancer to review existing service, identify areas for improvement and publish a local Service Pledge for Breast Cancer. This is happening at several breast care units across the country and also involves interviews with patients.

Specialist Services

06/12/2010 Complete 01/06/2012 Things that work well: communication from staff, waiting times, ward areas. Things that could be improved: décor of the waiting areas, information provision.

A pledge in the form of a patiemnt leaflet was produced but after months of waiting for it to be agreed by Communications it has still not been so will likely be abandoned as now out of date.

3104 Outcomes of Patients presenting with ST-elevation Myocardial Infarction

Dr Tiimothy Williams, FY1, Cardiology, Dr P Clifford, Consultant Cardiologist

Since June 2010 primary PCI has been offered for patients presenting with ST elevation myocardial infarction. This audit will look at the outcomes for these patients.

Integrated Medicine

06/12/2010 Complete 15/07/2011 Recommendations: Continue early alert of the pPCI service in High Wycombe hospital. Ensure record keeping standards are maintained in particular in relation to timing of intervention. This audit will form part of the Unit’s clinical governance strategy and become an ongoing analysis to continue monitoring performance in a formalised manner.

Changes required

3105 Pre-operative Fasting and Regular Medications

Dr Amy Thomson, CT1, Anaesthetics

A clinical survey of opinion regarding administration of routine medication in patients who are nil-by-mouth. There are concerns that patients are missing essential medications due to ambiguous Trust guidelines on nil-by-mouth. The aim is to obtain a consensus of opinion from Anaesthetists regarding routine medication and to educate staff accordingly.




3106 Emergency Laparotomy

Dr Jessamy Bagenal, FY1, General Surgery

To investigate process of care when taking patients for emergency laparotomy.


10/12/2010 Complete 23/09/2011 Educating juniors regarding evidence for pre-operative investigations empowers them to incorporate them into their practice and hence improves documentation of lactate and base excess prior to laparotomy. Further improvement could be achieved through the development of a proforma for pre-operative care prior to emergency laparotomy.

Simple educational measures were used to improve performance. A workshop for junior staff in surgery and anaesthetics was held and during the four week period following the teaching session 80% (8/10) of patients arriving in theatre for emergency laparotomy had a documented lactate and base excess.

3107 Hand Hygiene Observational Audit

Amanda Adkins, Infection Control

Observations of hand hygiene. Carried out in all wards each month. Annual report produced by Clinical Audit. (Audit 2923 for 2009/10)

Specialist Services

01/04/2009 On-going Ongoing audit

3108 Surgical Site Infection Pre-op and Peri-op Audit - General Theatres


Observational audit general theatres only.


01/09/2010 Complete 07/03/2011 Pre-Op 93% screened of which one found to be positive and treated appropriately. Peri-Op 40 patients audited, 5% some data not recorded, 33% non-compliant in at least one area. Action plans to be produced and carried out in all cases of non-compliance.

Infection Control monitor completion of action plans and re-audits.

3109 Surgical Site Infection Pre-op and Peri-op Audit - T&O Theatres


Observational audit T&O theatres only.


01/10/2010 Complete 07/03/2011 Pre-Op 96% screened for MRSA, 4% not. 1 patient found positive but not clear if treated appropriately. Peri-Op 6% not given prophylactic antimicrobial when should. Hair removal and monitoring of normothermia 100% compliance. Glucose control not maintained for 1 of 4 diabetic patients. Action plans to be produced and carried out in all cases of non-compliance.


3110 Hand hygiene Practice and Facilities


Audit of hand hygiene facilities and practice.


01/01/2011 Complete 04/03/2011 Results: The overall compliance for all areas of this audit was 95%. Only 16 areas achieved a compliance level of 100%. 5 of the 59 wards/areas who completed the audit achieved compliances of less than 85%. 34 wards/areas did not participate in the audit. Recommendations: All areas with non participation must produce an action plan on how they are monitoring the compliance with this audit. Areas who did not produce an action plan and return an action plan at the time of completing the audit must produce an action plan to show how areas of non- compliance have been addressed. All areas with ‘No’ answers are required to sign off this action plan to confirm all actions have been completed and then return to the IPC.


3111 Sharps Management


Audit of sharps management.


01/02/2011 Complete 27/05/2011 Results: 83 wards/areas returned audit tools. Overall compliance was 93%. Scores varied by unit from 73% “Yes” responses to 100%. 13 wards/areas had overall compliance less than 85%. Some units did not answer some of the questions. Compliance for each question varied from 56% to 100%. A total of 52 areas across the trust did not participate in this audit. 42 of the 83 units (51%) returned either no action plan or an incomplete action plan, where there was no action for at least one of the “No” responses. Recommendations: The Divisional Associate Director of Nursing to complete an action plan to address the issues highlighted. All the action must be signed off by the Divisional Associate Director of Nursing as completed. Increased input is required to educate staff. In addition to the current input at Trust induction sessions, the sharps management policy needs to be included in staff induction at department level. Education on sharps management should continue to be re-enforced in the mandatory annual update for all clinical staff by the infection control team. Department Managers need to monitor

Each division is monitoring the completion and signing off of action plans. Education continues in mandatory training. Discussion of points raised continues at IPCC meetings.

compliance to policy within their area and promote correct practice at all times. Adequate supplies of sharps trays must be available for staff to use.

3112 Transfer Audit Form


Audit of transfers. Clinical Support Services

01/02/2011 Complete 03/06/2011 Results: Inter-healthcare transfer form often not used. For anumber of patients transferred with known or potential infections, this information was absent. Recommendations: Matrons/Sisters are responsible for implementing the use of the Inter-Healthcare Transfer Form within their areas and monitoring compliance. If discharge/ transfers packs are available then the Inter-Healthcare Transfer Form must be included within the pack. The Transfer Policy is currently being drafted and includes the Inter-Health Transfer Form. Once this policy has been finalised it should be disseminated to all staff to ensure they are aware of its content. Further development of the Care Records System (CRS) must include the Inter-Health Transfer Form which will have to be completed on each transfer.An action plan must be completed to address the issue of low compliance.


3113 Surgical Site Infection Pre-op and Peri-op Audit - Urology


Observational audit urology only.


01/12/2010 Complete 07/03/2011 Pre-Op 1 patient not screened for MRSA. Peri-Op 1 patient (4%) not given prophylactic antimicrobial when should. 1 patient normothermia not monitored when should. Glucose control not maintained for the only diabetic patient. Action plans to be produced and carried out in all cases of non-compliance.


3115 Outbreak Policy Audit


Specialist Services

01/03/2011 Cancelled 01/05/2011 Cancelled as no outbreaks Cancelled

3116 Workplace Health & Safety Audit

Marion Carnell, Health & Safety Facilitator, Stoke Mandeville Hospital.

Audit of compliance with legal requirements regarding workplace health and safety.

Trustwide 06/12/2010 Complete 18/05/2011 N/a - No report drawn up - just quantative data of % of each division complying with legal requirements regarding workplace health and safety. This is annually re-audited.

This audit is to be annually re-audited. Re-audit commenced 15/11/11.

3117 Audit of Hysterectomy in Endometrial Cancer

Dr Anthony Crosse, Dr May Yoshida, (GPST1), SMH

An audit to assess the type of hysterectomy, complications and correlation of pathological staging and MRI staging in endometrial cancer. To assess the criteria for laparoscopic hysterectomy vs open hysterectomy and accuracy of MRI in guiding this decision.

Specialist Services

08/12/2010 Complete 01/02/2011 Laparoscopic hysterectomy is a suitable alternative to TAH. It is consistently associated with longer theatre time and shorter hospital stay. Major complication rates/ readmissions seem to be higher in TAH. TAH was associated with increased BMI. MRI only accurate in just over 50%, tends to be lower staged than final histology report. Compared to the previous year: more laparoscopic surgery was undertaken (50% to 68%); reduced conversion rate (23 to 8%), possibly leading to improved outcome in terms of complications and hospital stay.

No recommendations were made and thus no changes are forthcoming.

3118 Management of Women with Raised BMI in Pregnancy and Labour (SMH)

Dr Lamiese Ismail, ST4, Mr Tunde Dada

Prevalence of obesity is increasing with ensuing risks for mothers, babies and staff. Raised BMI confers higher morbidity and mortality risks. Early identification, good communication, referral and ongoing surveillance are required to reduce risk. To ensure that the department is meeting the needs of women with raised BMI by appropriate information sharing, referral and intrapartum management.

Specialist Services

14/12/2010 Cancelled 13/12/2011 Project cancelled, report not forthcoming. Cancelled

Guideline 446.3.3119 Long Term Effect

of MRI on SARS Implant in SCI Patients

Luis Lopez de Heredia, Research Scientist, Radiology

Patients with SCI usually have disruped bladder emptying due to disruption of normal reflex pathways. This can be circumvented by use of a SARS (Sacral Anterior Root Stimulator) implant which stimulates the detrusor muscle and relaxes the sphincter. SCI patients often undergo MRI scans which use magnetic fields and radiofrequency which might damage the implant. Audit to identify spinal patients with SARS who have had MRI scans to identify SARS complications.


16/12/2010 Complete 26/04/2011 Long-term follow-up showed no adverse effects attributed to more recent MRI examinations at 1.5 Tesla in patients with SARS.

None required. Audit showed no adverse effects.

3120 CEM Vital Signs National Audit 2010-11

Dr Mike Kazer, Staff Grade, EMC, WH

College of Emergency Medicine national audit based on the clinical standards for recording vital signs, developed by concensus from representatives of the CEM Clinical Effectiveness Committee, ENCA, FEN & RCN Emergency Care Association.

Medicine 08/12/2010 Complete 09/06/2011 ActionsCEM Guidance & Reports available on the Trust intranet within the Document Store/Emergency Medicine/Audit/CEM 2010 folder so that these are readily available for reference and as feedback. Training to be concentrated on the following areas which the CEM audit identified as areas for improvement. Recording of respiratory rate and, repeating observations within 60 minutes where initial obs are abnormal. A repeat audit will be performed later this year.

Changes required

3121 CEM Feverish Children National Audit 2010 -11


College of Emergency Medicine national audit based on the clinical standards for managing feverish children. Standards taken from NICE CG47.

Medicine 08/12/2010 Complete 06/06/2011 CEM Guidance & Reports available on the Trust intranet within the Document Store/Emergency Medicine/Audit/CEM 2010 folder so that these are readily available for reference and as feedback. A repeat audit will be performed later this year. Training to be concentrated on the following areas which the CEM audit has identified as areas for improvement; recording of temperature, recording of capillary refill time and promptness of recording of observations.

Changes required

3122 Efficiency of Hand Clinic

Mr Mike Tyler, Consultant, Plastic Surgery

An audit to examine whether patients are being brought back to the Hand Clinic unnecessarily and whether they could be managed in PDC or by physio/GP/consultant clinic.


Cancelled 31/12/2010 Cancelled as no information provided, doctor left Trust Feb 2010.

Project cancelled.

3123 Audit of Readmission of Babies within the First Ten Days of Life

Dr Cathy Noone, Consultant, Paediatrics (Dr Madhu Gangadhara, ST5)

A reaudit of the reasons for readmission of healthy, term neonates discharged from the postnatal ward.

Specialist Services

04/01/2011 Complete 31/10/2011 Results: Poor documentation of weight at birth, on day 5, and on readmission (15% of babies had poor weight documentation). Poor record of re-admissions from community. Patients still get readmitted due to feeding problems ( numbers slightly improved but still high). Most of readmissions are from primi mothers. 70% of babies still get discharged the first or second day. Recommendations: Review feeding before discharge. Weight check on day5 and review. Bilicheck availability in community. Biliblanket provision in community. More breast feeding support for mothers. Regular midwife/community follow-up (clinics). Parental awareness sessions re: problems and to seek advice early. Document D0 and D5 weight at re-admission. Re-audit.

No changes received 21/2/13 (CP)

3124 Intra-operative Surgical Timekeeping

Dr Angus McKnight, CT2, Anaesthetics, Project sponsor, Dr Sara McNeillis, Consultant, Anaesthetics

To determine how accurately surgeons are able to estimate when 5 minutes of operating time remains. To help determine whether the turnaround time between patients can be shortened.


06/01/2011 Cancelled 15/08/2011 Project cancelled by clinician, unable to collect enough data.

Not applicable, project cancelled by clinician.

3125 Extubation Practice

Dr Angus McKnight, CT2, Anaesthetics, Project sponsor, Dr Sara McNeillis, Consultant, Anaesthetics

The practice of tracheal extubation is changing in the UK, moving from left-lateral, head-down position at a deep level of anaesthesia towards supine, head-up extubation of the awake patient. Auditing current practice in the Trust will inform departmental discussion on the training of Junior Doctors and on risk management at extubation.


06/01/2011 Complete 18/07/2011 Results: UK tracheal extubation practice is changing from left-lateral, head down position, at a deep level of anaesthesia towards supine, head-up extubation of the awake patient. The results of this audit confirm suspected national trends regarding position at extubation (79% supine, head up). Depth of anaesthesia at extubation is similar to the published 1998 study (20% deep). This audit aimed to allow informed discussion of departmental practice surrounding extubation of adult patients. The summary of discussions was that although practice was not 'classical' teaching, there were several reasons why it was clinically justified, and additionally there was no evidence that it was better or worse than traditional practice.

No changes to practice were required.

3126 Audit of Unplanned Obsteric Admissions to ICU Post Merger

Dr Prabir Patel, ST4, Anaesthetics, Dr Ankers, Consultant Anaesthetics

To review all obstetric critical care admissions since the merger of maternity units at SMH and WH looking at reasons for admission, outcomes, and potentially avoidable cases to determine if the number of admissions could be reduced.


23/11/2010 Complete 23/09/2011 There has been a reduction in critical care admissions post merger, however, a greater proportion of admissions need higher level of care and longer stay - potentially due to a single larger unit now managing higher risk obstetric patients; creation of 4 bed close observation unit, increased consultant presence and 24 hour obstetric anaesthetic cover has resulted in this group that would otherwise have needed HDU bed being managed in a high dependency environment within labour ward; close observation bay also a step down area; increased use of IABP and appropriate staff training may potentially further reduce admissions to ICU - > ?cost implications. Readmissions after discharge: a need for focus on post partum sepsis and ‘surviving sepsis’ guidelines; failure to recognise severity of illness, delay in commencing appropriate therapy / intervention may cause longer stays and more support.

The Obstetric unit now uses the CEMACH inspired MEOWS early warning system for detecting sick mothers. This was a recommendation of this audit but was introduced as a CNST requirement. Obstetric HDUs are nationally thought in theory to be a good idea, but practically recognised nationally to be undeliverable. There are a myriad of reasons for this including cost, skill maintenance, midwives no longer training in nursing, safety, etc.

3127 Audit of Patients on Anti TNF's

Jane McVea, Asst Dir Quality Bucks PCT via John Quinn

Bucks PCT are working with BHT on drugs excluded from contract (through John Quinn) and need to do an audit of 50 patients who are on anti TNFs.

Specialist Services

24/01/2011 Cancelled 05/11/2012 cancelled cancelled

3128 Regional Audit of Emergency ENT Admissions

Hamish Thomson, Consultant, ENT

An audit looking at the workload involved in emergency ENT admissions with a view to determining the feasibility of merging ENT centres across the region.


01/03/2010 Complete 24/12/2010 If the Swindon numbers are accurate then the emergency admission workload is not excessive. Combination of emergency centres is probably feasible but has bed implications. We only looked at admissions. How much work is involved in advice, A&E referrals etc?

Partly as a result of the audit, emergency ENT admissions are now amalgamated between Wexham and Reading and ENT emergencies at Wycombe are now going to Oxford.

3129 Cataract Surgery under Topical Anaesthesia

Kanmin Xue, ST1, Ophthalmology, Zuzana Sipkova, FY1, Ophthalmology, Project sponsor, Mr Manuchehri, Consultant, Ophthalmology

Local anaesthesia for cataract surgery can be provided by either sub-tenon block or topical anaesthesia. This audit aims to assess the complication rates of cataract surgery under topical anaesthesia.


10/01/2011 Complete 23/03/2011 Results: Overall 11.1% patients developed complications post-op (national rate 14.4%). Higher CMO rate most likely associated with higher rate of pre-op ocular co-morbidities (e.g. diabetic retinopathy, ERM). In patients without ocular co-morbidities, post-op complication rate and VA outcome very similar to UK national rate. Recommendations: Cataract surgery using topical anaesthesia, supplemented with intracameral anaesthesia, in skilled hands could achieve good operative outcomes comparable to the national standard.

Cataract surgery is continuing under topical anaesthetic as the complication rates were non existent.

3130 Perinatal mortality (NPEU) (ongoing)

Dr Sanjay Salgia, Consultant, Paediatrics

National Audit of Perinatal Mortality (ongoing).

Specialist Services

01/01/2011 Ongoing data Collection


3131 Neonatal intensive and special care (NNAP)

Dr Sanjay Salgia, Consultant, Paediatrics

Audit of neonatal intensive and special care. Part of the National Neonatal Audit Programme run by RCPCH.

Specialist Services

01/01/2011 Ongoing data Collection

2011 National report available on line:http://www.rcpch.ac.uk/system/files/protected/page/RCPCHNNAPAnnuaReport2012.pdf

Changes required

3132 Emergency LSCS & P/N Analgesia

Dr Mohammed Yousafzai, Dr Abigail Blumenthal

CNST Audit as per EMCLSCS guideline 463.3. In addition, audit of analgesia used peri and post caesarean section as per local and NICE guidelines.

Women & Children

01/01/2011 Complete 17/03/2011 Results: Audit proforma completion 64% same as 2010. NICE grading at time of LSCS 97%, up from 50% in 2010. However of those completed 11% had differences in NICE category between the contemporaneous notes, operating note and audit note. Reason for LSCS 92% up from from 78.6% in 2010. Decision to delivery interval: Category 1 = 100% average being 13mins. Category 2 = 20% average being 45 mins. Category 3 = 27% average being 122 mins. Antibiotic prophylaxis 100%. LMWH 100%. Consultant informed 83%. Discussion with patients 50%. Recommendations: The audit showed that the dose of diclofenac that is given in theatre is not being written on the prescription chart. 80% of patients receiving BD diclofenac on the ward had already received 100mg in theatre. Codeine is not being given; 50% of patients received no codeine in the first 24hours and there is poor compliance with administration of the regular paracetamol, only 28% patients receiving it QDS as prescribed.

Junior doctor audit completed in 2011, changes chased but never received 21/2/13 (CP)

3133 Audit of Dr Mark Olavesen Audit of current Women & 01/01/2011 Complete 17/03/2011 Recommendations: Need for a comprehensive local Changes required

Management of Benign Vulval Disease

FY1, Dr Charlotte Benson, GPST1

practice, compared to RCOG recommendations, for management of Vaginal Intraepithelial Neoplasia and Extramammary Paget's Disease. Specifically to: identify a cohort of patients diagnosed with VIN and EMPD; identify date of diagnosis and grade; identify interventions/treatments and follow-up/recurrence; identify complications.

Children guideline for all practitioners. To include: 1. Information leaflets and referral to appropriate websites to be given to all women with new diagnosis. 2. All patients to be referred to Clinical Nurse Specialist. 3. All patients offered access to psychosexual counselling [poll]. 4. MDT and audit meetings should occur at least annually to review guidelines and outcomes (including patient feedback). MDT to include Gynaecology, Dermatology, Pathology, CNS. A diagnostic protocol regarding when to biopsy/ observe. A treatment protocol advising when to excise/monitor/ offer topical treatments. Guidelines on how often to follow-up: Patient feedback questionnaire to be sent to all patients one year following initial diagnosis. Understanding of condition, management of symptoms, psychological support.

3134 Infection Control Environment Audit November 2010


Use of tool to audit the cleanliness of the environment in all Trust areas.


01/12/2010 Complete 01/02/2011 Results: 75 wards/areas took part in the audit. To achieve the target compliance level the score must be 85% or above as set by the Infection Prevention Society. The overall compliance for all areas of this audit was 91%. Only 5 areas achieved a compliance level of 100%. 27 of the 136 audit questions (20%) achieved compliances of less than 85%. 18 of the 75 wards/areas (24%) achieved compliances of less than 85%. 27 areas did not return a completed action plan. 40 wards/areas did not participate in the audit. Recommendations: All areas below the compliance level must complete a re-audit to check if actions have been rectified and compliance level met. All areas which didn’t participate in the audit must complete the action plan to state how they are monitoring issues within their ward/areas.


3135 Audit of the use of MUST on Chemotherapy Outpatients Unit

Jessica Phillips, Macmillan Specialist Dietitian (BHT)

12/1/2011- MUST has been launched on the Chemotherapy units at Wycombe and Stoke Mandeville Hospital. NICE guidelines for nutritional support in Adults (2006) states that all outpatients should be nutritionally screened.

Specialist Services

12/01/2011 Complete 18/07/2011 53% patients at Stoke Mandeville Hospital and 44% at Wycombe Hospital had a Preliminary Nutritional Screening questionnaire present in their notes. Recommendations: 1. To discuss with nursing staff possible reasons for the lack of nutritional screening and strategies for improving compliance. 2. Additional training to reinforce the importance of the full completion of the Preliminary Nutritional Screening questionniare/MUST and accurate recording.

Changes required

3136 Radical Prostatectomy Data

Mr Neil Haldar, Consultant, Urology (Krystyna Caine, Clinical Nurse Specialist, Urology)

To record and monitor outcomes following Radical Prostatectomy.




3137 Audit of Adult Community Acquired Pneumonia (BTS)

Dr N Numbere, SpR, Respiratory Medicine, Dr M Shahidi, Consultant, Respiratory Medicine

To assess adherence to local and BTS guidelines regarding the management of pneumonia and to identify any areas for improvement.

Integrated Medicine



3138 Trustwide Consent Audit 2010/11

To assess the extent to which appropriate consent is obtained from patients within the Trust. To assess the quality of consent obtained from patients within the Trust. To educate clinicians in the standards of consent expected by the Trust.

Trustwide 10/01/2011 Analysis/Report


3139 Renal Nurse-Led Clinic

Sue Foster, Diabetes Specialist Nurse, Louise Meakes, Senior Diabetes Specialist Nurse

To assess effectiveness of a nurse-led renal clinic.

Integrated Medicine



3140 Insulin Pump Therapy for Type 1 Diabetes (SMH)

Viv Sandford, Diabetes Specialist Nurse

To assess whether patients with Type 1 Diabetes given insulin pump therapy benefit from reduced frequency of severe hypoglycaemia and restoration of early hypoglycaemia warning symptoms; improved glycaemic control; and improved quality of life.

Integrated Medicine

14/01/2011 Ongoing Results and Recommendations required Changes required

3141 Admissions to Observation Bay on Labour Ward

Christina Aye, ST3, Obs & Gynae

A review of admissions to the Observation Bay on the Labour Ward - are the patients appropriate or do they require HDU/ITU care? Does the bay decrease HDU/ITU admissions?

Specialist Services

22/03/2011 Complete 04/08/2011 Results: Combined with results from audit for HDU/ITU admissions, we found that there was a reduction in critical care admissions with a greater proportion of admissions needing a higher leverl of care and a longer stay. This could potentially be partly due to the creation of the four bed close observation unit, which means that some women who would have needed an HDU bed being managed in a high dependency environment within the labour ward. Recommendations: Could further use of invasive monitoring in the observation bay further reduce admission to ITU? There would be issues regarding training and equipment costs. However, if HDU/ITU admissions could be avoided the cost of this may be offset. In addtition there would be psychological benefits for the mother and she would have more appropriate access to obstetric care. Further audit recommended.

No change forthcoming. Further audit recommended.

3142 Audit into Consultant Clinic DNAs following Referral from Hand Clinic

Dr Adam Sykes, CT2, Plastics, Mr M Tyler, Consultant, Plastics

Patients referred to consultant clinics from hand clinics have anecdotally been shown to DNA more frequently than elective referrals.


18/01/2011 Complete 10/03/2011 This audit was useful as a preliminary audit to hone methodology but the small data set means it was difficult to draw solid conclusions from. Recommendations: DNA letters to have more information to allow easier data collection (or a DNA proforma to be filled in and sent to GPs instead); suggest repeating data collection from ALL consultants over a longer period before further decisions made regarding changes to follow up.

This audit was useful as a preliminary audit to hone methodology but the small data set means it was difficult to draw solid conclusions from. To be reaudited with larger data set.

3143 Macmillan Quality Environment Mark Audit

Sandy Barnett, Lead Cancer Nurse

Patient questionnaire produced by Macmillan to reflect the key aspects in providing a quality care environment. To evaluate questionnaires and use as evidence when applying for Macmillan Quality Environment Mark.


21/01/2011 Complete 11/05/2011 Results from the questionnaire confirmed that patients/carers/relatives have a positive experience when visiting the Cancer Care and Haematology Unit. It confirmed that parking is an ongoing problem for patients attending the hospital site.Recommendations: Questionnaires will be used as evidence for the MQEM on the 15th April 2011. Adapt questionnaire to use again annually. Drop off point outside the CCHU will remain ‘coned off’ to prevent unauthorised parking, blocking the drop off point and disabled bays.

All the recommendations have been actioned. Questionnaires were used as evidence for the MQEM. Drop off point outside CCHU remains coned off.

3144 Audit of CTPA (CT Pulmonary Angiogram) of Suspected Pulmonary Embolism in Spinal Cord Injured Patients

Sam Healy, Medical student, Tom Meagher, Radiology Consultant

VTE has high prevalence in SCI patients. Imaging with CTPA needs caution because of radiation. Identify positive outcomes of CTPA and evaluate clinical indications for it.


21/01/2011 Complete 22/02/2011 Results: 65 CTPA scans were performed in 59 patients. 12 (18.5%) of patients in the cohort had positive imaging for pulmonary embolus. This falls slightly short of the audit standard. 4 (6%) of studies were non-diagnostic, meeting the audit standard. Recommendations: Data sub analysis – prevalence of emboli in patients already on prophylactic anti-coagulation. Identifying neurological levels. Differentiating acute from readmission patients. Presentation of results with discussion at monthly Spinal cord injury audit meeting. Drafting consensus guidance for imaging suspected PE in SCI patients. Submission of Scientific paper for publication in Spinal Cord.

Results presented. TM is meeting up with a specialist from Oxford Brookes in December 2011 to discuss the results. The numbers are small and there may need to be a clinical trial before the drafting of consensus guidance for imaging suspected PE in SCI patients or submission of Scientific paper for publication in Spinal Cord is considered.

3146 VTE Prophylaxis for Hip & Knee Primary Arthroplasties

Peter Reilly, Trainee Operations manager, Orthopaedics, Liz Hollman

PCT has asked us to audit VTE prophylaxis in hip & knee arthroplasties for National Improving Quality Programme. Proforma provided.


21/01/2011 Complete 31/03/2012 Cancelled Cancelled

3145 Audit of Invasive Perinatal Screening Cycle in Down's Syndrome (SMH)

Miss Aparna Reddy, Consultant, Obs & Gynae (Dr S Palaniappan, ST4, Obs & Gynae)

An audit to determine whether the current Down's Syndrome screening cycle meets national screening and local standards. The sample is initially processed at SMH and then sent to Oxford. The results of PCR of amniocentesis should be communicated within 72 hours.

Specialist Services

01/02/2011 Complete 01/09/2011 Overall Bucks health care doesn’t meet the NSC standards. Results from Wycombe site don't meet the standards - 80% of serum reports issued within 3 days of the specimen at local lab (Standard - 97%). Results from SMH site meet NSC standards marginally (97.4% against standard of 97%). This is mainly due to delay in specimen reaching Oxford more than 1 working day (at both sites but more at Wycombe 84% and SMH 54%). 10% took 3 days. Also due to different dates for NT scan and bloods and dating and NT scan. Recommendations: Improve the standards at Wycombe site - booking midwife to advise women to get bloods done on the same day of the scan. Improve facilities for dating and NT scan on the same day. Improve quick appointments for NT scans as 18% more than 13+6. Improve the facilities so that all specimens reach Oxford within 1 working day.

No changes received and maternity re-configuration now completed 21/2/13 (CP)

3147 Myocardial Ischaemia National Audit Programme (MINAP)

Cardiac Specialist Nurse, SMH, Dr Piers Clifford, Consultant Cardiologist

The Myocardial Ischaemia National Audit Project (MINAP) was established in 1999, in response to the national service framework (NSF) for coronary heart disease, to examine the quality of management of heart attacks (myocardial infarction) in hospitals in England and Wales.

Integrated Medicine

01/01/2010 Ongoing Total number of admissions recorded = 18. Onset to needle time <120 mins - 36.6%. Call to needle time <60 mins - 49.1%.

Changes required

3148 Audit of Outcomes for Voice Therapy

Barbara Reynolds, Michelle Holmes, Speech Therapists

Audit of therapy outcomes for patients with voice disorders using Kent outcome


01/10/2010 Complete 25/01/2011 Outcome measures recorded for 12 patients. 9 achieved 100% objectives, 2 75/80%, 1 65%. Objectives achieved in less than 4 treatment sessions. VHI scores showed significant

All voice patients have an outcome measure sheet completed instead of the audit only taking account of patients

measures and patient self-evaluation using Voice Handicap Index (VHI).

improvement. GRBAS (voice therapist perceptual voice evaluation) scores also improved. Recommend to continue using same outcome measures format for every patient. Ensure VHI implemented pre and post therapy. Continue team training in GRBAS. Repeat audit Jan 2012. Outcome measure sheets to be recorded in patient casenotes.

seen during a selected quarter of the year. This means that the audit will measure progress for people attending a longer term course of therapy and not just those who complete their therapy within a specified quarter.Therapists now routinely implement VHI pre and post therapy. The voice therapists hone their skills in GRBAS during a practical session scheduled for each of their team meetings. Outcome measure sheets are filed in the patient’s notes and will be accessed from the discharge cabinet at the time of the audit in January. Previously, outcome sheets were sent to the team lead for voice by therapists.

3149 CEM - Renal Colic National Audit - 2010-11


Purpose of the audit is to compare current practice in Emergency Departments against CEM clinical standards. Audit criteria are based on the clinical standards for managing renal colic developed by the CEM Clinical Effectiveness Committee.

Medicine 01/09/2010 Complete 07/06/2011 The CEM Guidance & Reports have been published on the Trust intranet within the Document Store/Emergency Medicine/Audit/CEM 2010 folder so that these are readily available for reference and as feedback of our status. We will concentrate on improving the following areas; recording of pain score, promptness of provision of analgesia and re-evaluation of pain response to analgesia. A repeat audit will be performed later this year.

Changes required

3150 Elective Surgery Patients requiring HDU

Jo Eldridge, Acting Matron, Surgery

Patients identified as requiring HDU bed but bed may not be available. Patient either cancelled or goes ahead without available bed. Decision to do this often delays theatre. Want to identify number of cases and delays/cancellations involved.



3151 Wycombe and Aylesbury Birth Centres Patient Experience Survey

Carole Beetham, Lead Midwife, Aylesbury and Wycombe Birth Centres, Mr Tunde Dada, Consultant

Patient experience survey to assess the service provided by the Birth Centres at Wycombe and Aylesbury.

Specialist Services

27/01/2011 Cancelled 03/05/2011 Audit cancelled. Audit cancelled as survey covered by annual Maternity Survey in February.

3152 Audit of Third Degree Tear Following Spontaneous and Normal Vaginal Deliveries (WH)

Carole Beetham, Lead Midwife, Aylesbury and Wycombe Birth Centres, Mr Tunde Dada, Consultant

An audit of third degree tears following spontaneous and normal vaginal deliveries at Wycombe and Aylesbury Birth Centres.

Specialist Services

01/03/2011 Cancelled 13/12/2011 Audit cancelled. Audit cancelled

3153 Audit of External Cephalic Version (SMH)

Miss Nutan Mishra, Consultant, (Dr Dahlia Sikafi, Reg) Obs & Gynae

An audit of the success of ECVs and their outcome and to compare the success rate of SMH to national figures.

Specialist Services

01/02/2011 Complete 30/01/2012 1. Comparable success rates to national rates and previous rates. 2. Reduction in number of Emergency Caesarean Sections for successful ECVs (although numbers are small). 3. Place to offer more vaginal breech deliveries especially for multips. Recommendations: To further improve our success rates particularly with primips (this review success rate 34.5%). To continue to encourage community midwives to refer patients with suspected breech presentation to DAU or ANC.To increase awareness regarding benefits of ECV particularly to community midwives.

No changes received, Dr has now left Trust 21/2/2013 (CP)

3154 Audit of Fetal Blood Sampling (SMH, WH)

Dr Kawther Al-Shahib, ST1, Dr Doria Bouzebra, FY2

Audit of practice against Trust guidelines 425.3 on fetal blood sampling: if FBS taken when contraindicated; documentation of results; paired cord samples taken appropriately; referral and consultant review.

Women & Children

02/02/2011 Complete 17/03/2011 Results: In almost half of the cases the FBS were done when not indicated (after a suspicious CTG). Significant delays in performing FBS when indicated. FBS documentation needs to be improved (hardcopies to be stuck in the right place near to the handwritten plan). Timing of the FBS rarely documented on the CTG. In the majority of cases a plan post FBS was documented. Better recording of paired cord gases results is needed. Paired arterial and venous cord samples not always taken. Consultant advice was sought when appropriate.

No changes required as small sample size for audit and results disputed at academic half day.

3155 Audit of the Use of Propess for Induction of Labour in Primipari women (SMH)

Dr Anu Ram Mohan, ST5, Obs & Gynae

An audit to assess the effectiveness of Propess (vaginal pessary containing dinoprostone, prostaglandin E2) for IOL, introduced in November 2011 at SMH, and to compare the results with the use of Prostin E2 in primipari women. Guideline 415.

Specialist Services

02/02/2011 Complete 08/08/2011 The aim of the audit was to evaluate the use of Dinoprostone vaginal pessary (Propess) for induction of labour in primigravida, which was introduced at SMH in 2010. 26 cases identified 1/2 - 10/3 2011. The audit showed that Propess is well tolerated by women; there were no major complications. Recommendation is that there should be clear guidelines on management when the Propess pessary is expelled prematurely. Further audit should look at effectiveness, maternal satisfaction and acceptability of various regimens of prostaglandins, and different management policies for failed prostaglandin induction.

No changes received, Doctor now not with Trust 21/2/13 (CP)

3156 Audit of Neonatal Referrals for Paediatric Orthopaedics

Rachel Babajee, Sarah Evans, FY1s, T&O

Neonatal referrals of "clicky hips" to paediatric orthopaedics to identify congenital abnormalities of hips and treat appropriately. Identify how many require further intervention; are these a particular subgroup, if so should guidelines be implemented for "clicky hip" referrals rather than referring all?


02/02/2011 Cancelled 27/06/2011 Project not completed. Project cancelled.

3157 Management of Neonates with Suspected Hypoxic Ischaemic Encephalopathy

Angus Goodson, ST3, Neonatology

Current optimal treatment for neonates born with HIE is therapeutic whole body cooling, most effective when started within 6 hours of birth. No facilities for this at SMH so early referral to tertiary centre and passive cooling is required. To compare babies born at SMH who meet cooling criteria against neonatal unit protocol and identify any problems with achieving best practice.

Specialist Services

02/02/2011 Complete 30/12/2011 There was a lack of documentation in some areas. Delays in commencement of passive cooling contact with cooling centre. No babies had rectal temperatures documented. Recommend education of clinical staff, a checklist for doctors and a policy of obtaining signed consent from parents.

Junior doctor audit, no changes recevied and doctor has left Trust 21/2/13 (CP)

3158 Ventilatory Management of H1N1 Positive Patients on ITU

Carly Grandidge, FY1, Anaesthetics, Samantha Scammell. Project sponsor Dr Patrick Strube.

To determine whether Acute Respiratory Distress Syndrome protocols are followed for H1N1 positive patients on ITU and if not, does this result in worse mortality?



23/05/2011 This audit showed that no patients had predicted body weight calculated, and as such the first step of the ARDSNet protocol was not used. The high use of non-invasive ventilation on the ICU was highlighted. Recommendations included early intubation; the calculation of predicted body weight (to enable tidal volume calculation) for H1N1 suspected patients; and having copies of the ARDSNet protocol visible on the ICU.

Changes required

3159 Epidural Effectiveness Following Colorectal Surgery

Joyee Basu, FY1, Surgery

Epidural analgesia forms part of the ERAS programme following bowel surgery. This audit aims to identify the success rate of epidurals, the possible reasons for failure, ways to reduce the failure rate and the effect of failure on patient outcome.


02/02/2011 Cancelled 01/10/2012 Audit report not received, cancelled by audit & effectiveness lead.

Project cancelled

3160 Evaluation of Effectiveness of Physiotherapy for Shoulder Pain

Vicky Russell, Specialist Physiotherapist

Use of validated outcome measure to look at whether physiotherapy helps patients with shoulder pain. Also patient satisfaction questionnaire.

Specialist Services

03/02/2011 Complete 02/08/2012 •Results: 83% (40/48) patients achieved a reduction in their SPADI score of 10% or more, i.e. a significant improvement in symptoms. 82% patients rated the physiotherapy as very good and 16% rated it as good.74% patients had less pain after the physiotherapy, 89% had improved flexibility and 74% had increased the range of activities they could do. Action Plan : Physiotherapy staff to be guided by the mean number of physiotherapy appointments (7) as maximum number of appointments.Reinforce to physiotherapy staff to discuss with senior staff members after 3-4 sessions if patient not progressing to meet this objective. Physiotherapy staff at each site to meet and discuss management of each shoulder condition and decide some consensus for management and how efficiencies can be made, e.g. patient attends for 1:1 and then be progressed to shoulder class.

Changes required

3161 Smoking Prevalence Survey

Alyson Moss, Smoking Cessation Co-ordinator, Respiratory Medicine

The no smokiing policy enforced by the Trust means that patients who smoke require NRT whilst they are an inpatient of this Trust. The purpose of this audit is to establish the number of inpatients who smoke requiring NRT in order to estimate the potential cost of providing NRT.

Integrated Medicine

04/02/2011 Complete 26/08/2011 As part of a drive to improve the Nicotine Replacement Therapy (NRT) available to inpatients of Buckinghamshire Healthcare NHS Trust, a prevalence survey of smokers amongst inpatients was commissioned to establish the possible need for, and uptake of, NRT throughout the Trust and the subsequent cost implications. 363/398 patients who were asked whether they smoked or not answered this question. 56/363 patients responded yes they did smoke. This represents 15.4% of the total patient population. Higher proportion of NSIC patients were smokers - 24/101(24%) patients sampled said they smoked. The Clinical Audit and Effectiveness Department highlighted the possible inaccuracy of answers given by patients, due to the sensitive nature of the survey. It was also noted that some patients gave their status as non smoker as they had not smoked since their admission to hospital.

Improvement of Nicotine Replacement Therapy (NRT) available to inpatients of Buckinghamshire Healthcare Trust.

3162 Heart Failure Follow-up Project

Emma Parry, Service Innovation Manager, AH

The South Central Cardiac Network (SCCN) has identified

Integrated Medicine

07/02/2011 Complete 06/09/2011 Following the report the recommended model of care is: Following discharge from hospital appropriate patients with LVSD will be referred to

Changes required

outpatient follow up of patients with LVSD as an area of clinical activity where there may be potential to improve quality and reduce costs. A service evaluation to review the curent services provided.

community heart failure specialist nurses. Patients may return to secondary care outpatient for their first appointments and subsequent appointments will be made only if deemed necessary. Patients with heart failure not caused by LVSD should be seen as required by secondary care. Multidisciplinary support in the community for those with established heart failure should be available comprising of specialist nurses, GP’s, community nurses/matrons, palliative care teams and cardiac rehabilitation. Access to heart failure clinics for follow-up based in either primary (mainly subsequent appointments for those with LVSD) or secondary care (mainly initial appointments or those with heart failure due to other causes) should be available for those with confirmed heart failure. Access to diagnostics should be available based on clinical need in either primary or secondary care as per NICE guidelines (2010).

3163 Endoscopy Patient Experience Survey 2011

Sue Kenny, Sister, Endoscopy Unit, SMH & Deborah Dobree-Carey, Sister, Endoscopy Unit, WH

Re-audit - an experience survey of patients attending for endoscopy. The questionnaire has been designed in line with global rating scales for excellence.

Integrated Medicine

08/02/2011 Complete 15/09/2011 Recommendations: Improve signage to the Units. Ensure patients are given a realistic idea of waiting times. (WH) Consider the layout of the waiting area. (WH) Ensure staff at all entrances/receptions are able to provide accurate directions to the Endoscopy Unit (SMH) Consider the feasibility of holding single sex sessions. (SMH) Ensure the Unit reception is manned at all times. (SMH)

Estates have improved the signage at both sites. Appointment letter explains there may be a 2 to 4 hour wait. (WH) A flow chart has been put in the waiting area explaining the pathway. (WH) Staff to keep patients up dated on their progress. (WH) Re design of the waiting area at WH is not possible at present due to financial constraints. Sodexho staff have been reminder of the need to give patients accurate directions. (SMH) Feasibility of single sex sessions being explored. (SMH)

3164 IV in the Community Patient Survey

Emma Parry, Service Development

Some patients having IV are discharged and continued at home with visits from nurse. New service recently started. Questionnaire to evaluate.

Integrated Medicine

08/02/2010 Complete 17/05/2011 Results: The results demonstrate that the service has been very positively endorsed by the patients and the level of satisfaction is generally very high with all aspects of the service provision. 95% of the respondents stated the service was very good. Recommendations: We continue to monitor the patient experience to this service by on-going evaluation. We consider alternative community venues for patient so they can access the service at more convenient locations – this already is underway. A robust and formal training programme is already in place but we need to ensure it is reaching all the nursing teams so they feel they are appropriate prepared to manage the nursing tasks required of them. OPAT team will offer more targeted support to community nursing teams if required.

We now send patients home with a questionnaire on discharge from hospital. This way the experience is fresher in their mind and we are in a position to prompt them to return them when we discharge them from the community care. Two questionnaires have been developed – one for early supported discharges and one for our admission avoidance patients. We now have a variety of alternative venues including clinics in SMH, WGH, Amersham Hospital. However, in general most patients continue to be treated at home. The IV service train and educate all staff on a regular

basis via an ad hoc on the ward process or in a more formal setting. The IV team have established a full training programme with the education department. The team now deliver Venepuncture training, Community IV therapy full day & Community IV therapy update sessions commencing in January 2012. We have also been providing IV calculation sessions separately to the trust sessions to get the community hospital & community staff up to date with requirements of the trust.To date we have facilitated 61 staff through the calculation tests and are providing another 5 sessions over the next few months to ensure staff are trained.We also support the training department on the trust Central Venous Catheter days and other IV specific training as required.There have been difficulties with achieving the appropriate training needs of the community staff as there are different needs for the services that we are trying to establish pathways for.

3165 Evaluation of Meals in NSIC

Samford Wong, Dietitian, NSIC

Questionnaire to patients re meals provided. Similar questionnaire to staff. Also food intake to be measured for every patient in NSIC for 1 day to determine nutrition and food wastage.

Spinal Injuries

02/02/2010 Complete 03/08/2011 Morning, afternoon and evening snacks were rarely offered and were mostly consumed by those that had eaten all their meals.29 (48%) patients ate 3 full meals a day. 52 (85%) patients ate the equivalent of at least 2 full meals. 27% patients are satisfied with the meals. 47% are not. Recommendations: Ensure nutrition screening on admission is implemented effectively. Raise awareness. Arrange education sessions for catering staff, nursing staff, medical staff. Review the quality/choice of dishes on the hospital menu. To involve volunteer help in meal ordering; to make sure food is cut up and placed within reach. Ensure menu available to all patients. Create Breakfast / Lunch / Supper club – to give patient company and encouragement while they eat.

Nutrition sreening week held to increase awareness. Nutrition care plan updated. Audit findings disseminated. Nutrition education session held Jan 12 for all ward staff. Now included in NSIC induction and SHO training. New menu in May 2011 which is available to all patients. Facility to review hospital food is ongoing. Introduction of breakfast/lunch/supper clubs ongoing.

3166 An Audit into the Use of Exenatide in Type 2 Diabetes

Dr Itopa Fidelis Abedo, ST5, Diabetes

Review success of Exenatide treatment. Review whether patients receiving this treatment meet criteria drawn up by NICE. Find out how many patients have dropped out.

Integrated Medicine

11/02/2010 Complete 04/08/2011 Results: 17 out of 40 patients achieved NICE weight and HbA1C targets at 6 months. The same number met the above targets in the group treated with oral hypoglycaemic (17/29 patients). These results are comparable to the Association of British Clinical Diabetologist’s Nationwide exenatide audit. No one in the Insulin group achieved both targets. An audit of the exenatide treated patients should be done at 12 months to see whether the gains are sustained. A separate audit into insulin treated groups is advised once we have a substantial number of patients.

Changes required

3167 Audit of Radiology Request Forms

Libby James, Radiology

Radiology request forms should be fully completed to avoid mistakes and to increase value of radiology report. 476 radiology request forms audited.


01/01/2011 Complete 15/02/2011 8% forms were not fully completed. Data sent to Medical exposure Committee for comment and recommendation. Inadequately completed requests to be rejected, minimum data set required, referrer's identity required.

We are moving towards ordercomms – electronic requesting – this does not allow the requestor to request using an inadequately completed form. As to the paper requests we are continuing to reject inadequately completed forms – our goal is for all requests to be 100% fully completed, but due to the rapid introduction of ordercomms we will not repeat this audit. Review 2012.

3168 Audit to Check Compliance with Request Form Scanning


Radiology request forms should be scanned. 1975 radiology request forms audited.


01/01/2011 Complete 15/02/2011 94% compliance. We would wish for 100% compliance but will not be reauditing as ordercomms negate the need to scan in a request form. We will review this in 2012.

3169 Audit to Check Radiology Reports sent to MDT When Necessary


397 scans audited to see if sent to MDT when necessary.


01/01/2011 Complete 15/02/2011 14 cases referred properly and promptly. 7 referrals from GPs which should have needed referral were sent back to GP without referral. 6 cases from OP clinics should have been faxed or highlighted but weren't. Imaging capacity is adequate. Recommendations: Maintain adequate number of skills and staff in each clinic. All acute/unexpected cases with positive findings from GP clinics should be referred to hospital clinics. Acute/unexpected results from OP clinics should be faxed promptly to referrer. Keep to maximum capacity of clinics.

The sonography staff were instructed to record how the patients are managed on the report. The modality lead for U/S has been tasked with finding a way of auditing this, Practice Educator to follow this up in 3 months.

3170 Audit to Check All Radiology Results are Reported


All radiology results in March 2009 checked to see if reported.


01/01/2011 Complete 15/02/2011 Over 99% reported after 4 weeks (X Ray 99.6%, MR 99.3%, CT 99%, US 98.8%).

Ongoing departmental audit of unreported specials is now part of general housekeeping.

3171 National Care of the Dying Audit

Jeanette Tebbutt, Cancer Services

Audit run by Marie Curie Palliative Care Institute. Registered for organisational and clinical parts of audit - data collection April-July 2011.

Specialist Services

17/02/2011 Complete 30/04/2012 Results: Access to information regarding death - bottom 25% trusts. Access to specialist support for end of life care - top 25% trusts. Continuous education, training & audit - top 25% trusts. Clinical protocols regarding dignity & respect - middle 50% trusts. Anticipatory prescribing for key symptoms which may develop - bottom 25% trusts. Communication with relatives & carers regarding plan of care - middle 50% (SMH), top 25% (WH). Ongoing routine assessment - top 25% (SMH), bottom 25% (WH). Compliance with completion of LCP - middle 50% of trusts. Action Plan: Review existing information leaflets (ICP for the Dying Adult – Supporting care in the last days – CISS 64, Place of care options for patients with palliative care needs - CISS 57, Hospital Palliative Care Team - CISS 1). Through the educational roll out raise the importance of discussion and decisions with the patient/carer.Review the need for an educational roll out Trustwide on communication skills. Continue to recognise importance of palliative care service and produce off duty accordingly. Review present structure of acute

A robust teaching plan was developed and has been delivered. This is not yet mandatory but an e learning package has been written and once this is in operation it should be easier to access end of life training. The training incorporates training in spiritual care and the chaplains have received additional training. A recent audit showed that the prescription of suitable drugs had improved. Information has been added to the ICP paperwork re information given to health professionals so this should now improve. After the recent news reporting on the ICP an assurance paper has been written and

palliative care nurses and through current WTE create a LCP facilitator 4 days a week (30 hours). An established educational programme is in place, but does need to be reviewed this year to capture all the audit recommendations. Bring to discussion at the Nursing and Midwifery Board for agreement that it becomes mandatory for all staff to attend training regarding caring for dying patients and their families, on induction, and update annually. Develop elearning tool for yearly update for all clinical staff. To produce information leaflet on the process of ICP for healthcare professionals. To review allocation of ICP files to ensure each clinical area holds an up to date copy of the folder with training material and is ensure that this is updated by the palliative care link nurses and the acute palliative care CNS team leader/facilitator.To review roles and responsibilities of the link nurses and increase numbers on each clinical area following the possible reconfiguration.ICP on existing intranet, and will be placed on the new intranet.Raise awareness of spiritual care to be available for end of life care and carers support. Chaplains to audit uptake of spiritual care provision following notification of patient being placed on ICP. One of the chaplains will be identified as the lead for acute end of life care with the potential to be become a Macmillan postholder. Through the education programme raise the awareness and importance of clinicians prescribing medication for the five key symptoms. Through the education programme raise the importance of communication both verbally and in written format to carers and relatives regarding the plan of care. To raise awareness through education of the ward nursing team on the importance to hand out the leaflet Help for the Bereaved CISS 23, prior to relatives and carers leaving the ward. Carry out another audit on the compliance of the wards handing out of the Help for the Bereaved leaflet, and compare to previous audit. Review leaflet in March 2013. Part of the education programme will include encouraging the clinical staff to communication with the GP/primary health care teams on the initial assessment and ringing once the patient has died in order for the GP to support relatives/carers. The educational programme will include encouraging the clinical staff to assess and formally document the care delivered. Each division to run audits on the compliance of good documentation which should be reported at their divisional board on their balance scorecard. An established end of life steering group, however further commitment is required from each division for attendance. Issue to be raised at each divisional board.

will be delivered to the Trust board in December 12.

3172 Audit of Use of SBAR approach to patient handover and ward rounds

Mr Tunde Dada, Consultant, Obs & Gynae (Dr Fiona Legge, ST3)

An audit of clinical sheets used by the coordinator on delivery suite incorporating gynae

Specialist Services

07/03/2011 Complete 13/07/2011 Results: 1. Attendance of ‘the big 5’ (consultant obstetrician, anaesthetist, labour ward coordinator, obstetric registrar and obstetric SHO) at the morning handover meeting was 94%. The Consultant Anaesthetist was absent on 2 occasions. (I was not

No changes reported as junior doctor now not with Trust 21/2/13 (CP)

handover, in order to ensure that patients are being handed over using the SBAR approach (Situation, background, assessment, recommendation). Against RCOG Good Practice Guideline 12 Improving Patient Handover and Trust Handover Guideline BHT 43.1.

able to ascertain if s/he was busy). On average they signed in when they were present only 51% of the time. 2. 28 patients (1 not seen on the ward round and therefore not included). Of the 27 remaining patients, 17 (63%) had all appropriate information regarding their risk factors recorded on the smart board. 9 (33%) patients had risk factors or background information that should have been recorded on the smart board but was not. Some of these patient had 2 factors that should have been recorded. 3. The plan from the ward round should be followed (unless clinical indication to alter). The Plan was followed 86% of the time4 cases where the plan was not fully followed…i. No CSU sent (and the catheter bag was changed!) ii. No Teds applied. Iii. Bloods not chased. Iv. Plan changed by Reg. Recommendations: We should include BMI on the smart board. We need to be diligent about updating the smart boardWe need to ensure the technology can keep up with what we are asking of it. Good at attending meetings but there are often too many people there (average 25).

3173 Audit of Massive PPH, pre and post merge of WH and SMH

Dr Helen Jefferis, ST3, Mr Tunde Dada, Consultant, Obs & Gynae

A review of PPH of >1500 ml pre and post merge, focussing on the management of 3rd stage, and management of PPH according to Trust Guideline 550.1 and RCOG Greentop guideline 52.

Specialist Services

14/02/2011 Complete 04/08/2011 Only the post merge part of this audit was completed. Recommendations: 1). Risk factors for PPH to be highlighted in antenatal notes and on labour Admission. 2). Reminders to staff that hospital policy is to use Syntocinon IM for lower risk women but if higher risk for Syntometrine. 3). Senior obstetric and anaesthetic staff to be involved in all cases of massive PPH. 4). Remember the risk of bleeding with a retained placenta increases with time – consider whether earlier transfer to theatre possible. 5). Re-audit with larger sample size.

Post merger audit, no changes given 21/2/13 (CP)

3174 Resuscitation Trolley Audit

Jenny Wright, Resuscitation Service Manager

To monitor compliance of wards/departments checking of resuscitation trolleys in accordance with the Trust Resuscitation Policy (BHT Pol 098). To ensure all resuscitation trolleys are stocked with the approved equipment as listed in the Trust Resuscitation Policy and approved checklist.


01/12/2010 Complete 21/02/2011 Matrons/Ward Sisters to ensure staff are aware of need to check resuscitation trolley and actually carry out the check; improve documentation of checks; wards to contact the Resuscitation Service if unsure how to check trolley and trolley awareness sessions will be arranged; staff to familiarise themselves with the trolley information folders as most information required can be found within; Resuscitation Service to carry out repeat audit in 6 months to ensure better compliance with procedures and policy.

The trolleys were re-audited during July this year to ensure compliance with checking had improved. Following the initial audit in February 2011, trolleys that had been highlighted as having too much equipment on them were checked by one of the Resuscitation Team and extra equipment removed; staff were also familiarised with the checking process. At re-audit there was a marked improvement in checking procedures and trolleys no longer had the large amounts of excess equipment on them.

Areas that still had poor compliance were put on a spot check list and since the audit their compliance has also improved. Compliance will probably deteriorate over time but the trolleys will be re-audited on an annual basis to try to ensure this is not the case. The next audit will take place over the summer months of 2012.

3175 Unerupted Maxillary Central Incisors

Helen Veeroo, SpR, Dr Helen Travess, Consultant Orthodontics

To investigate the management of children referred to the department with unerupted maxillary central incisor teeth. To look at the orthodontic and surgical management, the treatment methods and the outcomes against the Royal College of Surgeons Guidelines for Unerupted Central Incisors.


28/02/2011 Complete 18/01/2012 Ensure all patients who are referred directly to Oral Maxillofacial Surgery are assessed by an orthodontist. Management decisions to be made on a case by case basis depending on the child’s level of dental development rather than the chronological age suggested in the guidelines.

Changes required

3176 Audit of Inpatient Deaths of Patients Admitted From Care Homes

Elizabeth Hollman, Associate Director Healthcare Governance

Mortality Task Force request to review the records of all patients from nursing homes who died in our care in the month of February 2011. The audit will contact the Nursing Home for each patient to find out whether the patient had an advanced care plan, and conduct a review of the clinical record, paying particular attention to end of life care.

Trustwide 01/03/2011 Complete 01/12/2011 Results and Recommendations required Changes required

3177 Enhanced Recovery Audit

Emily Hubbard, CT1, Anaesthetics

Audit of intra-op care during colorectal resections compared to evidence-based enhanced recovery protocols.


02/03/2011 Cancelled 24/10/2011 Project cancelled as Doctor left Trust before completion.

Not applicable - project cancelled.

3178 Implementation and Delivery of Nutrition in ICU

Dr George Hadjipavlou, CT1, Anaesthetics

An audit to assess whether SMH delivers nutritional care to its intensive care patients in accordance with guidelines, focussing on initiation and safe delivery of nutrition.


03/03/2011 Complete 26/07/2011 Results: Oral and enteral feeding predominate; more than half of patients have an established feeding route early (0-8 hrs); despite this, only approximately half of people are fed within 24hrs; few people had some form of dietician assessment within 24hrs; those on oral feeding had little / no recording of nutritional intake. Tthere was no data collection on the following: 1) feeding delayed by >24hrs, 2) mean level of nutrition over 7 days, 3) number of feeding holds, 4) Nursing at 30-45 degrees, 5) Use of prokinetics, and use of chlorhexidine mouthwash. Recommendations: everyone should have a nutritional assessment on admission to ITU; everyone should have documented the NICE recommended feeding route; aim that everyone should have nutrition started within 24hrs; those on oral feeding should have feeding documented and not just sips; suggest a simple A4 form to be completed on admission.

After discussion with Nutritional ITU lead a form has been drafted and is currently under review before implementation.

3181 Reaudit of WHO Surgical Safety Checklist

John Abbott, Operations Manager

Reaudit of 2955 to assess implementation of Safer Surgery Checklist. This audit will include documentation audit and observation audit.


03/03/2011 Complete 10/08/2011 1. The Day Surgery booklet should be redesigned to follow a similar format to the Intra-Operative booklet, incorporating the WHO Checklist.2. The Intra-Operative booklet should become the standard documentation for all patients irrespective of whether they are elective (planned) or emergency/trauma patients. 3. Where there are specific Integrated Care Pathway documents for patients e.g. Fractured Neck of Femur, these should have the Time Out checklist incorporated into the document. 4.Clinicians who have already taken up the use of the checklist should be requested to encourage others, especially more junior doctors, to use it in their own procedures. Given that the introduction of the checklist in the two hospitals was in February 2010, a strategy for increasing its use should be found (see Appendix 1). 5. The Time Out section of the checklist should be read by the surgeon or scrub nurse just prior to putting knife to skin, when all theatre staff must pause and respond verbally to the questions asked. Just prior to knife to skin means that all patient preparation and draping

1. New Day Surgery booklet, incorporating checklist will be put out in all admission areas e.g. Mandeville Wing at SMH, A&E, Day Ward at Wycombe etc. in November. 2. Standardised in-patient booklet containing WHO time-out checklist already in all admission areas. 3. Only applies to the fractured neck of femur ICP. 4. Celina Eves and Rachel Young have agreed that Rachel will meet individually with each SDU lead to talk through when this will be included as part of team/audit/governance meetings, as well as training sessions, so that all grades of doctors receive ‘training’/reminder. As

etc. is complete so staff will be able to pause to listen and respond to the Time Out.

evidence, the SDU leads will be asked to send copies of agendas/minutes demonstrating this was discussed.5. Rachel has met with all SDU leads to confirm that this means the surgeon and scrub nurse need to vocalise the WHO Time Out, so that all staff present in the theatre pause and are aware it is taking place and they can hear the questions and the respondent’s reply. RachelI will follow this up with observational audits as part of the on-going TPOT work. Any non-compliance will be reported to both the theatre matron and SDU lead for that speciality.

3179 Delivery and Administration of Medication on Medical Wards

Dr Claire Greszczuk, FY1, Dr Mariam Abbas Syed, FY1, Gastro, Dr R Sekhar, Consultant Gastroenterologist

An audit of administration of prescribed medicines on 3 medical wards at SMH. This will look at which drugs were not administered, the timing and dose, and whether reasons for not administering drug are recorded.

Integrated Medicine

25/01/2011 Cancelled 18/01/2012 Not applicable - project cancelled. Changes required

3180 Nursing Record Keeping with Regard to Child Protection

Pauline Collins, Child Protection Liaison Sister, Jane Bramnath, Named Nurse for Child Protection

A review of nursing records to include parental interaction sheet with regard to child protection issues. To ensure effective information gathering and communication with other agencies.

Specialist Services

22/03/2011 Complete 06/06/2011 1. To ensure that personal details are recorded for all parents of babies admitted to the Neonatal Unit and that they are easily identifiable and accessible in the notes. 2. To ensure that the name, professional role and contact details for other professionals working with the family are documented and easily accessible. 3. To maintain, at all times, best practice in record keeping as per Trust policy (27.3 Record Keeping Policy for Registered Nurses and Midwives) to enable clear and accurate documentation, effective information sharing within the Neonatal unit and other professionals working with the family, to ensure that, where there are concerns, babies are safeguarded from harm. 4. To review the Parental Interaction Sheet and develop a more comprehensive record keeping tool to enable a more effective record keeping process for babies where there are child protection concerns. A standardised system of recording information should be adopted

New proforma for Child Protection Record Keeping designed and presented to Clinical Governance meeting in November 2011.

by all medical and nursing staff working within the Unit.

3182 Orthotic Clinic Patient Survey

Dot Tussler, Physiotherapist, Spinal Audit Lead

Follow up of patients 6 months after having been given orthosis to see if still using and if not, why not, and also to ask if they were satisfied with the service.

Specialist Services


3184 Audit of Patient Readmissions within 28 days following Discharge from Medicine

Robert MacKenzie-Ross, SpR, Respiratory Medicine, Dr Mitra Shahidi, Respiratory Consultant

Audit to look at the reasons for readmission of patients within 28 days following discharge from Medicine. Results will be compared with those of the previous audit, 2941.

Integrated Medicine

07/03/2011 Complete 01/11/2011 Distinguishing between a readmission for the same/related complaint, readmission for a new complaint and planned hospital attendance for clinic/day case procedures is difficult to perform without the use of the hospital notes. Malignancy and respiratory problems make up the largest proportion of readmissions to hospital within 28 days. Episodes of continuous care ‘divided’ between WGH and SMH or the trust and John Radcliffe hospital would be classed as a re-admission using the parameters of this audit.

Changes required

3185 COPD Discharge Support Service Evaluation

Jo Hockley, Programme Director for Change

Early supported discharge service for COPD patients was introduced in November 2010. This audit is to evaluate the service from the patient's perspective.

Medicine 07/03/2011 Complete 17/05/2011 Results: Overall, the patients were satisfied or very satisfied with the discharge support service, they felt it was safe and effective, and no major issues were identified. All liked having their COPD flare up managed at home, and most felt they had a better understanding of their COPD as a result of contact with the specialist nurses. In particular, they were all confident that they understood their medications. Patients felt well supported and would all use the service again if asked. Recommendations: Ensure all patients are aware of the content and location of the patient leaflet before discharge and again when at home.

Patients are all now made aware of the leaflet and are given the phone number of the specialist nurse.

3186 Audit of Nutritional Assessment, Falls, Depression Screening and Dementia Screening in Older People

Jo Birrell, Matron, Medicine for Older People

Audit to assess whether or not appropriate assessment of older people takes place when they are admitted to hospital. This audit includes nutritional assessment, falls, depression screening and dementia screening.

Integrated Medicine

02/03/2011 Complete 31/01/2012 The Trust must ensure that the revised nursing documentation is in place. Ward staff should be made aware that they accountable for completion of required documentation. Dementia awareness training to be cascaded to all nursing staff.

Changes required

3187 European COPD Audit (BTS)

Dr Mitra Shahidi, Respiratory Consultant

It is the intention of this COPD audit to develop a core data set that can be used to audit COPD in acute hospital admissions across Europe, with a view to raising the standards of care to a level consistent with the European management guidelines.

Medicine 02/03/2011 Not yet started


3188 National Cardiac Arrest Audit (NCAA)

None The National Cardiac Arrest Audit (NCAA) is an ongoing, national, comparative outcome audit of in-hospital cardiac arrests. It is a joint initiative between Resuscitation Council (UK) and ICNARC (Intensive Care National Audit & Research Centre) and is open to all acute hospitals in the UK and Ireland.




3189 Clopidogrel and Trauma Patients

Mr Harish Karup, Consultant, T&O (Dr Anan Ramasamy, FY1, T&O)

To assess the delay and complications of trauma patients on clopidogrel. Do we


09/03/2011 Complete 18/07/2011 Results: 37% (n=8) patients were operated within the 48 hours of admission as per the BOA guidelines. The drop in haemoglobin post-operatively in those who were operated within 48 hours, 3-7 days and

Education meetings were organised to educate surgeons and advocate early surgery for patients on

need to wait 7 days before operating? British Orthopaedic Association standards.

more than 8 days were statistically significant; p=0.0022, p=0.0360, p=0.0381 respectively. Therefore, delaying the surgery because of clopidogrel does not reduce the haemoglobin drop during operation. Half of the patients (n=11) required blood transfusion but there was no correlation between the different groups. None of the patients required platelet transfusion. Patients who waited longer for operation had more complications (myocardial infarction, pneumonia, stroke and death). Recommendations: educational meetings suggesting a) early surgery for patients on clopidogrel rather than waiting days/weeks and b) use of general anaesthetic rather than spinal in patients on clopidogrel; ensure cross-match is available; ensure clopidogrel is restarted post-surgery; liaise with haematologist re: Buckinghamshire Trust policy on patients on clopidogrel requiring surgery.

clopidogrel. Junior staffs were reminded to ensure cross match is available for patients before operation. We liaised with the haematologist to devise a local trust guideline for patients admitted on clopidogrel requiring trauma surgery.

3190 Ankle Fractures: Screws or Tight Rope?

Mr Harish Karup, Consultant, T&O (Nik Bakti, CT1, Surgery)

To compare any differences/benefits of 2 different surgical techniques in managing ankle fractures.


09/03/2011 Complete 27/07/2011 Results of this audit indicate that tightropes achieve radiologically similar reduction of syndesmosis as screws without any significant difference in complications. The need for a second operation is significantly lower with tightrope fixation.

Recommendations for change were not made as numbers for tightrope were too small.

3191 Pre-op Haemoglobin and Joint Replacement: Impact on Blood Transfusion

Dr Sara McNeillis, Consultant, Anaesthetics (Tamsin McAllister, CT1, Anaesthetics)

Audit against NATA guidelines Jan 2011. What level of haemoglobin are we accepting prior to joint replacement surgery and what are we doing to optimise it? How is this impacting on need for post-op transfusion?


10/03/2011 Complete 28/10/2011 Recommendations included: improve % patients with pre-op Hb close to 28 days prior to operation; patients with low Hb - investigation and optimisation; raising awareness - pre-op / juniors; clear guidelines for acceptable pre-operative Hb; guidelines for referral / investigating low pre-op Hb; re-audit.

A guideline incorporating a flowchart for pre-operative anaemia management has been developed by Dr Tamsin McAllister. It has not yet been implemented.

3192 Audit of Community Acquired Pneumonia Q4 2010/11

Dr Mitra Shahidi, Respiratory Consultant and Liz Hollman, Associate Director Healthcare Governance

IQP audit to assess patients with community acquired pneumonia.

Integrated Medicine

11/03/2011 Complete 31/03/2012 Results and Recommendations required Changes required

3193 NJR Hip Mortality Review

Mr Alastair Graham, Dr Graz Luzzi

Mortality review of THR deaths following alert from National Joint Registry.


11/03/2011 Draft Report with Clinician


3194 Effectiveness of Temporo-Mandibular Joint Arthrocentesis

Mr Bahattin Bagdadi, Specialty Doctor

To determine the effectiveness of the TMJ arthrocentesis procedure and to determine which patients would benefit from the procedure.


14/03/2011 Complete 26/10/2011 The audit showed that the procedure can benefit patients but no demonstrable link to the Wilkes classification was found.

No changes to current practice required.

3195 End of Life Care in ITU

C Graham, Consultant (Dr Makris, ST5 Anaesthetics)

Comparing end of life care in a 1 year period in Wycombe ICU with standards set by DoH and the Liverpool Care Pathway for the Dying Adult.




3196 Survey of Patients having Orthodontic Treatment and Facial Surgery

Miss Helen Travess, Consultant (Dr Helen Veeroo, Specialty Registrar)

Part of a regional audit being organised by Oxford to look at satisfaction and outcomes following orthognathic treatment using a nationally approved survey form.


15/03/2011 Complete 27/06/2011 Overall patients appear to be very satisfied with the treatment they have received. However, it appears that patients could be better informed about what to expect in the immediate post operative period. Patients would also benefit from more information regarding retainer wear and the importance of good compliance. Recommendations: A detailed verbal explanation of pre-surgical orthodontic treatment, proposed surgery and post-surgical orthodontics including retention should be given to all; the risks and benefits of all aspects of treatment should be discussed and this should be documented in the notes; all patients must receive relevant orthodontic and surgical information leaflets pre-operatively; all patients should be given the option of watching the BOS DVD on orthognathic surgery; consider the benefits of meeting patients who have previously had orthognathic surgery; all patients should be given the leaflet on post-operative care following orthognathic surgery; all patients should be seen by a dietician prior to discharge; the audit cycle should be repeated in 12-18 months to review compliance with current recommendations.

A detailed verbal explanation of pre-surgical orthodontic treatment, proposed surgery and post-surgical orthodontics including retention is given in our combined clinics by both orthodontists and surgeons; the risks and benefits of all aspects of treatment are discussed and documented in the notes in our combined clinics by both orthodontists and surgeons; all patients are given national leaflets at initial appointments and/or combined clinic; DVDs are loaned out at no charge and we ask patients to return them to the department - we have very good feedback from their use; meeting patients who have previously had orthognathic surgery is offered on a case by case basis, and is not something many patients ask for. The leaflet on post-operative care following orthognathic surgery was designed in Oxford where the patients have their in patient episode, so this is not under the control of this Trust; all patients should be seen by a dietician prior to discharge from their inpatient episode in Oxford so this is not under the control of this Trust.

3197 Management of children and young people 0 - 18 years with

C G Rastogi, Consultant, Dr Abhijit Mazumdar, Paediatrics

This audit aims to assess whether children presenting to emergency

Specialist Services

01/03/2011 Complete 28/02/2012 The key challenge of this audit in Buckinghamshire Healthcare NHS Trust was the identification of eligible cases which was particularly problematic perhaps due to the following factors: 1. Genuinely

No changes as not sufficient number of eligible cases (2).

decreased conscious level

departments and acute paediatric assessment units, with a decreased conscious level, are receiving the appropriate assessments, investigations and management in line with guidance issued by the Paediatric Accident and Emergency Research Group, 2005.

low numbers of eligible cases; 2. Possible difficulty in systematically identifying these patients because they fall into a multitude of diagnostic categories; and 3. Possible difficulty in managing the audit's data collection across two specialties (paediatrics and emergency medicine) which may have hampered engagement with the audit. Trust had only two cases, therefore no definitive statements on the management of children presenting with a decreased conscious level can be made. The Trust should consider a limited re-audit (six months afterthe dissemination of the audit's findings) of the management of children presenting with a decreased conscious level focusing on the following key areas: 1. documentation of the clinical history features; 2. documentation of the observations of heart rate, respiratory rate, blood pressure and temperature on presentation to hospital; 3. documentation of GCS measurements within the recommended frequency; and4. documentation of capillary blood glucose taken within 15 minutes of presentation to hospital.

3198 Neonatal Abstinence Syndrome

Dr Rupjani Banerjee, ST4, Paediatrics

To determine the number of newborns being scored for neonatal abstinence syndrome; the number of babies needing admission; criteria for admission; recovery time, admission and plan of management.

Specialist Services

20/03/2011 Cancelled 09/04/2012 Audit cancelled. Doctor left Trust without completing audit.

Changes required

3199 Audit of Hyponatraemia

Dr Ian Gallen, Consultant (Dr Alice Davenport)

Audit of the recognition, investigation and management of hyponatraemia. Are clinicians following the Trust guideline?

Integrated Medicine

18/03/2011 Complete 15/07/2011 The current hospital guideline gives advice regarding how to approach and further investigate hyponatraemia however the guideline lacks practical advice regarding the management of these results. It is possible that a management plan which included practical advice may have a greater uptake. Suggest revising the present guideline. In order for a greater uptake of current guidelines we would recommend incorporating teaching about the importance of recognition and further investigation of abnormal Sodium results into Junior Doctor teaching syllabuses and to widen knowledge of the existence of hospital guidelines through bulletins on biochemistry review systems and hospital communication systems (e.g. PMS).

Changes required

3200 National Colonoscopy Audit

Dr Sue Cullen, Consultant & Dr Ravi Sekhar, Consultant

This project aims to assess and record the quality of current colonoscopy practice in the United Kingdom. It is supported by the British Society ofGastroenterology and the Association of Coloproctologists of Great Britain and Ireland.

Integrated Medicine



3201 Hand Hygiene Observational Audit April 2010 to March 2011


Hand hygiene audits carried out on all wards monthly (audit 3107) and recorded in spreadsheet. To analyse spreadsheets to produce annual summary.

Specialist Services

01/04/2011 Complete 06/06/2011 Results: Overall, hand hygiene was carried out in 97% cases, an increase of three percentage points on the 2009/10 compliance of 94%. Compliance had increased for all staff groups since 2009/10. Compliance had increased for all situations since 2009/10. Compliance by ward/area varied from 79% to 100%. Recommendations: If the month‟s compliance level is below the recommended level then weekly audits must be completed along with an action plan. This must show how low compliance is being addressed. Areas of non participation throughout the year (not highlighted in this audit) should be addressed on a monthly basis. All hand hygiene results must be displayed at ward level for public information.

All recommendations have been completed and ongoing re-audit each month to ensure compliance remains high.

3202 Junior Doctors' Record Keeping Audit February 2011

Dr Graz Luzzi, Medical Director

Junior Doctors' Record Keeping Audit carried out by February 2011 intake.


3203 National Outpatient Survey 2011

National Outpatient Survey of sample of 850 patients seen in April 2011.

Trustwide 20/05/2011 Complete 16/08/2012 Scores similar to other Trusts. Several improvements since 2009. Not so many worse results. Actions: Access to the organisation has been assessed and the next steps will include

Changes required

implementing standardised processes, improving clinic utilisation and ensuring the best pathway for the patients. The surgical division have reviewed the slot utilisation and have increased capacity at Amersham hospital to provide additional ophthalmology clinics and have added an additional plastics clinic to assist with the increased demands on the service. The nursing staff are to work closely with the reception staff to ensure that any delays are communicated to the patient early and that patients are informed at each step of the process what the waiting time will be. The matron is to ensure that the cleaning plan is reviewed on a weekly basis and the department or shift leader is to escalate any concerns as soon as they become apparent. Medical Staffing to address improved explanation of tests and treatment at doctors induction. This will be picked up on induction of staff and the service standards cover staff being courteous to patients and ensuring that the patient knows who they are talking to and their role within the organisation.A quality check for patients leaving the outpatient department is to be introduced in order to ensure that patients leave the department feeling that they have all the information that they need and their visit has me their expectations. Medical team to explain to patients in clinic any changes in medication and the nursing staff to ensure that the patient understands before leaving clinic. Pharmacy team will ensure that patients that are attending the pharmacy to pick up their medication are provided with both a verbal and a written explanation about their new medication. ADO to review with admin staff to ensure patients receive copies of GP letters. Medical and Nursing staff to ensure that the patients are informed verbally and in writing for possible issues or complications that may arise from their condition in clinic. Nursing Staff to ensure that the patient is assured that they have all the information that they need prior to leaving the clinic by asking quality check questions. Matron and the department manager to ensure that staff are engaged in supporting patients with dignity and respect and that dignity champions are encouraged in the OPD area. Therapies are to take part in the patient experience feedback questionnaire in order to get live feedback to address any issues.

3205 Prolonged VTE Prophylaxis in High Risk Surgery

J Pattinson, Consultant, Haematology (Kabir Ahluwalia FY1, Surgery)

Audit to determine whether prescribing for DVT prophylaxis is meeting NICE recommendations for patients undergoing surgery for cancer, as well as orthopaedic (hip/knee replacement, major trauma and fractured neck of femur). This is part of rolling audit which is repeated each year.

Specialist Services

25/03/2011 Complete 21/06/2011 Results: Patients were being given appropriate in hospital prophylaxis whilst in hospital. The results for prolonged prophylaxis are disappointing with only 2 patients out of the 48 being provided with the appropriate therapy. There are a significant number of patients being given Aspirin as prolonged prophylaxis which is not within the recommendations as stated by NICE. There is a 4% risk of development of either Deep Vein Thrombosis or Pulmonary Embolism following the procedures audited.Recommendations: To speak to members of the Trauma and Orthopaedics team, including nurses and senior doctors to highlight the guidance suggested by NICE and advise on prolonged prophylaxis to be prescribed in future practice. Re-audit of April 2011.

Dr Pattinson spoke to members of the Trauma and Orthopaedics team, including nurses and senior doctors to highlight the guidance suggested by NICE and advised on prolonged prophylaxis to be prescribed in future practice. Re-audit of April 2011commenced.

3206 Audit of the Use of Flumazenil (BHNHST)

Dr Alister McIntyre, Consultant Gastroenterologist

The original audit was carried outfolllowing an NPSA alert regarding reducing the risk of over sedation in adults. Use of the reversing agent flumazenil was audited. Since the original audit new procedures have been implemented and this audit is to monitor their effectiveness.

Integrated Medicine

18/03/2011 Cancelled 04/08/2011 Cancelled - not applicable Changes required

3207 Iatrogenic Errors Associated With ICU Admission

J Graniewski, ITU Consultant (Dr Kumar Panikkar, ITU Consultant, Dr Olusegun Olusanya, ST4 Anaesthetics)

Six month study of iatrogenic events that have led to ITU admission at SMH.


30/03/2011 Complete 16/01/2012 Results: This was a comprehensive review to ascertain the incidence, type, severity and preventability of iatrogenic events leading to ICU admission in six UK hospitals: Royal Berkshire; John Radcliffe; Wexham Park; Stoke Mandeville; Milton Keynes; and Lewisham Hospital. The Stoke Mandeville arm of the audit showed that 26 out of 49 ICU admissions were associated with an iatrogenic event (53%). The average across all six ICUs was 29%, suggesting that Stoke Mandeville experiences a much higher incidence of iatrogenic events prior to ICU than other hospitals. There is a suggestion of increased mortality in the event group versus the non-event group. These findings are significant, and have been escalated to the Medical Director for further action.Recommendations: It is difficult to define a set of recommendations that will remedy this multifactorial issue. This audit demonstrates challenges to be faced across the board, from nursing staff to medical consultants. Education in the recognition of the critically unwell patient, adequate staffing numbers,

Critical Care Outreach was started on Aug 13th 2012. Adequate staffing numbers are an issue especially with the current reconfiguration. Intensive Care is consultant led as it is. All the other recommendations are the remit of the divisions of Medicine and Surgery. Reauditing will occur as part of the outreach data collection which has begun.

timely consultant reviews, the use of a Medical Emergency Response Team (MERT), improved handover- especially when discussing seriously ill patients on the ward, and improved communication between professional groups may all go some way towards remedying the situation. One of the highest recommendations is the implementation of some form of ICU Outreach service. This already exists in High Wycombe and has proved popular and effective. It may be that having a similar “track and trigger” system may lead to a reduction in the number of events, with a corresponding effect on patient mortality. A repeat of this study to encompass High Wycombe and Stoke Mandeville has been recommended by the Medical Director

3208 Re-audit of MUST (BHNHST)

Liz Pryke, Chief Dietitian

MUST was last audited at the end of 2008. As a trust we should be aiming to nutritionally screen all our inpatients and this is required to be reported as part of CQC standard 'Meeting Nutritional Needs'.

Specialist Services

30/03/2011 Complete 31/01/2012 Results: Improved compliance still needs to be achieved regarding the completion of the Waterlow Pressure Ulcer Risk Assessment Form as this is required to initially identify patients at risk of malnutrition. 19% cases at Stoke Mandeville Hospital and 36% at Wycombe Hospital did not have Waterlow Tool completed with 48 hours of admission. Where a Waterlow Tool has been completed, not all 3 trigger questions indicating whether a patient is at risk of malnutrition had been completed. However the question regarding BMI was answered in 77% of cases at Stoke Mandeville and Wycombe Hospital. Where indicated MUST forms are being completed in the majority of cases, however not all sections on the MUST form are being completed fully. The MUST action plan is not being recorded in the patients’ notes; only 3% cases at Stoke Mandeville and 3% cases at Wycombe Hospital stated that the MUST action plan had been recorded. Comparing results to 2009 MUST audit these results show some improvement in specific areas e.g. initial screening at SMH has improved from 72 to 81%, and weights recorded on MUST forms have improved on all sites. However in many areas this re-audit appears to have shown that little improvement has been accomplished since 2009, and also there is huge variation between wards.

Recommendations: 1) To disseminate audit results to nursing management to enable Associate Directors of Nursing to produce divisional action plans to address issues specific to their wards. 2) To continue with monthly training sessions for trained nurses, and also to target specific wards that may need further support. 3) To monitor MUST scores on an ongoing basis, results to be reported to Associate Directors of Nursing and the Trust Nutrition Committee on a quarterly basis.

Monthly traning sessions arranged. MUST scores reported at AND's and Nutrition Committee. Shift leaders check MUST and Waterlow charts to ensure compliance. Results of audit discussed with ward staff. Areas of good practice shared at monthly ward meeting. Sisters to ensure nutrition folders are kept up to date.

3209 Out of Hours Calls in Spinal Unit

Mr Belei, Spinal Consultant (Dr Malik, FY2)

To plan medical workforce and on call rotas and assess compliance with European work time directives.

Specialist Services

05/03/2011 Complete 10/06/2011 75% nights required intervention from junior doctor with average 87 mins/night. Junior doctors should be supervised and able to liaise with middle grade on-call doctor. Hospital at night team should be involved and develop close co-operation with ITU because many interventions related to ventilators. Workload increased by 20% since previous audit. Recommendations: Increase no. of junior doctors. Change rota to full shift. Negotiate with ITU to explore combined on-call cover.

All the recommendations have been discussed at the Acute quality improvement group NSIC, Medical staff committee meeting NSIC, Divisional board NSIC.Further discussion with the ITU CD at the NSIC medical staff committee will take place this month in order to finalize the rota & define the level of out of hours collaboration with the ITU. 2 new posts for Physician Assistants were created and are being interviewed.

3210 Audit of Third Degree Tear Following Spontaneous and Normal Vaginal Deliveries (SMH)

Mr Tunde Dada, Consultant, Obs & Gynae (Dr Han Wing Cheung, SpR)

A retrospective and prospective audit of the incidence of third degree tears following spontaneous and normal vaginal deliveries at Stoke Mandeville September 2010 - February 2011.

Specialist Services

07/04/2011 Complete 13/07/2011 Results: Incidence of perineal tears in SVD - 44/1801 = 2.4%. 63.7% Midwives had less than 5 years experience. 29.5% babies weiged more than 4Kg. Difficulty using risk factors to predict or prevent obstetric anal sphincter tears.

No recommendations made. Small sample and difficulty in using risk factors to predict or prevent obstetric anal sphincter tears.

3211 DNACPR Use in Surgery

Mr Arnold Goede, Locum Consultant, Surgery (Dr Chiraush Patel, FY1, Surgery)

To assess the quality of uptake and implementation of DNACPR orders on surgical/T&O wards and nursing attitude towards it.


08/04/2011 Complete 26/07/2011 Recommendations: resuscitation status should be considered and documented on ALL patients on admission to the hospital; add DNACPR section to the PTWR sheet; decision made by consultant on the PTWR; communicate decision to other healthcare members, patient and family; educational sessions on resuscitations; re-audit.

The recommendations have been followed. The presentation and the audit are on our server to be available to future incoming trainees, and are part of the induction process.

3212 Critical Care Point Prevalence Audit 2011

Jenny Ricketts, Outreach Lead Nurse, Deputy Matron, Critical Care

Re-audit of point prevalence Trust wide, taking place on 11th and 12th April 2011.

Trustwide 11/04/2011 Complete 01/06/2011 1. The Critical Care Delivery Group must implement all elements of NICE Guideline 50 as a priority. 2. Trained nurses and Ward Managers to be accountable for implementation of Trust standard for observations (clinical guideline 26). 3. Improve compliance with completion of EWS for all patients through mandatory training. 4. Complete critical care bed modelling work. 5. Amend audit tool to include audit of fluid balance chart accuracy, respiratory rate and oxygen administration, in addition to audit of observation compliance against Trust standard. 6. Develop a Trust wide strategy to ensure patients who trigger EWS of 4 or more are assessed by personnel with core competencies to manage acute illness as recommended by NCEPOD 2005.

The BEACH course is well attended. Productive Ward carries out observations audits on all wards and shows that there is a slow improvement. Oxygen training is underway. The business case for Outreach at Stoke Mandeville is again going out for approval. Audit of Iatrogenic Errors associated with ICU admission shortly to be reported. Re-audit of point prevalence is scheduled for April 2012.

3213 Appropriateness of Red Cell Transfusion at Wycombe Hospital December 2010 - February 2011

Mr Andrew Huang, Consultant, General Surgery (Catherine McGlennan, FY1, Surgery)

To assess whether red cell transfusions given between December 2010 and February 2011 were compliant with hospital and national guidelines.


12/04/2011 Complete 28/09/2011 90% of transfusions were justified. Recommendations: improve education to junior doctors to ensure that they a) re-check haemoglobin values in patients who have an aberrantly low haemoglobin with no cause and b) check a post transfusion haemoglobin at intervals throughout the transfusion to avoid over-transfusing stable patients receiving multiple units of red cells; clarify Buckinghamshire Healthcare NHS Trust guidelines of when to transfuse the bleeding patient, who is not compromised and is sustaining their haemoglobin.

In terms of education to junior doctors, a presentation was made at a grand round on 29 September 2011 to inform the junior doctors of the results of the audit and the transfusion protocol that should be adhered to. Dr Watson, Consultant Haematologist incorporated audit findings into the transfusion department annual report.

3214 Trial of an SLT Outcome Measure for Stroke Patients

Elizabeth Fraser, Acute Clinical Lead, SLT

Acute SLT teams used Functional Oral Intake Scale (FOIS) with stroke patients over 2 month period to identify improvements in oral intake.

Specialist Services

01/11/2010 Complete 11/04/2011 FOIS suitable for stroke patients. To be implemented on stoke units at WH and SMH. SLT team to investigate alternative outcome measures for other medical conditions. Acute clinical lead to implement guidelines for Dysphagia Trained Nurses and to develop outcome paperwork for them to complete.

FOIS is now part of an Acute Stroke Pathway Outcome measure that SLTs are completing for Stroke patients across both sites.The team identified Malcolmess Care Aims as a potential outcome measure for the general medical patients on the SLT caseload. This was trialled over the summer and agreed at the most recent team meeting in October to be effective and useful. The acute team are now completing these care aims as an outcome measure for all other patients.Dysphagia Trained Nurse (DTN) guidelines were developed and submitted to the Nursing and Midwifery

Board for approval. Unfortunately these were not approved so at the moment there is no further progress with establishing DTNs with up to date training and guidelines. We are continuing to reveiw this situation.

3215 Assessment of Visual Impairment in Patients Admitted with Falls

Dr C Yau, Consultant, MFOP (Dr Zuzanna Sipkova, FY1, General Medicine)

Multifactorial assessment of patients admitted to hospital with falls should include visual impairment assessment. Vision assessment and referral is an important component of a successful falls prevention programme.

Integrated Medicine

12/04/2011 Complete 27/07/2011 Updating the examination part of the medical clerking proforma to include a section on testing visual acuity. Improving availability of Snellen charts on the wards and A&E, especially hand-held Snellen charts that could be brought to the bedside for testing visual acuity in elderly patients with mobility issues. Development of Buckinghamshire Hospitals “Falls Guidelines” for patients admitted with a fall aimed at doctors. The currently used “Falls Care Plan” is aimed mainly at nursing staff and it is written for prevention and management of falls in hospital.

A new Trust guideline 683.1 How to Measure Visual Acuity (VA) using the Snellen Chart has been introduced. This has improved the availability of Snellen charts on the wards. Trust policy 197.2 Prevention & Management of Patient Slips, Trips and Falls includes a section on vision.

3216 An Audit of Operation Notes: Time to Change to a Computerised Form?

Mr G Biring, Consultant, T&O (Dr Anantharaman Ramasamy, FY1, General Surgery)

To ascertain our clinical practice regarding writing operation notes. Legible, complete and contemporaneous operation notes are a professional and legal requirement.



15/07/2011 Surgeon education through meetings. Problems identified: omission of important information, illegible hand written notes. Recommendations: Use of a proforma - computer generated template, aide-memoire - check list for surgeons and encourage computer typed operation notes. Re-audit.

Changes required

3217 Intraoperative and Post Operative Complications of Tension Free Vaginal Tape Insertion

Mr Ian Currie, Consultant, Obs & Gynae (Dr Han Wing Cheung, SpR)

To assess the intraoperative and postoperative complications of tension-free vaginal tape insertion, and length of hospital stay. To assess the feasibility of carrying out this procedure as a day case.

Specialist Services

28/04/2011 Cancelled 01/05/2012 Audit cancelled. Doctor left Trust without submitting report.

Cancelled.

3218 Audit of Discharges Resulting in Complaints

Elizabeth Hollman, Associate Director Healthcare Governance

To assess the discharges of patients that subsequently resulted in complaints. To ascertain whether improvements can be made to the discharge process.

Trustwide 15/04/2011 Complete Results and Recommendations required Changes required

3219 Mortality Review October 2010 - March 2011



Trustwide 21/04/2011 Complete 12/10/2011 Medical Director and Associate Director Healthcare Governance (ADHG) to review the 1 potentially avoidable death and 4 deaths which were not expected. Iindependent consultant to confirm the assessment that death was potentially avoidable or not expected in the cases identified. If the final assessment is death was probably avoidable then these should be investigated as Serious Incidents. Medical Director to remind all consultants about the timely review of patients, the need to obtain investigations without delay, appropriate supervision of junior doctors and documentation. Director of Infection Prevention & Control to remind all staff about the need to use VIP charts. Associate Directors of Nursing (ADNs) to review the actions put in place to improve the use of the Early Warning Score and fluid balance management. Continued focus on reducing harm from falls and pressure ulcers as part of the Safety Express programme. To continue the 6-monthly mortality reviews and submit the audit reports to the Risk Monitoring Group for monitoring and action.

The review of the 1 potentially avoidable death and 4 deaths which were not expected concluded that no deaths were avoidable. Ongoing 6-monthly mortality reviews are being carried out.

3220 Paediatric Occupational Therapy Resource Pack

Emma Parry, Service Innovation Manager; Catriona Johnstone,Team Lead for Wycombe Paediatric Occupational Therapists

A survey carried out on a random sample of parents to get their views on a newly introduced resource pack for use with children prior to their first OT assessment, in order to make amendments before continuing with another print run.

Specialist Services

14/04/2011 Complete 04/11/2011 Only 17/100 questionnaires were returned. Many of the comments related to the fact that although the resource pack could possibly be useful it was no substitute for being able to see an OT specialist who could give specific advice on their child. The Occupational Therapy service has reduced the length of the time waiting from referral from 2 ½ years to 18 weeks. Some children were sent a Resource Pack following having waiting for an assessment for 2 plus years. Therefore initial problems with parents being dissatisfied with receiving a Resource Pack in place of an assessment is no longer an issue. No complaints are received now as Resource Pack are sent out in timely manner following referral. Recommendations: Occupational Therapist to deliver training sessions on how to use and implement activities from Resource Pack to cluster of schools. All schools to have a named therapist who visits 2 hours termly to discuss any issues school have and offer advice. A second Resource Pack will be introduced aimed at children over 10 years old. To amend Occupational Therapy terminology within Resource Pack.

All mainstream school in Bucks have received invitations to the Universal Training on the Resource pack. We have delivered 9 talks since September which have been well attended. All mainstream schools in Bucks have been offered School Advice Clinics, there has been a significant take up and all interested schools have received termly visits from their link therapist. There have been many compliments about these. The Resource pack for Older Kids has been compiled and is awaiting printing. It will then be distributed in response to appropriate referrals received. Amendments to Resource Pack have been completed.

3221 NCEPOD Bariatric Surgery Study

TBA A NCEPOD study looking at Bariatric Surgery (e.g. gastric bands, gastric bypass).


01/04/2011 Complete 18/10/2012 Report published: http://www.ncepod.org.uk/2012bs.htm

Changes required

3222 BTS Non Invasive Ventilation (Adult) Audit 2011

Dr A Prasad, Consultant, Respiratory Medicine (Dr Shivani Kochhar, FY1, Medicine)

A national audit by the Britsh Thorasic Society (BTS) looking at patients treated with non invasive ventilatioon outside ICU. Comparing care received with the standards of care set by the BTS.

Integrated Medicine



3223 VTE Prophylaxis in the Urology Patient

Neil Haldar, Consultant, Urology (Dr Natalia White, FY1, Urology), Jonathan Pattinson, Consultant Haematologist

To audit adherence to clinical guidelines on VTE prophylaxis risk assessment and prescription.


05/05/2011 Complete 05/09/2011 Initial audit results: 50 patients’ case notes were reviewed. Only 12% of inpatients were treated in a way that was fully compliant with NICE guidance. Recommendations: Deliver verbal and written teaching & guidance to the current clinical team. Devise a useful clerking tool that prompts VTE risk assessment, incorporates a VTE risk assessment form, and prompts the prescription of prophylaxis. Reaudit Sep 2011.

Presentation of audit at M&M meeting (June). Induction presentation given to new FY1s (August).Informal guidance given on the wards (August) Creation of guidance sheet on ‘routine’ prophylaxis for urological conditions and procedures according to typical VTE and bleeding risks.Audit data, recommendations and reminders emailed to nursing staff, junior and senior doctors (August).Creation of induction material for use by FY1 doctors when new to urology. Creation and distribution of an integrated urology emergency admissions clerking proforma containing a VTE form.

3224 Traumatic Limp in Children/Transient Synovitis

Dr Atanu Dutta, Consultant, Paediatrics, (Katherina Kastrissianakis, ST1)

A retrospective review of case notes of children presenting with a traumatic limp, looking at assessment and management of this and presenting complaint, and how it compares with recommendations found in the literature.

Specialist Services

05/05/2011 Complete 17/11/2011 The main recommendation is that a guideline should be produced for the management of children presenting with a non-traumatic limp. 1. Pelvic X-rays should be used more selectively in children presenting to our unit with non-traumatic limp (e.g. to rule out SUFE in >9 years of age, to rule out NAI in children < 3years, if there is bony tenderness on examination, to rule out Perthes if the history is prolonged). 2. If concerned about a hip effusion (i.e. septic arthritis or transient synovitis), a hip ultrasound should be the first line investigation and not a pelvic X-ray. 3. Improvements could be made in the documentation of examination findings such as gait, hip examination, and abdominal examination.4. Normal inflammatory markers do not rule out septic arthritis. 5. Should we follow-up all children presenting with non-traumatic limp? What is the best timing and pathway for follow-up? 6. Should we send an ESR in

No changes recevied as Junior doctor now not with the Trust 21/3/13 (CP)

addition to CRP and FBC when checking inflammatory markers

3225 Cardiovascular Morbidity in Rheumatoid Arthritis

Jane Reeback, Consultant Rheumatologist (Dr Kuljeet Bhamra, SpR, Rheumatlogy)

To assess whether patients with RA are being assessed for CVD and whether they are treated appropriately as per EULAR guidelines.

Integrated Medicine

08/05/2011 Analysis/Report


3226 Audit of End of Life Care in the Division of Surgery

Karen Brown, Divisional Manager Surgery. Celina Eves, Associate Director of Nursing Surgery.

To assess patients who died as inpatients under the Division of Surgery between 01/11/2010 and 30/04/2011 against the EOL template.


13/05/2011 Complete 03/05/2012 1. For all surgical patients identified as requiring end of life care that they are commenced on the Trust’s ICP as soon as possible to ensure the care is appropriate and individualised. 2. Once the ICP has commenced all aspects of the goals are reviewed and actioned by the medical and nursing teams. 3. Excellent communication with the patient and their family is continued and assessed to ensure the correct care planning is in place. Action Plan: Training in the introduction and use of the Integrated Care Pathway for end of life care to ensure that medical and nursing staff have update sessions to access throughout the year. Repeat audit planned for early 2013.

Emailed to John Clark, new interim Associate Director of Nursing, Surgery as Celina and Karen have both left. 7/2/13 (LS). John Clark emailed back 22/2/13 to say he has passed matter on to new Associate Director of Nursing Surgery Carolyn Morrice as he has now left the interim post. (LS).

3227 Management of Shoulder Dystocia (continuous)

Miss Hall, Consultant, Obs & Gynae (Zoe Barber, FY1 and Rhiannon Darcy FY1)

To follow up previous audit and compare performance to NICE and Trust guidelines. (Previous numbers 2270, 2354, 2960).

Specialist Services

16/04/2011 Complete 01/06/2011 Results - 60 patients audited. 13 did not have a shoulder dystocia proforma filled in. 18 patients had a shoulder dystocia proforma completed but did not have shoulder dystocia listed as a delivery complication in the delivery book. Delay between head delivery and shoulder delivery documented in 100% cases. 2.91 minutes average time delay (range 1 - 11 mins). Recommendations - All patients with shoulder dystocia must have a proforma filled out and listed as a complication in the delivery book. The whole of the proforma must be completed accurately, particularly suspected fetal injury, incident reporting and discussion with parents.

On going CNST audit now under 3524 20/2/13 (CP)

3228 Management of Hypertension in Pregnancy against NICE and Trust Guidelines

Nutan Mishra, Consultant, (Lisa Procter) Obs & Gynae

An audit of the management of hypertension in pregnant patients. Prospective audit of about 50 patients between April and June 2011.

Specialist Services

01/04/2011 Complete 01/06/2011 Audit results showed improvement since last audit in use of MEWS chart; discussion with obs consultant and in involving paediatricians in delivery decisions. It found room for improvement in documentation - use of proforma to identify severe criteria and management; fluid balance and restriction; checking for reflexes and clonus; use of MgSO4 prophylaxis.

On going CNST audit repeated in 2012 CP 21/2/13

3229 Audit of Operative Vaginal Delivery (continuous)

Veronica Miller, Consultant, Obs & Gynae (Heather Counsell, ST1)

A continuous audit of operative vaginal deliveries. Required for CNST. (Previous numbers 2749/50, 2961)

Specialist Services

01/05/2011 Complete 01/06/2011 Results June 2011: Strong preference for Neville Barnes forceps, operator dependent. Little evidence of adequacy of analgesia. Episiotomy 79%. The rate of instrumental deliveries is above national levels. Documentation is a key area for improvement - requires accurate and full completion. Proforma requires updating to meet audit criteria.

CNST requirement to complete continuous audit of all cases 21/2/13 CP

3230 Audit of the Management of Ectopic Pregnancy

S.A. Akinsola, Consultant, Obs & Gynae (M. Sadik Haleem, SpR)

An audit to measure the proportion of tubal pregnancy cases managed laparoscopically, January to December 2010. (Previous audit numbers 2131, 2133).

Specialist Services

31/05/2011 Cancelled 07/09/2011 Cancelled. Dr has left Trust and audit never started. Project cancelled.

3231 Copying of Letters to Patients Survey

Dr G Luzzi, Medical Director

A survey of practice in relation to copying patients into clinical letters.

Trustwide 10/05/2011 Complete 20/05/2011 Dr Luzzi to use the results to inform discussions on copying letters to patients.

Changes required

3232 Audit of Management of Pelvic Inflammatory Disease

Tunde Dada, Consultant, Obs & Gynae (Arass Ahmed FY1, Louise Cripps, FY1)

Audit of Management of PID against RCOG guidelines (Greentop Guidelines 32).

Specialist Services

30/05/2011 Complete 13/07/2011 18 cases over a period of seven months Dec 2010 - June 2011. 14 admitted for PID. 4 attendances at AE from May to June 2011. All seen by gynaecology team. 2 were initially referred to surgical team from A&E for appendicitis. All had abdominal pain/tenderness. Under diagnosed/Missed cases or low rate of PID. Poor documentation in majority of the cases. Incomplete clinical examinations. Not aware of/not following the guidelines. Five admissions could have been avoided. Recommendations: Juniors to be more aware of PID and the relevant guidelines. Suggest including this topic in the induction programme. Use of a proforma for clerking patients with PID. Re-audit once above implemented.

No chnages forthcoming, to be reaudited in 2013 by another junior 21/2/13 (CP)

3233 Post Take Ward Round Documentation

Dr Syed Hasan, Consultant MFOP (Dr Anthony Dimarco, CT2, Medicine)

To asses the completeness of documentation of information on the post take ward round proforma

Integrated Medicine

19/05/2011 Complete 27/07/2011 Areas of strength and weakness have been indentified through this audit. Although documentation of patient data met the standards, the time of the encounter was not well documented. Considering there are government targets linked to this then this is an area which needs to be improved. Other areas for improvement are investigation findings and completion of tick boxes to assist the team that take over the care of the patient. Following feedback at the Medical Grand Round it was decided to make a concerted effort to improve documentation. If this approach fails then modifications to the proforma may be required.

Changes required

3234 Intrathecal Opioids Dr Hans Mathew, Associate Specialist, Anaesthetics, Mary Miller, Lead Nurse Pain Management (Dr Dana Kelly, ST5, Anaesthetics)

To determine current practice relating to the timing of administration of systemic opioids after intrathecal opioid with the aim of producing formal guidance.


19/05/2011 Complete 25/07/2011 Recommendations:all patients who have received intrathecal opioids should have naloxone prescribed on drug chart (if not already prescribed on a PCA chart); consider formal published guidance relating to the use of intrathecal/ epidural opioids (to be available on the hospital intranet); consider reducing dose of opioids and increasing frequency of monitoring in high risk groups - this could be altered on the new sticker easily (i.e. writing half hourly instead of hourly observations); suggest a review of current IT opioid stickers.

Intrathecal (Spinal) Opioid Guidelines for Adults are being developed.

3235 National Parkinson's Audit 2011

Dr Syed Hasan, Consultant MFOP

This is a national audit designed to help Trusts evaluate their Parkinson's service against the NICE Guideline and National Service Framework for Long Term Neurological Conditions, compare their Parkinson's service to others around the UK, highlight strengths and weaknesses in current service and develop an action plan to improve services.

Integrated Medicine



3236 Audit on the Management of Hyperglycaemia in ACS Patients

Dr Firoozan, Cardiology Consultant (Dr Catherine Hildyard, FY2, Medicine)

Assessment of the proportion of patients with ACS, with documented hyperglycaemia, that are started on an insulin sliding scale, in accordance with guidelines.

Integrated Medicine

20/05/2011 Complete 14/11/2011 It was felt that poor performance in commencing lipid and glucose lowering therapy are likely to be due to lack of awareness of guidelines. In particular, lipid lowering therapy was previously not felt to be an important part of in hospital management, and was therefore left to the patient's GP to start; however there is increasing evidence to suggest the benefits of starting a stain immediately afar an ACS event. Recommendations: Draft a new ACS clerking proforma, witha management pathway advising initiation of lipid and glucose lowering therapy. This will also allow specific areas of weakness to be highlighted in teaching sessions.

A new ACS clerking proforma has been introduced which includes a management pathway advising initiation of lipids and glucose lowering therapy.

3237 Distal Finger Tip Injuries in Children

Mr Heywood, Consultant, Plastic Surgery (Roman Mykula, SpR, Plastic Surgery)

Retrospective survey of surgical treatment and outcomes of distal fingertip injuries in children aged 12 and under from January to June 2010.


24/05/2011 Complete 12/01/2012 This survey included 52 injured digits in 50 children aged 12 and under. Data was collected on the mechanism and nature of the injury, the operative details and the outcome of surgery. The data was presented in the June 2011 Plastic Surgery RITA Day and was combined with data from Oxford, Salisbury, and Plymouth. No recommendations for change were recorded.

No recommendations for change were recorded.

3238 Skin Cancer Patient Experience Survey

Rubeta Matin, Specialist Registrar, Dermatology, Fiona Briggs, Skin Cancer Clinical Nurse Specialist, Dr Katharine Acland (MDT Lead)

To determine the effect of the introduction of the CNS Skin Cancer Clinic on patient experience regarding being given a diagnosis of SCC or Melanoma. Survey of all patients seen in the Skin Cancer Clinic from 1 Jan to 30 June 2011.

Specialist Services

17/05/2011 Complete 06/02/2012 Recommendations: all SCCs, melanoma and high risk lesions should continue to be flagged for histology as urgent; all patients should be advised that histology results can take 4-6 weeks before patients will be informed – this has been amended on the patient information leaflet; specimens sent to another Institute for a second opinion can result in a delay which can increase anxiety – this needs to be detailed in the patient information leaflet; a clear plan should be in place so that patients receive their result / appointment in a timely manner; all patients with biopsy results outstanding will be advised that they will receive an appointment to be given the diagnosis. This ensures that patients with a diagnosis of a cancer will be seen face-to-face. If the lesion is benign/BCC a letter will be sent; patients must be given appropriate preparation at the time of first referral and/or time of surgery so that their expectations can be managed; there are times when it is still appropriate, however, to give a diagnosis of a low risk skin cancer (including BCCs) by post or over the telephone providing that this is followed up with written information and an offer to discuss the diagnosis face-to-face; patients should be given a telephone contact number (Cancer Nurse Specialist) as a point of contact once a skin cancer is diagnosed or at the discretion of the doctor at the point of initial referral; all patients should be clear when given the diagnosis what the ongoing plan for care involves and this may require additional written information; consider review of the cause of breech in individuals when this occurs; rescheduling of appointments due to hospital factors e.g. absence / leave / cancellation of clinics need to be discussed with management regarding the possible options to reduce this.

Managing patient expectation: Patient leaflet has been amended. Repeat survey has been completed - except for action plan.Breeches: 2 trackers have been employed to investigate.Rescheduling of appointments: When skin patients are seen by dermatology and have their lesions removed they are automatically given an appt for follow up usually for 6 weeks. If the lesion proves positive then this appt will be altered i.e. brought forward.Patient Information: Along with the network we currently issue the Macmillan information booklets - we are waiting for the go ahead with Skin information prescriptions.Histology 2nd opinion: Tracking system is in place; a report issued immediately stating that lesion is possibly malignant and has been sent for second opinion; case added to next MDT list so that MDT can monitor.

3239 Prescription of Intravenous Fluid and Electrolytes in Emergency Surgery

A Goede, Consultant, Surgery (Robin Spacie, FY1, General Surgery)

Prospective audit of fluid prescription and administration in emergency surgery, based on British Association for


23/05/2011 Complete 12/09/2011 Results: The audit shows a clear need for better fluid prescribing for adult emergency surgery patients as no audit standard was met. The audit did show some improvement in prescribing following teaching but the difference was lower than expected. Possible reasons for this are that the session was

Teaching sessions have taken place and a re-audit is planned.

Parenteral and Enteral Nutrition (BAPEN) guidelines: British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients.

fairly short and was delivered near the end of the FY1 year when it may be difficult to change prescribing habits amongst doctors. Also, whilst a handout was provided there was no post teaching assessment of knowledge to ensure that knowledge had improved and hence provide extra help as needed. Recommendations: Fluid prescribing by junior doctors needs to be improved, and this can be done through teaching sessions. In future, doctors starting their surgery rotation should be taught best practice fluid prescription based on the national guidance. The ideal time for this would be before they start working in the department so should form part of their departmental induction, or occur during induction week in August prior to starting work. Once this recommendation is implemented it will be necessary to re-audit practice to ensure prescribing is improving.

3240 Management of Multiple Pregnancies

Aparna Reddy, Consultant, Obs & Gynae (Anne Beh, FY2)

Review of notes to audit the management of multiple pregnancies - antenatal, intrapartum, second and third stage care, to assess compliance with Trust and CNST guidelines.

Specialist Services

09/05/2011 Cancelled 03/08/2011 Cancelled, audit never carried out. Doctor now left the Trust.

Project cancelled

3241 Staff Questionnaire to Evaluate HPV Information Sheets

Cathie Hansen, Colposcopy Nurse

Smear test from January 2012 will incorporate HPV test to identify whether any HPV infection is high or low risk for cervical cancer. Results will affect necessity for recall.

Specialist Services

24/05/2011 Complete 06/10/2011 Action Plan: Rewrite leaflet to give clearer explanation of what a positive HPV test means to an individual patient. Avoid repetitive statements. Include a flow chart to simplify the new protocols

The National Guidelines have been withdrawn as they have changed from the original concept.The information leaflet would not now be correct and new guidelines are not yet agreed.

3114 Surgical Site Infection Pre-op and Peri-op Audit - Spinal


Observational audit spinal only.


01/12/2010 Complete 31/05/2011 3/10 patients were not screened for MRSA pre-op when they should have been. Peri-op: The WHO surgical checklist was undertaken in 100% of cases. Within New Wing Theatres prophylactic


antimicrobials were administered in line with Trust antibiotic guidelines. However on discussing the regime with the cystoscopy unit, it was clear that they are not following the guidelines correctly. Ciprofloxacin is being given on induction. 1 patient had hair removed by shaving. All hair must be removed using clippers not shaving. It is unclear if the glucose monitoring and normothermia should have been maintained or if it was‘not applicable’. Staff should be reminded to complete the form correctly by ticking the appropriate column. All areas with non participation must produce an action plan on how they are monitoring thecompliance with this audit. Areas who did not produce an action plan must produce an action plan to show how areas of non- compliance have been addressed. All areas with ‘No’ answers are required to sign off this action plan to confirm all actions have been completed and then return to the IPC.

3242 Audit of Management of Alcohol Withdrawal (WH)

Dr David Goddard, Consultant Gastroenterologist (Dr Michael Pavlides, SpR, Gastroenterology)

Are patients being assessed and treated in line with Trust guidelines.

Integrated Medicine

03/06/2011 Complete 20/10/2011 Recommendations: Poor adherence to guidelines for treatment of alcohol withdrawal. Patients discharged too soon without completing their detox. Vernicke’s encephalopathy not sought and only 50% of at risk patients receive pabrinex. Coding not accurate. Recommendations: Educate medical and nursing staff. Make guidelines more easily available via posters, printed CIWA sheets in clinical areas, reminder on clerking proforma. Alcohol assessment team need to identify Themselves to medical and nursing staff. Annual re-audit

Changes required

3243 NAPA Guidelines Assessment: Airway and Aspiration

Dr J Drake, Dr Ramaswamy, Consultants, Anaesthetics (Dr J Hughes, SHO, Anaesthetics)

Assessment of whether or not a formal complete airway assessment and aspiration assessment has been completed.


03/06/2011 Complete 18/10/2011 Recommendations: Training of the juniors. Emphasis on the importance of pre-assessment and subsequent documentation. Improve the anaesthetic chart. Re-audit.

An academic morning in May was devoted to a department airway teaching for all anaesthetists.We already carry out training for novice anaesthetists in the Trust and are aiming to include something regarding airway training in their induction programme. Regarding documentation, there is a new anaesthetic chart in the pipe line, a specific one for obstetrics is already in circulation, with a formalised airway assessment to be completed by the anaesthetist. Re auditing will take place once this chart is in circulation

3244 Antenatal blood screening against CNST, NICE and Trust Guidelines

Miss Aparna Reddy, Consultant, Obs & Gynae, (Kirstie Kinross, FY1)

An audit of antenatal screening for infections, i.e. HepB, C, HIV, rubella, syphilis. To check whether all women are offered screening and, if found positive, were they correctly managed. Retrospective audit for March 2011.

Specialist Services

06/06/2011 Complete 13/07/2011 Results: 1. HepB - 346 births, 1 positive HepB, correctly managed. Random sample of 52 patients checked and no other cases identified. 2. No record of any HIV positive patients found in birth register, none identified in random sample of 52 patients. 3. No record of any negative rubella immunity status patients in register and none identified in random sample. 100% women/babies being offered screening within 13 weeks. Recommendations: Patients with rubella susceptibly have been identified by ante-natal blood test. Unfortunately, no result to cross reference with the lab. No clear documentation if MMR being offered post-natally, refused or advice sent to GP. Recommend rubella ante-natal audit and evidence of regular training on screening for staff.

No changes forthcoming as junior doctor now left. Audit to be repeated in 2013 21/2/13 (CP)

3245 Audit of Exenatide NICE Compliance

Dr Henrietta Brain, Consultant, Diabetes & Endocrinology (Maire Stapleton, Formulatory Manager)

Audit of approx 20 patients to ascertain whether NICE initiation and continuation criteria are met.

Specialist Services





Specialist Services

01/05/2011 Complete 10/08/2011 There was one instance in St George’s Ward where hand hygiene was not performed prior to the procedure. In all other cases there was 100% compliance. This equates to an overall compliance for all applicable elements performed of 99%. This is better than in all previous years.

No changes required. Re-audit next year.



To evaluate results of High Impact Intervention (HII) 5 tool used in Saving

Specialist Services

01/05/2011 Complete 28/11/2011 Results: 99% compliance for all elements for urinary catheter insertion. 94% compliance for urinary catheter continuing care. Recommendations: Ensure all areas with non participation complete the

All actions have been addressed and the audit form has been updated.

Lives Infection Control programme.

audit within their area and address any issues highlighted by producing an action plan detailing how they are monitoring the compliance with this audit.Ensure that all areas who did not produce and return an action plan at the time of completing the audit now produce an action plan to show how areas of non- compliance have been addressed.Ensure all areas with ‘No’ answers sign off this action plan to confirm all actions have been completed and then return it to the IPCT.Adapt audit tool to make it clearer how to respond.Future audits should record the staff group of the individual carrying out the urinary catheter insertion. This should be added to the audit tool. The Urinary Catheter Assessment and Monitoring Form tool has successfully been piloted in specific areas and will be introduced across the Trust following ratification. The form acts as a prompt to inform practice and should be integrated into individual staff group training sessions and updates including Infection Control Link Practitioner days, HCA Induction and Nurse Development and update days.

3248 Environment, Kitchens, Patient Equipment Infection Control May-Jul 2011


To audit cleanliness, infection control etc in all environments and equipment in all areas of the Trust.

Specialist Services


3249 National Paediatric Diabetes Audit 2010 to 2011

Dr A Dutta, Paediatric Consultant, SMH, Dr M Russell-Taylor, Paediatric Consultant, WH


Specialist Services

08/06/2011 Complete 28/09/2012 To be added. File on website damaged, cannot read.

Changes required

3250 Perioperative Management of Diabetes Mellitus in Elective Day Surgery Patients

Dr P Strube, Consultant Anaesthetist (Dr Matthew Brown, FY1, Anaesthetics)

An audit to investigate perioperative optimisation of blood sugar and adherence to perioperative measures in diabetic patients.


08/06/2011 Complete 31/10/2011 None of the audit standards were met. Recommendations: Raise awareness of local protocol and national guidance with regard to perioperative management of diabetes. Check HbA1c on all preoperative diabetic patients to assess stability of disease. Perform urinalysis on all diabetic patients admitted for day case surgery. Prioritise diabetic patients on the operating list to limit starvation times. Ensure regular perioperative blood glucose measurements as per guidance, to enable identification and treatment of hypo or hyperglycaemia.

Changes required

3251 Audit of management of incomplete/missed miscarriage

Chris Wayne, Consultant, Obs & Gynae (Dr Will Gray, FY1)

An audit of management of patients who present to EPAU with miscarriage. Are ultrasounds requested appropriately and what proportion of patients subsequently have confirmed, incomplete or missed miscarriage? Against EPAU and RCOG Greentop guidelines.

Specialist Services

24/05/2011 Complete 13/07/2011 Results: On the whole the Unit functions very effectively for such a busy unit. Record keeping is on the whole excellent, and information readily available. Referral criteria by and large are met. Recommendations: 1. To discourage patients being permitted to self refer, as many could perhaps be filtered by Primary Care. 2. To be stricter on meeting criteria for scans, especially those with a hx of recurrent miscarriages. 3. To re-audit in the future, ? a prospective audit looking at the management of missed miscarriage and what percentage of those receiving conservative tx go on to have heavy PV loss -> ERPC.

Re audit completed in Nov 2012 21/2/13 (CP)

3252 National Oesophago-Gastric Cancer Audit (NOGCA)

Maureen Kiely, Clinical Nurse Specialist, GI Cancer

This national audit has now been reopened collecting data on all patients diagnosed from the 1st April 2011onwards.

Integrated Medicine



3253 NSIC Family-Centred Care Staff Survey

Dr Alison Graham, Consultant, NSIC

A survey to assess staff understanding of the NSIC as providing "family-centred" care.

Specialist Services

13/06/2011 Complete 26/09/2011 Organisational change: 1. Develop action plans to advance the practice of patient- and family-centred care and create sustained organisational and cultural change. 2. Apply patient- and family-centred principles to policies, programmes, environmental changes, staff practices, and professional education. 3. Facilitate and enhance collaboration with patients and families across disciplines and settings. 4. Develop or revise methods for gathering information about patients’ and families' perceptions of care. Staff development and professional education: 5. Conduct training programmes on best practices and innovations in patient- and family-centered care. 6. Create partnerships for quality and safety. 7. Develop peer support and family-to-family support. 8. Integrate patient- and family-centred concepts in staff education. Environmental review: 9. Review projects for consistency with patient- and family-centred principles and strategies. 10. Involve patients and families in planning processes. 11. Review planning documents, plans, concepts for interior finishes, furnishings, and decor to meet the overall goals and needs of all users.

1. A multidisciplinary quality improvement group has been set up to review patient and family centred care for both the paediatric and the adult service. This meets monthly and reports to the Quality Improvement Group overal,l as identified by our CARF recommendations which reports to Divisional Board. 2. Ongoing- family room and quiet room have been changed to enable more families to access them. We are reviewing the PFCC agenda as part of the Kings Fund initiative to improve family invovlement in the ward round process. Family education is being supported by the development of an education channel. 3. Pilot of family involvement in structurd format for Dr Graham adult and paed ward rounds. 4. Use exisitng experience - data- productive ward, relatives' day and patient experience data needs to be reviewed by more members than current rehab lead. Family Counsellor to establish coffee mornings for informal review. 5. Training programmes being introduced on a bedside model around 1 consulatnt ward round to pilot invovlement. 6.Partnership still needs further development- need more input- plan is to start with work

around medication and then review use. Paediatric medication sharing knowledge in first instance but will use this with adult population. 7. Family coffee mornings, sibling workshops and spin group for networking and suggestion sharing with clinical staff. Family week activities for social events. 8. Work with practice development nurse and also with medical education to ensure family considered in all areas of work- sample audit. 9. Education channel is to be used as a major scheme for family involvement.

3254 Management of Soft Tissue Infections

Mike Tyler, Consultant, Plastics (Sophie Dann, ST3, Plastics)

An audit to assess the time lapse between prescription and administration of IV antibiotics for soft tissue infection.




3255 Compliance of Rate of Reporting by Non-Radiology Clinicians

Dr Rowena Warwick, Consultant Radiologist

Non radiology clinicians are required by the IR(ME) regulations to provide an interpretation of radiology images in patient records in certain clinical areas where there is an agreement with the radiology department. This audit measures compliance with this.

Specialist Services

16/06/2011 Complete 05/09/2011 Results: 35 (73%) patient notes contained a report of the X-ray either in the clinical notes or in the GP letter. 13/48 (27%) patient notes contained no report of the X-ray. Recommendations: Results to be fed back to Trauma and Orthopaedics and Oral Surgery and Orthodontics.Re-audit October 2012.

Results fed back to Trauma and Orthopaedics and Oral Surgery and Orthodontics.

3256 Prolonged VTE Prophylaxis in High Risk Surgery Re-audit

J Pattinson, Consultant, Haematology (Kabir Ahluwalia FY1, Surgery)

Audit to determine whether prescribing for DVT prophylaxis is meeting NICE recommendations for patients undergoing surgery for cancer, as well as orthopaedic (hip/knee replacement, major trauma and fractured neck of femur). Re-audit of 3205 based on April 2011 data.

Specialist Services

21/06/2011 Complete 01/08/2011 Re-audit of 3205 after discussing results with T&O team. The number of patients being prescribed prolonged prophylaxis has increased to 98%, representing that implementations made have been successful. The number of patients being prescribed Aspirin has also reduced to 0.There continues to be good medical prophylaxis for inpatients during the perioperative period.Unfortunately, prescriptions for TEDS stockings actually were decreased compared to the data collected in JanuaryThe number of VTE assessments is decreased compared to those in January. However, it appears that the correct form of prophylaxis is being prescribed despite this.There was 0 PE’s or DVT’s for the patients audited during the month of April, possibly representing the benefit of providing prolonged prophylaxis.

Results have been reported to T&O.

3257 Outcomes of Back/Lower Limb Exercise Classes

Sharine Ballicanta, Physio WH

An audit to determine effectiveness of back/lower limb exercise classes.

Specialist Services

23/06/2011 Complete 20/09/2011 Results: The class discharges an average of 7.7 patients per month. The majority of patients drop out before completing the course; with only 37% completing the full course. Of the 17 completing the class, 13 had the LEFS outcome measure recorded before and after the class.Of these 13, 12 had an improved outcome, 9 of them significantly improved. This shows that the class is effective in improving the patient’s functional abilities. Recommendations: Ensure that every one referred to the class has pre-class LEFS scores. Present results of audit to the Wycombe Physiotherapy Department. In future, record LEFS scores after 4 sessions and at the end of the course.

We have implemented the recommendations for the LL class based on the results of audit. i.e. everyone referred to the class has pre-class LEFS scores. LEFS scores recorded after 4 sessions and at the end of the course. The future plan is to audit the LL classes across sites and follow up patients who have dropped out. There is no immediate plan to do this at the moment. However, we are continuing to collate this information.

3258 Community Nursing Team for Children with a Learning Disability Client Experience Survey

Anne Poll, Clinical Nurse Specialist Children with Learning Disabilities

Client experience survey to obtain feedback on the service provided by the community nursing team for children/young people with a learning disability.

Specialist Services

27/06/2011 Complete 12/01/2012 Action plan: Make information about services available for children with a learning disability more ease for healthcare professionals to access. Make parents more aware of the contents of their child’s care plan. Reduce the waiting time following referral. Identify which families require written information in a language other than English. Investigate the feasibility of assisting parents with the transporting of children to appointments.

Intranet updated to improve accessibility of information to professionals. Training updated to ensure Community Staff Nurses are making parents more aware of the contents of the child's care plan. Recruitment for an additional member of staff is currently being implemented. Written information provided in another language is in-hand. The final action regarding assisting parents with the transporting of children to appointments is proving to be challenging and a solutions is yet to be found.

3259 Paediatric A&E Reports Re-audit

Sydnella Terry, Paediatric Liaison Nurse, Jane Bremnath, Named Nurse for Child Protection

A re-audit of 2913. Specialist Services

27/06/2011 Complete 31/10/2011 The new ‘First Net’ CRS system for both emergency departments will improve the recording of patient information. Diagnosis and school will be mandatory fields; address and GP details will be taken from the NHS spine. An audit of the free text fields should be carried out in 2012 to see if adequate information is being provided.

See audit 3424.

3260 Speech & Language Therapy Annual Statistical report

Debbie Begent, Service Manager

Summary of clinical activity data and referral data 2010 to ensure collecting right info and to identify trends.

Specialist Services

01/05/2011 Complete 28/06/2011 Results: The distribution of Acute staff, from statistics shown appears to be at the correct level. The number breached waiting times is stabilising. We are receiving more referrals from ENT Consultants and the hub for Head and Neck Cancer care is moving more patient care to local services. The Voice team have done much to improve their efficiency with introduction of a telephone screening system. Recommendations: Monitor statistics and re-distribute staff as required in response to changes in the Trust. To continue to develop the care pathway for patients with Long Term Conditions. Also to make ongoing improvements in the Waiting List management ensuring we have enough designated initial appointments each week. Continued collection of statistics in order to monitor referral and response rates so that we can be flexible in an organisation that is changing and developing.

1. Continue to monitor statistics and are re-distributing staff as the Trust re-organises e.g. to Stroke Unit based at WGH.2. There is a delay on the start of ESD Speech Therapy due to recruitment problems and this post commences 12.3.12. Reviewing the pathway for people with long term aphasia and working with the Stroke Association to develop a new pathway in better partnership.3. Keeping a referral datbase which indicates if a patient is referred with Head and Neck cancer4. Continue to collect stats.

3261 Lung Cancer Inpatient Experience Survey 2011

Jill Mowforth, Hayley Adams, Lung Cancer Specialist Nurses

To explore patient experience for those patients with lung cancer and mesothelioma who are admitted to hospital. To identify the role of the CNS in supporting the patient during an admission.

Specialist Services

30/06/2011 Cancelled 10/07/2012 Project cancelled due to insufficient numbers. Patients either die while still inpatient or go home or to hospice to die post admission.

Project cancelled

3262 Local Enhanced Service: Below Knee Wounds

Sarah Mobsby, Specialist Vascular Nurse

Evaluation of training for practice nurses on how to perform doppler assessment and compression bandaging.

Integrated Medicine

01/07/2011 Complete 10/07/2012 No recommendations or action plan received. No plans to continue the service at present.

Changes not required

3263 Gestational Diabetes Dietetic Clinic Patient Experience Survey

Anna Martin, Dietitian Survey of gestational diabetes dietetic clinic patients.

Specialist Services

28/06/2011 Complete 05/11/2012 Looking at the results, all participants were satisfied with the dietetic service in question. All patients were given consistent advice post their diagnosis of Gestational Diabetes. Although advice was given by a number of health professional including midvives, consultants and dietitians, patients were not given conflicting or confusing advice.Most patients made positive changes to their diet in accordance with the most up to date evidence based advice for Gestational Diabetes after their consultation with the Dietitian, but some had made changes prior to their consultation.

None required

3264 Spinal Trauma Audit

Mr Belci, Consultant, Spinal, Temi Ayorinde

Review clinical notes of spinal injury patients to design and plan spinal trauma pathways. Auditing against National Spinal Injuries Pathways International Guidelines.

Specialist Services

04/07/2011 Cancelled Results and Recommendations required Changes required

3265 Audit of Obstetric Anaesthetic Handover

Matthew Size, Consultant Anaesthetics

Prospective audit of the quality of handover between the obstetric anaesthetists on call at shift handover.


01/07/2011 Complete 31/08/2011 The length of handover (10 mins) seems appropriate but could be improved. Small numbers of handovers measured due to problems during data collection period. Significant number of patients not handed over. Plan to introduce SAFE proforma and then re-audit 3 months after introduction. (Sick patients/At risk of major anaesthetic problems/Follow-ups/Epidurals).

No changes have been received 21/2/13 (CP)

3266 Investigation and Management of Babies Born to Mothers with Thyroid Disease at Risk of Thyrotoxicosis (SMH)

Dr A Dutta, Consultant Paediatrician, Dr Ashish Marwaha, ST1

Different policies exist on how babies are managed; both recent literature and the local tertiary hospital suggest investigating only babies whose parents have hyperthyroidism. The aim of the audit is to see if we pick up any extra cases and how often these patients are followed up; would changing the guideline reduce the workload?

Specialist Services

30/06/2011 Cancelled 09/04/2012 Audit cancelled. Doctor left Trust without completing audit.

Changes required

3267 General Surgical Post-take Proforma Audit

Mr Goede, Consultant Surgeon (Tom Bannister, F1, T&O)

The consultant post-take ward round entry of general surgical admissions from 1/5/11 to 31/5/11 will be reviewed following introduction of a new proforma in order to assess how well the proforma is being completed.


06/07/2011 Complete 27/07/2011 The recommendation from the General Surgical M&M meeting where the audit was presented was that the proforma should be slightly revised and trialled for another month. This is in progress.

Proforma revised and trialled for another month.

3268 Maternity Record Keeping Audit


An audit of maternity recording keeping carried out by SoM's and band 7 midwives

Specialist Services

01/01/2011 Complete 30/07/2012 Recommendations: Pregnancy and general - 1. VTE assessment to be completed at designated times: compliance to improve from 60% to 90%. 2. All women with a growth chart to have this correctly

annually. Required for CNST.

completed: compliance to improve from 78% to 90%. 3. All women to have lead professional and place of care/birth to be correctly recorded on the front of the pregnancy notes with appropriate amendments: compliance to improve from 50% to 80%. 4. Special features boxes on inside front cover of lilac notes to be completed appropriately: compliance to improve from average of 52% to 80%. 5. All practitioners involved in care to provide a sample signature: compliance to improve from average 52% to 80%. 6. Betal blood sampling results to be written on appropriate labour page: compliance to improve from 50% to 80%. 7. C-section operative page to be fully and correctly completed: compliance to improve from 67% to 80%. 8. All continuation sheets to be numbered: compliance to improve from 63% to 80%. 9. All continuation sheets to be headed with woman's name and NHS number: compliance to improve from 21% to 80%. 10. CTGs, use of Pinards, monitor number, otcomes, signature on completion, use of fresh eyes stickers, signature on review, significant events on CTGs: compliance to all areas to improve from average 50% to 80%. 11. Prescription charts, use of PGDs to be correctly documented: compliance to improve from 68% to 80%. 12. All obstetric emergencies to be recorded on appropriate pro forma: compliance to improve from average of 80% to 90%.

3269 Infection Prevention & Control Knowledge Survey 2010


A questionnaire to assess staff knowledge of Infection Prevention & Control. In the past this has been carried out by post. This year an online survey was used.

Specialist Services

01/11/2010 Complete 12/07/2011 376 clinical staff completed survey. Education around when hand sanitiser must not be used needs to be prioritised due to a total of 47% answering that hand sanitiser can be used with patients with diarrhoea, with Norovirus and when a ward is closed due to Norovirus. Leading up to months when H1N1can be an issue, information must be given to the appropriate areas and staff groups around PPE and what to wear and when. For low risk procedures with no aerosol generation 37.2% would wear FFP3 masks instead of the correct theatre masks.20% answered that the single use symbol means single patient use. This could lead to cross infection by reusing items that aremanufactured as single use only. 96% of staff answered correctly that the first thing to do following a needlestick injury is to bleed, wash and report it. Completing the IPC mandatory training has changed various staff's practice.

All the recommendations from the knowledge survey have been addressed. They were highlighted in the IC times, discussed at relevant meeting e.g. Sister’s and Nursing and Midwifery board meeting. The AND’s have assured us all audits are discussed at their Clinical Governance and Divisional Board meetings.

3270 Peri & Post-operative Complications Associated with Cystectomy following Neoadjuvant Chemotherapy

Mr N Haldar, Consultant Urologist, (Dr Chris Blick, SpR Urology)

To compare operative and post operative complications and assess safety of neoadjuvant chemotherapy in muscle invasive bladder cancer.




3271 LSVT Service in SALT

Norma Ramsay, Specialist SLT, Clinical Lead for LTC team

Within Speech & Language Therapy, LSVT (a specialised voice treatment programme) is a specialist service to patients with Parkinson's Disease. The waiting time has been excessive at 12 months. They are attempting to reduce wait times and provide equitable geographical access to service. Looking at all patients April 2010 to April 2012.

Specialist Services


3272 SALT Community Waiting List Management

Norma Ramsay, Specialist SLT, Clinical Lead for LTC team

Looking at all patients April 2011 to April 2012.

Specialist Services


3276 Therapeutic Hypothermia in Cardiac Arrest

Dr Sarah McNeillis, Consultant Anaesthetist (Dr Peter Valentine, CT2, Anaesthetics)

A pre and post NICE guideline audit of the use of therapeutic hypothermia in Cardiac Arrest.




3277 Audit of Outcome of Sacroiliac Joint (SIJ) Injections

Dr John Edwin, Staff Grade, Anaesthetics, Dr K Bakshi, Consultant in Pain Medicine & Anaesthesia (Murli Thiyagarajan, medical student)

Audit of the outcome following Sacroiliac Joint (SIJ) injections for patients with chronic SIJ related pain.



04/12/2011 Sacroiliac joint injection is shown to be a clinically effective diagnostic tool and intervention, producing short term pain relief for patients of chronic back pain. Patients who do not get adequate pain relief from SIJ injection should be considered for long term pain relief interventions. Recommendations: A further audit should be performed to look at the reasons behind the large percentage of incomplete notes; further research into the validity of sacroiliac joint injection and its cost effectiveness; further research into the effectiveness of long term treatment such as radiofrequency denervation and ligament prolotherapy.

Changes required

3278 Audit of Refractive Outcomes Following Cataract Surgery

David Sculfor, Head of Optometry

It recommended by the College of Ophthalmologists that the glasses prescription of patients who have had cataract surgery is audited. If there is a systematic error then adjustments can be made to lens calculations.


02/08/2011 Cancelled 31/12/2011 Audit cancelled - no activity. Project cancelled.

3279 Audit of The Effectiveness of Iontophoresis Treatment for

Sarah Colebrook, Deputy Sister, Derrmatology OPD

Patients who suffer from hyperhydrosis of their hands, feet and armpits are given

Integrated Medicine

02/08/2011 Complete 03/01/2013 67% patients treated with Iontophoresis found the treatment either 'significantly' or 'to some extent' reduced their hyperhidorsos. Recommendations: All patients must be provided with written information

Patient information booklets are sent out to each patient with their appointment schedules. These booklets

Dermatology Patients suffering from Hyperhydrosis

Iontophoresis treatment provided by Dermatology OPD. Once discharged from Dermatology OPD they are able to continue this treatment at home using an Iontophoresis machine. The aim of the audit is to find out how many people continued to treat themselves, if they find the treatment useful and still effective.

and useful links to the internet. Time to be created for patients to discuss any additional questions or concerns prior to treatment. Look into the possibility of machine rental for iontophoresis treatment to be self-administered at home.

include links to useful websites. Patients are also provided with contact numbers to discuss any questions or concerns which may have arisen before their treatment. STD pharmaceuticals and Ionto centre to be contacted during January to establish if it is possible to rent the iontophoresis machines for home use.

3280 Identifying Patients at Risk Following Fragility Fractures

Mr A Graham, T&O Consultant (Dr J Wigley, SHO, T&O)

To idenitfy whether patients who sustain distal radius fractures through a low energy mechanism are assessed for secondary presentation.


02/08/2011 Complete 20/10/2011 A considerable proportion of patients are not being considered for the secondary prevention of fractures in line with NICE guidelines. Recommendation that all patients seen in fracture clinic be considered for osteoporosis prevention. Patients over the age of 75 sustaining fragility fractures should be commenced on empirical osteoporosis treatment, and those under this age be referred for further assessment or DEXA scan. Awareness of this issue needs to be increased. A further audit will be commenced in the months ahead to evaluate any improvements.

Awareness of this issue and subsequent recommendations has been disseminated throughout the department by means of an ‘Academic day’ presentation.

3281 An Exploration of Attitudes and Perceived Barriers of Dietitians in relation to Oral Nutritional Supplements

Gbonyefa Samani, Dietitian

Oral Nutritional Supplements (ONS) are used for undernutrition but guidelines suggest first line measures should be tried first. Survey of dietitians to determine attitudes to ONS.

Specialist Services


3282 Effectiveness of Hydrotherapy Treatment

Keith Pickard, Physiotherapist

Hydrotherapy given for various conditions. Patient completes MYMOP outcome measure before and after 6 week course. To assess effectiveness of course.

Specialist Services



3283 BTS Emergency Oxygen Audit 2011

Jenny Ricketts, ICU Outreach Lead Nurse

National British Thoracic Society (BTS) audit to establish the practice of oxygen presribing and delivery throughout the Trust.

Integrated Medicine

02/08/2011 Complete 05/01/2012 Recommendations: All doctors must take responsibility for prescribing oxygen. Junior doctor prescriptions should be checked on all senior ward rounds. All nursing staff/ healthcare assistants should take responsibility for signing for oxygen, when administered, in the same way as any other drug. Senior staff nurses / matrons should do a brief spot check at regular intervals to check this is being done (eg weekly). The oxygen audit should be repeated at 3 monthly intervals by each ward. Action Plan: The oxygen audit results will be presented at either the hospital audit meeting or a grand round along side an educational lecture on the use and prescription of oxygen. To be done following doctors change over in February. Ward based education should occur for nursing staff and healthcare assistants regarding the use and prescription of oxygen. The oxygen audit will be repeated (in house only) three months after the educational programme.

Changes required

3284 BTS National Pleural Procedures Audit 2011

Dr Charlotte Campbell, Respiratory Consultant

National audit looking at pleural procedures - diagnosis, treatment and outcomes.

Integrated Medicine



3285 British HIV Association

Dr Veena Reddy, GU Consultant, Dr Sunita

National audit looking at timeliness of HIV

Specialist Services

01/09/2010 Complete 01/10/2011 HIV specialists should re-double efforts to promote implementation of national testing guidelines. BHIVA

Changes required

National Audit 2010

Duggal diagnosis and impact of 2008 national testing guidelines, in particular: local action to promote testing, circumstances of diagnosis, previous history and missed opportunities for testing, time from first positive test to be seen in HIV service. A survey of local testing policy and practice. Retrospective review of patients first seen post-diagnosis during August-October 2010, regardless of date of test. Up to 40 patients/site.

should engage nationally with primary care and medical specialties, especially gastroenterology and haematology. National monitoring of both CD4 count at diagnosis and AIDS defining illness within 3 months should continue. Commissioners should consider extending CQUIN and LES arrangements to promote earlier diagnosis. Develop pathways to ensure patients testing positive are seen quickly (within 14 days).

3286 National Diabetes Audit 2010 - 2011 (BHNHST)

Dr Stephen Gardener, Consultant, SMH and Dr Ian Gallen, Consultant, WH


Integrated Medicine




National Inpatient Survey of sample of 850 patients seen in July 2011.

Trustwide Complete 17/08/2012 There has been a decline in information given in A&E, waiting time for a bed, waiting time to be admitted, explanation of how the operation had gone and delay at discharge. Our Trust was worse than other trusts for 5 questions but not better than other trusts for any questions. Actions: A&E. The nursing staff are reviewing the possible introduction of red pegs/or alternatively do not disturb signs. Documentation and Ops Policies are being reviewed currently due to the amalgamation of staff onto one site. Urgent Care Pathways for patients are discussed and actions are brought forward to look at best care pathways. The whole team are working on being 18 week compliant by the end of August 2012. Ward/Department managers are to ensure that the bathrooms are specifically identified and designated to the appropriate sex and that patients are informed in order to provide appropriate dignity. Regular walk rounds by nursing staff to ensure that patients are

Changes required

comfortable during the night, lights are to be turned down and a peaceful environment to be created to enable sleep. Staff not to congregate at nursing station. Staff asked to wear correct footwear to ensure quiet walking. The Matron and Ward Manager to work with the domestic team to ensure that cleaning plans are robust and that regular audits are carried out to ensure that they are compliant with expected standards. Matron rounds in place to monitor progress. Ward / Department areas to ensure that patient property is kept safe at all times providing patient property bags and the facility to check valuables into the ward safe/general office as required. Lockers to be maintained and in working order.Hand gel, posters to be evident at the beginning of the ward / department and hand gel to be available at every bedside with appropriate facilities for hand washing for patients and relatives identified. Hand hygiene audits to be monitored and evaluated.Ward / Department and Matrons to ensure that patients eating and drinking is assessed continuously and any issues to be identified and assistance to be given to patients with eating and drinking. Red Trays usage to be enhanced on each ward area. Menu’s to be used and specialist assistance from the Speech and Language team and the nutrition team to be sought in a timely manner. Matron’s rounds are carried out weekly to monitor nutrition and hydration charts. Patient drinks and food being in easy reach is addressed at ward level.

DoctorsCustomer service standards to be rolled out at medical staffing induction with feedback from patients to be shared with the medical teams.Hand Hygiene audit results to be shared with the medical teams and results of which to be discussed and shared at Divisional Board.Customer service standards to be rolled out at induction, local induction to clarify expectations of role, mentorship, preceptorship and clinical supervision to pick up any individual development issues. Ward / Department Managers to act as role models and to promote best practice. Leadership training and continuing professional development to continue throughout the nursing teams to ensure professional behaviour. Rota reviews, skill mix reviews have taken place with each ADN. Recruitment drives to ensure that vacancies are filled. Sickness and leave to be managed by the ward / department manager. Rosters to be centralised and to ensure that they are robust and fit for purpose allowing the ward manager to agree the roster rules to provide sufficient staff on the ward. Staffing skill mix requirements are review daily by a Matron and in exceptional circumstances additional resources may be identified and escalated to support. Patient Experience Trackers to be

introduced to the organisation Sept/October to pick up live reporting of quality issues. Verbal Quality checks to be a part of day ro day nurse patient communication.Matrons templates to be reviewed to identify whether patients are having the appropriate levels of communication. The review of patients privacy should be ongoing and the appropriate utilisation of curtains, offices and quiet areas are to be used, the review of the red peg for curtains to ensure that patients are not disturbed are to be reviewed by the organisation

Patients are to be assessed for levels of pain on a regular basis, finding appropriate solutions to pain control and monitoring and recording the effectiveness of the analgesia administered. Nurse led pain pathways in place .All call bells to be responded to within five rings, this can be responded to by any member of the ward / department team who may need to seek further advice as required. Areas that are not provided with pre-op clinic are currently reviewing their pathway as to what information the patients are receiving.Enhanced recovery pathways are being rolled out to elective surgery patients. Hip and Knee classes in place for orthopaedics. Dedicated anaesthetist for the pre operative pathway working with the nursing team to highlight risks and ensure correct assessment prior to surgery. Development of information booklets by all specialities to explain operative or investigatory procedures. Daily facilitated Meetings (DFM) being rolled out across all specialities ensure MDT approach and involvement of patient and family.Zone project on T&O emergency pathway ensures patient involvement in understanding their recovery pathway and reducing length of hospital stay.Nurse led discharge for elective pathway in Gynaecology and surgery.

Green bag system assisting with delays . DFM’s ensuring timely writing up of TTO’s.Pharmacy are reviewing the process of how TTO charts are getting to pharmacy and this is also being picked up in medical inductionPre – planning of patients discharge is of paramount importance and discharge dates to be identified for all patients on ward roundsContinued development of patient leaflets by specialities.Nurses instructed to explain the take home medications to patient and families on discharge to ensure complete understanding. Patient Leaflets to be utilised for specific conditions. Specialist Nurse review for newly diagnosed patients with specific conditions. Programme Manager for CRS to be contacted to determine whether we can send letters out to patients utilising the system or whether there were alternative systems that we could review.

Matron and Ward managers to ensure staff promote dignity becoming dignity champions for their patientsWard rounds to involve senior nurse to actively participate in the patients treatment plan, courtesy and professionalism to be promoted at all times. MDT’s to be attended by senior nurse and patients.Matrons rounds, patients trackers and staff to ask patients quality questions whilst delivery daily care to raise any concerns or issues early. Ensure patient involvement on a daily basis whilst delivering care, asking the patients their views. Productive ward surveys utilised whilst waiting for patient tracker system to show involvement and quality of care for app patients Weekly Matron Rounds, Productive Ward feedback, patient experience monitoring to commence for monthly reviews October. Patient involvement in changes, improvements and innovation ideas.PALS, complaints team to do a walk around the site to ensure enough marketing material is available to each ward / department with regards to raising concerns.

3288 Audit of reasons for length of stay of community hospital inpatients

Marianne Smith, Clinical Excellence Lead

This audit is to ascertain the reasons for delayed discharged of community hospital inpatients.

Integrated Medicine

05/08/2011 Complete 26/01/2012 Results: The average age of inpatients in the community hospitals is 82.9 years and the main reason for admission is for ‘reablement’ (88%). On the whole, patients met the admission criteria; however 6 (10%) patients did not, with 3/6 of these patients requiring either placement or re-housing and 2/6 patients needing acute medical care. The average length of stay at the time of the audit was 27.4 days. 3 patients had a length of stay of between 85-112 days, 2/3 of these patients did not meet the admission criteria. 8 patients who were not recorded as a delayed discharge had exceeded their Estimated Date of Discharge by between 3-46 days. 92% of patients who required a referral to social services had the date of referral documented in their notes. 94% had social services documentation with section 2 completed filed in their notes. Where the patient was fit for discharge section 5 of the social services documentation had not been completed in 75% of cases. 16% of patients requiring a referral to social services had not yet been assessed. For 45% of patients being discharged to their own home, a home visit had yet to be carried out and for 17% of patients who required equipment, the equipment had not yet been ordered. Finally, of the 23 patients recorded as a delayed discharge - 30% were awaiting a care package and 30% were waiting for a nursing home placement. Recommendations: The Community Hospital discharge planning process is not currently standardised. It is recommended that the Productive Series module on admission and discharge planning is implemented at all units and includes accurate and timely referral to Social Services. A multi-disciplinary approach to decision making for completion of Estimated Date of Discharge is best practice. Currently Estimated Date of Discharge does not relate to an evidence based patient pathway and it is recommended that

1. Training and implementation of Social Service Service referral via Strata. 2. Accurate recording of delayed discharge - Training on completion of return. Increase understanidng of reporting system using feedback from weekly review meetings. 3. Implement productive ward module - admissions and planned discharge. Implement evidence based length of stay for identified pathways and MDT approach to treatment completion dates for specific pathways. 4. Identification of lead professional for each discharge. Explore options for working relationship with BHT discharge team. Explore use of daily facilitated discharge meeting in community hosital setting.

pathways should be identified for development and implementation. Planned completion dates for treatment are not recorded consistently. Setting agreed dates with the patient and multi-disciplinary team would improve communication and discharge planning.Recording the date of referral to Social Services, Section 2 and Section 5, is inconsistent across the Community Hospitals. A standardised approach is needed to this. Social Services are not required to source the care required for discharge until a patient has been declared fit for discharge and a Section 5 is submitted by the Community Hospital. Submission of Section 5s can be unreliable, causing delays in discharge. A standardised approach to Social Service referral should be an outcome of the Productive Series admission and discharge module implementation. Current recording of delayed discharges by the Community Hospitals is inaccurate and requires weekly revision when reviewed by the Clinical and Operational Lead and Lead for Social Services. Training to improve knowledge and use of the reporting system is required. Complex discharge management for patients who are non-weight bearing, homeless and needing re-housing, are admitted awaiting long term care or have other complex discharge needs is not consistent across the Community Hospitals. To improve communication, planning and identify potential delays a lead professional is required for each complex discharge and the use of a facilitated discharge meeting should be explored.

3289 Audit of Elective Angioplasty, Stable Angina and Optimal Medical Therapy

Piers Clifford, Consultant, Cardiology (Alex Woodroffe, Project Manager, South Central Cardiovascular Network)

A case note audit in advance of the NICE guidance due to be released in July 2011 on treating Stable Angina to give an indication of what trends there are within the procedure data for South Central.

Integrated Medicine



3290 2011 National Comparative Audit of the Medical Use of Red Cells

Dr Ann Watson, Consultant Haematologist, Terry Perry (WH), Donna-Beckford-Smith (SMH), Haematology Nurse Specialists

Audit to evaluate the use of red cell transfusions in adult medical patients against standards derived from the BCSH guidelines and to ensure that associated clinical documentation is recorded consistently.

Specialist Services



3291 Can the Introduction of a Cardiac Research Nurse Role Enhance Service Development?

Nicola Bowers, Cardiac Research Sister

This audit is being undertaken as part of a research project for an MSc.

Integrated Medicine

01/08/2011 Complete 14/11/2011 Not applicable Not applicable.

3292 Review of Umbilical Hernia Repairs

Dr G Luzzi, Medical Director and Mr A McLaren, Divisional Chair for Surgery

A review of recent readmissions following hernia repairs, following a Dr Foster alert.


26/08/2011 Complete 31/03/2012 All Umbilical / paraumbilical hernia repairs at Stoke or Wycombe Hospital between February and August 2011 were reviewed. Of 49 cases there were 3 (6.12%) readmissions within 28 days post surgery. Results are similar to standard results published in surgical journals.

No changes required

3293 National Diabetes Inpatient Audit 2011

Dr Chatterjee, Consultant Diabetes & Endocrinology

National audit aiming to answer the following questions: Did diabetes management minimise the risk of avoidable complications? Did harm result from the inpatient stay? Was patient experience of the inpatient stay favourable? Has the quality of care and patient feedback changed since NaDIA 2010?

Integrated Medicine



3294 National Health Promotion in Hospitals 2011

Dr Luzzi, Medical Director

Reaudit of 2645. National audit to assess the level of health promotion which takes place for inpatients at the Trust.

Trustwide 01/03/2011 Awaiting Report/Action Plan


3295 Audit of Dog Bite Treatment & Outcomes

Mr T Heywood, Consultant Plastic Surgeon (Dr Adnan Gul, SpR, Dr Ross Muir, CT2, Plastics)

An audit of patients treated for dog bite injuries - treatment received and outcomes.


09/08/2011 Cancelled 26/11/2012 Junior doctor has left Trust, audit has not been presented.

Project cancelled.

3296 Urology Cancer PES 2011

Hilary Baker, Krystyna Caine, Clinical Nurse Specialists Uro-Oncology

Obtain patient feedback regarding the service and information provided. Required for peer review.

Specialist Services

01/04/2011 Complete 31/08/2011 Results: The Uro-oncology Clinical Nurse Specialists feel the report is a true, honest, fair report. As a team we value patients’ comments, opinions, suggestions and thoughts to help develop the service and improve the care they receive. Recommendations: To review pain management at time of patient investigations and how this can be better communicated and managed. To review discharge information for patients following their investigations. To emphasise the importance of patients bringing a relative/carer/ friend when they receive the results of their investigations.

Changes required

3297 Health Promotion in Cardiology PES

Dr Piers Clifford, Consultant Cardiologist (Nicola Bowers, Research Sister)

To assess whether health care professional intervention influenced patient uptake of physical activity.

Integrated Medicine

22/08/2011 Cancelled 05/11/2012 Cancelled. Project cancelled.

3298 Readmissions following appendicectomy

Mr Chris Gatzen, Consultant, Colorectal Surgery (Mr Nigel D'Souza, CT3, Surgery)

There has been a high readmission rate post appendicectomy for intra-abdominal abscesses. This audit will investigate the readmission rate and determine what risk factors are present that may be influenced.


01/09/2011 Complete 22/12/2011 Results: Wound infection and abscess rates are not very high at Bucks; high rate of abscess after Laparoscopic Appendectomy for uncomplicated appendicitis; no clear or statistically significant evidence showing Laparoscopic Appendectomy worse than Open Appendectomy; longer operation and more expensive; beneficial for post-op pain, reduced hospital stay, return to work, wound infection.


3299 IQP Community Acquired Pneumonia 2011/2012

Liz Hollman, Associate Director Healthcare Governance (Dr Mitra Shahidi, Respiratory Consultant, Dr Nandini Biswas, Respiratory Consultant)

IQP audit to assess patients with community acquired pneumonia.

Integrated Medicine

01/09/2011 Complete 13/06/2012 Dr Shahidi is investigating whether a report was produced.

No report to date.

3300 Audit of Cardiology Patients with Stable Angina

Dr Piers Clifford, Consultant Cardiologist (Nicola Bowers, Research Sister)

Audit against NICE guidance for treatment of patients with stable angina.

Integrated Medicine

01/09/2011 Complete 19/03/2012 Overall the results highlight good clinical practice locally such as, all patients being considered or prescribed Aspirin 75mg OD. For 97% of patients with diabetes, ACE inhibitors had been considered and documented. For 91% of patients it was documented that GTN spray had been offered. For 98% of patients a statin was prescribed or considered, 97% of patients were offered some form of first line treatment, yet 3 patients went straight for procedure. However, only 4% of patients were clinically reviewed after being prescribed and starting on first line therapy. No review prior to procedure precipitated 41% of patient’s asymptomatic on day of procedure. Recommendations: To improve documentation within the medical records of clinical decision making in relation to treatment plan and choice of medication. Clinical review essential after commencing a patient on a new drug therapy for stable angina. If clinically appropriate, a third line medical treatment to be offered prior to clinical intervention. To increase the number of patients taking the recommended 40mg OD Simvastatin and, if not documented, justification for another lipid lowering treatment being prescribed. GTN spray is a cheap and effective treatment for patients with stable angina, it should be offered, prescribed and documented to all. To encourage second and third line medical therapy, where appropriate, for patients prior to consideration of interventional treatment.

Changes required

3301 Audit of Emergency Laparotomy Outcomes in line with the Emergency Laparotomy Network Guideline

Dr Jeremy Drake, Consultant, Anaesthetic (Dr Duncan McLean, FY1, Anaesthetics)

To gain baseline data for emergency laparotomies using Emergency Laparotomy Network data collection tool.




3302 VTE Prophylaxis after leg immobilisation

Dr Jonathan Pattinson, Consultant, Haematology (Dr Ahmed Arif, F1, Haematology)

Audit of VTE Prophylaxis after leg immobilisation against NICE guidelines.


02/09/2011 Cancelled 23/12/2011 Audit was not completed as the Plaster Cast Pathway in A&E still does not incorporate VTE prophylaxis.

Project cancelled

3303 Bedside Transfusion (National Comparative Audit of Blood Transfusion)

Donna Beckford-Smith, Transfusion Nurse

April - June 2011. National audit.

Specialist Services

01/04/2011 Complete 06/06/2012 Action Plan: Continued transfusions theory training, education & competency assessments.Research for the provision of wristband printers to those areas which are still without.Re-auditing ward wristbands.In the future electronic bar-coding to the bedside.

Theory training and competency assessments continue. We have capture the porter and phlebotomist will be addressed early in the new year.New assessors are being trained to carry out assessment in their areas and divisions.We have secured training for representatives from the community to assist us competency assessor District nurses, again this starts in Jan 2013.We are still trying to secure wristband printers to ensure patient safety. To be discussed again at our HTC. Following configuration all areas will need reassessing,

as the current Ward 20 are without a printer now.Blood transfusion nurses have conducted Quick wristband audits in keys areas such as A&E, ITU etc. to continue with auditing throughout 2013 for Regional purposes as well as for local data.Electronic to the bedside is subject to funding.

3305 Allergy Clinic Patient Experience Survey

Liz Potts, Staff Nurse, Dermatology

Re-audit of audit 1930 in 2007.

Integrated Medicine



3306 Patch Test Clinic Patient Experience Survey

Sue Hyde, Nurse, Dermatology

Re-audit of audit 1930 in 2007.

Integrated Medicine



3307 VTE Prophylaxis in the Urology Patient Re-audit

Neil Haldar, Consultant, Urology (Dr Natalia White, FY1, Urology), Jonathan Pattinson, Consultant Haematologist

To audit adherence to clinical guidelines on VTE prophylaxis risk assessment and prescription. Re-audit of 3223.


05/09/2011 Complete 13/04/2012 VTE prophylaxis compliance had increased from 10% in previous audit to 65% in this audit. Targeted interventions, including a urology admissions clerking proforma (UAP) and guidance sheet advising on routine VTE prophylaxis in urology, had improved NICE guideline compliance greatly. No further recommendations were made from this re-audit.

No recommendations or action plan from this re-audit.

3308 Audit of Massive Obstetric Haemorrhage

Veronica Miller, Consultant, Obs & Gynae (Dr Tanya Boland, FY1)

Audit of incidence of massive obstetric haemorrhage (>1500 ml) between 04/06/11 and 02/08/11. Audit against CNST, BHT guideline 550.1 and NICE.

Specialist Services

30/08/2011 Complete 17/10/2011 Rates at this Trust reflect the national average. Good documentation and use of the proformas by midwives at vaginal deliveries. At LSCS the proformas are not used as well. The audit recommends that there is a focus on better use of the proforma at LSCS with a person being designated to complete it at the time and proposes that a separate proforma for use at LSCS is devised. It also raised the question about releasing blood once the immediate crisis has passed if it is not required, highlighting the need for good communication between staff and the lab.

Continuing CNST audit 21/2/13 (CP)

3309 Paediatric Occupational Therapy Group PES

Alison Lyle, Community Paediatric Occupational Therapist

PES of parents of children attending community Occupational Therapy groups and talks.

Specialist Services

05/09/2011 Complete 25/07/2012 Overall feedback was very positive. Actions: Parent Groups: Attendees to be provided with a map detailing parking. Ensure parents are aware that alternative venues/times/days are available across the county. Invitation method to be reviewed to include this information.Make parents aware of School Advice Clinics as a method of reviewing child and answering specific questions. Verbal reminder of SAC to be given to parents at the end of group. Group information/activity sheets to be updated to give details of practical home ideas. Ensure handouts are available. Handwriting pathway to be reviewed by OT service.Information sheet/group focus to be made available for OT to include with invitation. Parent Talks: Consider alternative venue at SMH. OT presenting to inform parents of School Advice Clinics. Talk to include information on methods of referral to OT. OTs to be aware of pacing of the talk. Produce suggested timeline for talks. Make OTs aware of availability of Trust training on presentation skills.

Changes required

Handout emailed to parents after talks. OT to ensure handouts tally with presentation.Consult managers for progress on website plans. OTs referring parents to the talk should consider individual situations. Review initial letter. Universal Training: Handouts to be given at all talks, at beginning. Training session to all staff involved to maintain consistency of delivery across the county. Create a flyer to advertise the training session accurately. Create a document clearly stating the requirements for the course to the school hosting the training. Recent review has moved towards a workshop style of delivery. Need to cover this in training. Produce reference list of resource books. OT to allow 30 minutes, if needed, for individuals to ask any further questions. OT to inform participants where Resource Pack available. Take set of appropriate resources to each session. Time to be set aside for this – part of final 30 minutes. Team lead/managers to discuss the practicalities of offering further training sessions. Greater use of flyers, OT giving clear information on how to obtain Resource Pack.

3310 Management of Emergency Caesarian Section

Veronica Miller, Consultant, Obs & Gynae (Lee Aye, GPVTS, Katie Eyre, FY2)

Ongoing audit of management of LSCS.

Specialist Services

01/05/2011 Complete 17/11/2011 68 notes in total identified using birth register on labour ward and requested. 49 notes (72%) received and analysed (5 excluded - 4 Category 4 sections entered as emergencies excluded and 1 trial +/- section). Completion of the proforma: 39/44 (89%) Completed 5/44 (11%) Not completed/ in notes. Dec 2010 (64%) Completed Feb 2010 (64%) Completed NICE classification 100%, also good compliance with ABx, thromboprophylaxis and consultant awareness. Points for improvement: 1. Forms often partially complete. 2. Delivery times cat 2 & 3. Post-op review ?D1 reviews and mode delivery of next pregnancy.

On going CNST audit 21/2/13 (CP)

3311 Audit of Driving Advice Provided by the A&E Dept

Dr Gillian Kelly, A&E Consultant (Richard Simpson, GPVTS)

To evaluate how well A&E doctors provide accurate and relevant advice about driving to patients who attend the department with relevant symptoms/signs.

Integrated Medicine

06/09/2011 Complete 19/12/2011 Conclusion; All grades of practitioner missed opportunities to give appropriate driving advice. Documentation that appropriate driving advice was given was poor. Patients presenting with severe mental illness or a past diagnosis of epilepsy were the scenerios where doctors were most likely to fail to document the provision of appropriate driving advice. Recommendations; Emphasis should be placed on recognizing when driving advice is necessary and checking what it should be from the available guidance/poster. It should be an aim that all patients who present with a seizure, collapse, alcohol-related problems, mental illness and visual problems should have driving advice specifically documented. Poster to be drafted and put up in the A&E department. Information leaflet for patients to be drafted and distributed..

Changes required

3312 National Diabetes Multidisciplinary Footcare Team Foot Ulcer Audit

Dr Stephen Gardner, Diabetes & Endocrinology Consultant (Jane Coles, Erin Lee, Podiatrists)

This is a pilot project being undertaken by NHS Diabetes of Diabetes Footcare Services. Data to be collected on all patients presenting with a new foot ulcer between the 1st September and 30th November 2011.

Integrated Medicine



3313 VTE Audit Trauma & Orthopaedics

Jonathan Pattinson, Consultant Haematologist (Laura Watts, Dr Panchal, F1s T&O)

Part of rolling VTE audit which involved audits 3090, 3205, 3256, 3274 which looks at VTE assessment and prophylaxis in each division. This audit relates to Trauma admissions. 30 admissions from 26/8/11.

Specialist Services

07/09/2011 Complete 03/02/2012 Results: None of the 40 patients included in the audit were non-compliant with the guideline (Table 1), meaning that all patients received appropriate prophylaxis. However, only 57.5% were fully compliant with the guideline, leaving 42.5% in whom appropriate prophylaxis was given, but without any evidence of a VTE risk assessment having been performed. Recommendations: Posters in the trauma office reminding SHOs to fill out VTE assessments when admitting new patients. A talk on the importance of VTE prophylaxis. An email sent out to admitting doctors reminding them that it is their responsibility to complete the VTE assessment and prescribe accordingly on admission. Add information on DVTs and PEs to the weekly morbidity and mortality meeting which happens every Friday afternoon. Altering the VTE assessment form so that it is more user friendly, and making in stand out more by adding some colour and a larger title so that it is more likely to be filled in. Nominating members of staff to be responsible for checking the VTE form. For example, increasing

Email sent to Trauma consultants with some of our results as a gentle reminder to let the juniors know to complete the form on admission. Also trying to add another button to the PMS system to remind everyone to complete the form. This would remind the juniors, let the consultants know on the Friday round who hasn't had one as it appears on the list, remind the nursing staff to pester the doctors to fill it out as well as hopefully make further auditing easier. Contacted IT about this but still awaiting reply.

awareness among nurses so that they could check whether a VTE assessment had been completed for their patient on admission. Also at the John Radcliffe Hospital in Oxford on the post-take general medicine ward rounds the post-take form which has to be completed has a box stating whether the VTE assessment has been completed.

3314 Post-Delivery Blood Transfusions

Dr Drake, Consultant Anaesthetist (Eleanor Harvey, CT2 Anaesthetics)

An audit of Hb level at which patients are transfused post-delivery and the Hb level they are transferred to. RCOG guidelines.


07/09/2011 Complete 15/10/2012 Appropriate adherence to RCOG Guideline for transfusion is evident. The re-audit shows improvement in measuring pre-transfusion Hb; 10-15% transfusions were for Hb>8 (Guidance states little evidence of benefit for fit healthy asymptomatic pts, but most of these patients are deemed as lethargic and hence tranfused); majority of transfusions were 2 or 3 units of PRBC, appear to be aiming for Hb of 10. No recommendations for change were made.


3315 Fetal Monitoring Audit

Miss Veronical Miller, Consultant, Obs & Gynae, Amanda Mansfield, Consultant Midwife, Lucy Spanswick, GPVTS

Fetal monitoring in labour against the trust guidance for best practice.

Specialist Services

19/08/2011 Complete 17/11/2011 No changes as no results or recommendations received 21/2/2013 (CP)

3316 NASH (National audit of Seizure Management)

Dr Mike Kazer, Staff Grade, A&E

Audit tol examine the facilities and care available to patients presenting to Emergency Departments with seizures in order to identify how best to change services to reduce the numbers presenting at hospital.

Integrated Medicine



3317 Personal Protective Equipment Audit July 2011


Use of personal protective equipment tool in all wards to evaluate if infection control guidelines are being followed.

Specialist Services

13/09/2011 Complete 25/10/2011 Compliance by question varied from 92% to 100%, with an overall compliance of 99%. 68 of the 80 areas were compliant for all applicable questions. Action plans were only completed for 2 of the 14 “No” responses.

Infection Control are responsible for ensuring that all areas complete action plans if non compliant for any question and that action plans are followed up to ensure actions completed. Re-audit next year.

3318 Rhuematology/Podiatry Joint Annual Review Clinic PES

Antonia Fisher, Podiatry rheumatology lead

Podiatry now involved in rheumatology annual reviews. Want to get patients views on these.

Specialist Services

13/09/2011 Complete 11/02/2013 Results: Low (63%) numbers of patients who saw a podiatrist in the annual review clinics. The summary of results for the specialist nurses were all very positive, with all respondents very satisfied with the assessment undertaken and the outcome of the appointment and the action to deal with any problems identified. All of the patients seen by the podiatrist reported a positive experience. Recommendations: Need more patients to fill the clinics.Need a podiatrist to see all the patients. Need to look at increasing the things the specialist nurses can do independently of the doctors.Look at providing a pack of information or making more information more readily accessible and to include the outcome of the individual assessments.

Changes required

3319 Biological Therapy in RA: Are we NICE compliant?

Dr Sally Edmonds, Consultant Rheumatologist (Dr Jasroop Chana, Rheumatology, ST5, Dr Shoma Banerjee, ST3)

Audit of patients commenced on biologics (anti TNF) for RA since 2007 to assess whether they are being initiated and monitored as per NICE guidance.

Integrated Medicine

14/08/2011 Complete 01/02/2012 General trend from 2007 to present was of increasing guideline adherence. 6 monthly monitoring possibly hindered by lack of appointments / cancellations / DNAs. TNFi trialled for longer than 6 month period due to issues with infections, low blood counts etc. Excellent patient focused care but NICE would like more information provided to patients. Overall performance was good but there were differences between sites. Recommendations: 1. Standard format for Biologics data across all sites (better use of database?). 2. Improve documentation. 3. Provide patients with ‘Understanding NICE guidance’ booklet and information about the departmental service. 4. Re-audit

Changes required

3320 CEM Audit of Pain in Children 2011

Dr Mike Kazer, Staff Grade, A&E (Clinical Audit Lead A&E)

A national audit of the management of pain, in children, against CEM standards.

Integrated Medicine

01/09/2011 Cancelled 11/10/2012 Mike Kazer said that staff did not complete audit and no data submitted. Change in computer systems used in A&E and the difficulties this has produced in extracting clinical reports for such audits.

Audit cancelled.

3321 CEM Audit of Severe Sepsis and Septic Shock 2011


A national audit of the management of severe sepsis and septic shock against CEM standards.

Integrated Medicine

01/09/2011 Cancelled 11/10/2012 Mike Kazer said that staff did not complete audit and no data submitted. Change in computer systems used in A&E and the difficulties this has produced in extracting clinical reports for such audits.

Audit cancelled.

3322 CEM Consultant Sign Off Audit


In December 2010 the College of Emergency Medicine published a standard

Integrated Medicine

01/09/2011 Complete 22/12/2011 National Audit results published 22/12/2011. In total, 9142 cases from 134 EDs, of which 126 were in England (64% of English EDs), were included in the audit between Monday 5th September 2011 (9 am)

A re-audit will be carried out by the CEM in February 2013.

for “Consultant Sign-Off” in Emergency Departments. The purpose of this audit is to assess current levels of compliance with this standarad.

and Monday 19th September 2011 (9 am). Overall 12% of discharged patients (Table 1) and 11% of all admitted and discharged patients (Table 2) were seen by a consultant/associate specialist. 44% of discharged patients and 41% of all audited patients were seen by an ED doctor of ST4 seniority or above. In total, 22% were seen by or discussed with a consultant/associate specialist. Overall, data from 134 EDs show that only 12% of patients in the identified high risk groups are seen by a consultant prior to discharge, but nearly half are seen by a ST4 trainee or more senior doctor, which is encouraging. The current gaps in consultant cover are clearly demonstrated, particularly in the evenings and overnight, and progressive expansion within the consultant tier should work to address this.

3323 Adult Asthma Audit (BTS) 2011

Dr Anjani Prasad, Respiratory Consultant (Dr Su Lyn Leong, SpR)

An audit of asthma management in adults against the standards contained in the BTS/SIGN British Guideline for the Management of Asthma.

Integrated Medicine



3324 Bronchiectasis Audit (BTS) 2011

Dr Anjani Prasad, Respiratory Consultant

The source of the standards for the BTS Bronchiectasis audit is the BTS Guideline for non-CF Bronchiectasis (July 2010).

Integrated Medicine



3325 Oxygen Therapy Audit

John Quinn, SDU Director, Pharmacy (Satinder Bhandal)

Audit of the prescribing, administration and monitoring of oxygen therapy over a week for all wards with the exception of ITU and neonatal intensive care units.

Specialist Services

01/04/2011 Complete 16/09/2011 Recommendations: The results of this audit need be fed through the Divisional Structures and Safety Score Cards within the Trust. Individual ward teams must be made aware of their performance relative to the standards and to other ward teams. Good prescribing, administration and monitoring of oxygen should form part of Key Performance Indicators for the wards. Further ongoing training needs to be carried out for all healthcare professionals involved in the prescribing administration and delivery of oxygen therapy. This audit needs to be repeated quarterly with refinements as prescribing and monitoring rates improve. Pharmacists must ensure patients do not receive oxygen without prescription or with inappropriate monitoring on wards to which they provide a clinical pharmacy service.

Changes required

3326 Management of Multiple Pregnancies against CNST guideline

Miss Aparna Reddy, Consultant, (Joanna Goldie, GPVTS) Obs & Gynae

Audit of management of multiple pregnancies based on CNST guideline. 30 patients between January and April 2011.

Specialist Services

01/09/2011 Complete 17/11/2011 1. Twin information leaflets should be readily available in consulting rooms to give to patients. 2. Be aware of page 21 in antenatal book. It has preferences to tick for options during labour- maybe a good prompt. 3. A pre-prepared sticker with tick boxes for the things that need to be documented antenatally. This appears to have worked well for VBAC discussions.

No changes received 21/2/13 (CP)

3327 Audit of Use of the Customised Growth Chart in the Identification of Small For Gestational Age Babies

Miss Aparna Reddy, Consultant Jackie Baxter, Divisional Clinical Governance Midwife, (John Heathcote, FY), Obs & Gynae

Audit of the use of the customised growth chart in the identification of small for gestational age babies. Prospective audit of 100 maternity case notes during the month of October 2011.

Specialist Services

01/10/2011 Complete 15/04/2012 Results: 96% records contained CGCs. 92% charts contained 3 or more plots. 31/98 (32%) suspicious patterns identified. 17/31 appropriate action taken. 14/31 incorrect management. 1/14 babies born with low birth weight. Recommendations: Need for further in house training and through National Perinatal Epidemiology Unit. Ongoing audit with presentations to multidisciplinary team.

Changes required

3328 Audit of Malignant Melanoma in Buckinghamshire 2003 - 2005

Mr M Tyler, Consultant (Jonathan Cubitt, ST3) Plastics

Investigating patients who were diagnosed with melanoma in 2004 and 2005 focusing on the presentation, histology, complications, surgery and outcome. Comparing results to previous audit of patients diagnosed in 2003.


19/09/2011 Complete 24/07/2012 This was a retrospective analysis of all patients who were diagnosed with melanoma in 2003, focussing on the new diagnoses of cutaneous malnoma and excluding all non cutaneous melanoma and all patients who received their initial diagnosis before 2003. 82.9% of patients survived 5 years with no nodal, local or metastatic recurrence. 87.5% of patients survived 5 years, overall, irrespective of recurrence. There was no significant difference between the recurrence rates in women or men.

No recommendations for change made. Audit being written up for publication.

3329 Audit of Malignant Melanoma in Buckinghamshire 2010

Mr M Tyler, Consultant (Jonathan Cubitt, ST3) Plastics

Comparing current practice to the recently published guidelines.


19/09/2011 Complete 12/03/2012 SMH is adhering to The American Joint Commission on Cancer (AJCC).

No changes required, guidelines are being adhered to, continue adhering to current guidelines.

3330 National Cancer Intelligence Network - Secondary Breast Cancer Project

Mr Giles Cunnick, Consultant, Breast Surgery (Fiona Charlton, Surgical Practitioner)

To support the piloting of the collection of data on recurrent and metastatic breast cancer. The aim of the pilot is to ascertain what information about patients presenting with local and distant recurrences and metastatic disease can be gathered through local MDTs and to compare with routine data collected via cancer registries. During 2011/12 we will pilot the collection of data on recurrence/metastase


20/09/2011 Complete 01/06/2012 The following recommendations aim to support better data collection and improved care for patients with recurrent and metastatic breast cancer: 1) All breast cancer units in England to submit data on patients with recurrent and metastatic breast cancer through the NCWTMDS. 2) Breast Unit MDT co-ordinators and data managers should ensure, in collaboration with clinical colleagues, that data are collected for each breast team. 3) Additional information on supportive care is to be collected as required from January 2013 in the COSD. 4) GPs to ensure that patients with a previous history of breast cancer and symptoms that could indicate recurrent or metastatic disease are referred urgently for assessment through the existing cancer wait process. 5) Providers should ensure that local arrangements are in place for urgent clinical review of patients with suspected recurrence or metastasis. 6) Patients with recurrent or metastatic breast cancer should receive multidisciplinary care and the support of a CNS, as outlined in the NICE breast quality standard.

Data is collected on all breast cancer patients as part of the cancer waiting time targets. Additional information on supportive care, part of the COSD, will be collected as soon as possible. The database has been purchased and work is underway. All GP referrals for breast patients are now booked and seen within two weeks (irrespective of whether they suspect cancer), in line with national guidance. Local arrangements are in place for urgent clinical review of patients with suspected recurrence or metastasis. Patients with recurrent or metastatic breast cancer receive multidisciplinary care and the support of a CNS, as

s on patients with breast cancer with the aim of undertaking full collection from April 2012.

outlined in the NICE breast quality standard.

3331 Abdominal Surgery Mobilisation

Sam Burden, Physio A clinical indicator has been developed and tested by consultant at London Hospital stating that 80% patients having major abdominal surgery should be walking 30m by day 3 after surgery. This is an audit of surgery patients at SMH to determine how we compare.

Specialist Services



3332 NSIC/Shepherd Centre Skype Rehabilitation Comparison

Kirsten Hart, Clinical Specialist Physiotherapist

A comparison of the rehab process and discharge outcome between 2 adolescent SCI establishments, NSIC and USA privately funded Shepherd Centre.

Specialist Services



3333 Antibiotic Prophylaxis in Surgery

Dr Waghorn, Consultant Microbiologist, Trust Antimicrobial Pharmacist (no-one in post)

We have guidelines relating to antibiotic prophylaxis at surgery. Audit to look at 12 different types of surgery and compare with guideline. 15 cases from each surgery area to be audited for a 6 month period every year.

Specialist Services

27/09/2011 Complete 30/04/2012 Results: 82/170 (48%) patients were given incorrect antibiotic prophylaxis. Recommendations: 1. Highlight the individual surgical category results of this audit to the relevant SDU lead and make sure they are aware of current prophylaxis guidelines. 2. Highlight the results of prophylaxis documentation to the anaesthetic SDU lead so that recording of regimens particularly on prescription charts increases.3. Discuss with senior theatre management a potential revision of the WHO Surgical Checklist to improve the prompting of surgeons/ anaesthetist for prophylaxis. 4. Confirm with senior theatre management that there are member(s) of staff in each theatre area responsible for holding the most up to date surgical prophylaxis guidelines so that

Meeting held with Matron Alison Byrne, Pre-op Assessment. Asked to take up improved documentation in urology patients of catheterisation status and pre-op urine culture results.Audit report with individual covering letter distributed to all relevant SDU management and clinical governance leads requesting review of report, dissemination of results within their departments and improvement in antibiotic prophylaxis consistency with

they are immediately available for surgeons/anaesthetists. 5. Next audit based on Jul-Dec 12 data.

Trust guidelines.Anaesthetic SDU representatives asked to increase documentation of antibiotic administration on Trust prescription charts. New Theatres Medicines Policy also introduced November 2012 to support prophylaxis documentation on drug charts.Meetings held with senior theatre and urology staff to agree change to WHO surgical checklist in order to raise awareness of potential need for antibiotic prophylaxis at the pre-induction stage. Amended checklists introduced December 2012 across Trust.Meetings held with senior theatre and pharmacy staff to establish specific responsibility for making sure current versions of Trust prophylaxis guidelines are available in all theatres across both Trust sites. New folders containing relevant guidelines introduced Wycombe September 2012 and Stoke Mandeville October 2012.

3334 Sharps Management August 2011



Specialist Services

21/09/2011 Complete 10/10/2011 Scores varied by unit from 78% “Yes” responses to 100%. Overall compliance was 95%. 2 wards had an overall compliance less than 85% target. Overall compliances by division varied from 90% (Women & Children) to 97% (Medicine). Compliance had reduced considerably for the following questions: Are sharps bins stored safely, away from the public and out of reach of children? (90%), Is an empty sharps bin available on the cardiac arrest trolley? (89%). 9 of the 54 units (17%) should have completed an action plan but didn’t. 10 of the 54 units (19%) returned incomplete action plans, where there was no action for at least one of the “No” responses.

Infection Control are responsible for ensuring that all areas complete action plans if non compliant for any question and that action plans are followed up to ensure actions completed. Re-audit next year.

3335 Omission of Antibiotics SMH Nov 2010

Timothy Lim, FY1 The omission or delay of doses of critical medicines such as antibiotics can result in serious patient harm, and omissions of intravenous medications are widely reported in

Medicine 01/11/2010 Complete 01/04/2011 2.74% (43/1569) doses were omitted during the survey period affecting 16.8% (24/143) of patients. Of these, 20.9% (9/43) of missed doses were associated with documented harm affecting 20.8% (5/24) of patients who had doses omitted. 2 patients developed pyrexia >37.5°C with 1 developing tachycardia and another hypotension. The other 3 patients developed low-grade fevers (37.3-37.5°C). Despite the existence of medicine ‘not administered’ codes, the most common reason for omitted doses

Changes required

hospitals. The aim of this audit is to quantify omitted doses of intravenous antibiotics in Stoke Mandeville Hospital.

was no entry on the drug chart (48.8%). Other reasons included the patient being off the ward (18.6%), lack of venous access (6.9%), wrongly prescribed antibiotics (6.9%) and medications not being on the ward (6.9%). Action Plan1. Contact Nursing Director regarding training of nurses in timely administration of IV antibiotics, usage of ‘Medicine not administered’ codes and cannulation skills.2. Contact Pharmacy Director regarding changes to drug charts, ensuring adequate supplies of antibiotics and minimising the time that drug charts are off wards.3. Teaching for junior doctors on antibiotic prescribing and the importance of ensuring venous access in patients needing IV antibiotics.Re-audit will occur in November 2011.

3336 Parenteral Nutrition (TPN) and associated Line Infection Rates

Bernadette Tavner-Allsopp, Dietitian

Intestinal Failure Network (SHIFNET) formed as a result of NCEPOD June 2010. The hospitals which provide TPN will collate agreed TPN data annually to monitor use, safety and good medical practice. All adults who receive TPN in BHT to be audited.

Specialist Services

27/09/2011 Complete 30/09/2012 Recommendations: 1.Collect data prospectively: this will reduce error and reduce the incidence of missing data. It will also allow a more rigorous reporting of line sepsis and the timely completion of DATIX forms. 2. Ensure each NT is collecting/ measuring data in the same way: to prevent confusion and misinterpretation enabling more consistency. 3. Ensure appropriate lines are used in all cases. 4. Ensure all CVC tips are sent for MC&S when TPN lines are removed.

Changes required

3337 Vetting of Endoscopy Request Forms

E Wells-Cole, FY1 Audit the vetting process over 1 month of inpatient and outpatient endoscopy requests from non-GI firms to see if appropriate requests and how they are prioritised.

Integrated Medicine

27/09/2011 Cancelled 22/12/2011 Cancelled Not applicable

3340 Post Natal Medical Discharge Planning

Geraldine Tasker, Consultant (Daniel Jackson, GPVTS) Obs & Gynae

Audit of completion of patient discharge forms for instrumental births and caesarian section.

Specialist Services

30/09/2011 Cancelled 18/11/2011 Audit cancelled. Project cancelled.

3338 Referrals to Level 3 Sexual Health from Level 2

Dr Veena Reddy, Associate Specialist, GUM

Analyse the reasons for referral and appropriateness.

Specialist Services

26/09/2011 Complete 22/02/2012 As seen in the Standards for the management of sexually transmitted infections, level 3 should be able to coordinate and support all levels of sexual health delivery. The results demonstrate that the two services had some differences in their reason for referral to Level 3. Both services required the tertiary expertise for genital wart management. However the nurse led service was unable to manage symptomatic females and needed further assessment – in particular a bimanual examination to exclude pelvic inflammatory disease. With the new level 2 service insertion of coils is part of the specification. This means that delivery must be by professionals that are able to conduct a pelvic assessment. A few instances of referral for administration of hepatitis B vaccination could be deemed inappropriate. There was duplication of sample taking sometimes because results were not sent with the referral and sometimes because the patient was symptomatic and needed microscopy. This has cost implications. At our annual meeting with the Practice this issue was discussed and action was taken to speed up the transfer of results. New contracts for level 2 have now been issued so only recommendation is that this is audited again after 1 yesr.

No changes required

3341 Peripheral Line Insertion and Continuing Care Audit June 2011


Patients with Iv cannula device in situ should have VIP form properly completed.

Specialist Services

05/10/2011 Complete 03/01/2012 Results: Insertion: 1153 observations were made from 40 wards/areas, the majority of which were from theatres. Overall compliance 92%.Continuing care: VIP forms were completed for 84% patients with IV lines. Insertion documentation was particularly badly completed. Overall the compliance for all applicable elements has increased from 44% to 47% since 2010. Recommendations: All high peripheral cannula user areas MUST complete no less than 20 assessments in both insertion and continuing care. Use of the VIP chart must continue to be promoted and is now part of the matron’s round to help ensure compliance. The continuing need to emphasise labelling of ALL giving sets that are used. To continue using red emergency stickers for

Education continued.

peripheral devices that are inserted in a manner deemed non-compliant with recommended practice. That education/ training continues to ensure that insertion and on going care of peripheral cannula devices is provided for all healthcare workers involved in this skill.

3342 Urinalysis Audit Sexual Health

Dr G Luzzi, Consultant GU Medicine (Dr Amanda Roberts, Associate Specialist, GU Medicine)

To ascertain whether too many MSUs are sent and whether treatment and follow up are appropriate.

Specialist Services

04/10/2011 Complete 26/07/2012 Results: All patients with bacteruria were treated according to Trust guidelines with correct antibiotics.More MSU specimens were sent for testing by following the Trust guidelines than would have been sent by following NICE guidelines. This resulted in patients with asymptomatic bacteruria being treated which is against the NICE guidelines. Recommendations: Only dipstick test those pregnant or with symptoms Only send MSU in symptomatic patients if there is NO concurrent infection with BV, Candida, TV, GC or known Chlamydia, unless dipstick is positive for nitrites. Advise follow up for patients with haematuria and positive MSU culture.

The recommendations have been actioned. Far fewer dipstick tests are being done and far fewer MSUs being sent after refining the criteria for sending. One change was made to the recommendations which was that all new patients would have dipstick urine testing on their first visit. This is currently being done but will be part of the next audit and will be reviewed.

3343 Audit of Accuracy of Clinical Coding of T&O Procedures

Mr Biring, Dr Aneesh Mohindra, T&O

An audit of the clinical coding of T&O procedures in order to assess whether inaccurate clinical documentation leads to reduced income from inappropriate coding.


06/10/2011 Complete 26/06/2012 Recommendations: Juniors: to be introduced to the importance of co-morbidities and complete documentation at admission and discharge via TTOs, including any complications; to be provided with lists of relevant co-morbidities at induction. Surgeons: highlight complications and abnormalities arising intra-operatively in the notes; consider coding book in theatres for staff to indicate operative code; monthly review of cases with senior surgeon (SpR/ Cons) for cases that coders are unsure of. Coders: education about fracture terms, e.g. Monteggia fracture being a fracture dislocation; highlight confusing cases at monthly meets in order to clarify and achieve consistency in coding; consider at source coding (in theatre) either via dedicated orthopaedic coder or via surgeons noting the procedure codes.Action plan: Meeting with hand consultant with cases needing clarification i.e. re: K-wires, June 2012 (A. Mohindra FY2); coders to be informed of finding of this audit and items of concern (K.Rolls); consultants to discuss merits of at source coding June/July 2012 (Mr Chennagiri/Mr Graham)

Junior doctor induction now includes information on the importance of documenting relevant co-morbidities. The audit has been presented to the surgeons and in addition, Kevin Rolls from the coding department has presented talks to the department on two academic half-days. It was agreed that the coders would get in touch with the relevant surgeon when in doubt about the codes rather than monthly meetings. Employment of a dedicated coder in theatres was discussed in the business meeting and was not considered viable at present due to the economic situation. The audit has been extremely beneficial in opening up a direct communication pathway between the coding department and T&O and it is expected that coding efficiency will improve.

3344 National Audit of Dementia 2012 (2nd round)

Dr Dominic Walshe, Consultant Medicine for Older People (Ana Phelps, SpR, MfOP)

A national audit looking at the care of patients with dementia in general hospitals.

Integrated Medicine

01/04/2012 Awaiting action plan

26/02/2013 Changes required

3345 Audit of Complication Rate and Cost of ORIF of Distal Radius Fractures

Ramesh Chennagiri, Orthopaedic Consultant (Nik Bakti CT2)

To assess rate of complications after distal radius ORIF. To assess implant choice and cost.


12/10/2011 Complete 03/05/2012 Summary: complication rates are well within figures described in literature; functional outcomes 1 year post recovery satisfactory; acumed implants cost effective in comparison to AO implants. Recommendations: utilise other resources such as physiotherapy to reduce number of outpatient visits; improve communication, e.g. information leaflets to patients to reinforce information at time of discharge.

A patient information leaflet is being trialled along with early discharge to physiotherapy. This is currently being audited with patients under the care of Mr Chennagiri and Mr. Graham to ensure that it works well before it is recommended for all patients.

3346 VTE Prophylaxis in Acute Surgery

Dr J Pattinson, Consultant, Haematology (Camilla Arthur, Surgery)

Audit to determine whether prescribing for DVT prophylaxis is meeting NICE recommendations for patients undergoing surgery for cancer, as well as orthopaedic (hip/knee replacement, major trauma and fractured neck of femur). This is part of rolling audit which is repeated each year.

Specialist Services


3347 Audit on the Use of Curosurf in NICU

Ruth Waters, Lead Pharmacist Women & Children (Yogeeta Bhupal, Pre-reg Pharmacist)

To identify whether curosurf is being prescribed and adminstered correctly and therefore cost effectively.

Specialist Services

14/10/2011 Cancelled 05/11/2012 Results and Recommendations required Changes required

3348 Audit of Consent for Hysterectomy

Miss G Tasker, Consultant, Obs & Gynae (Dr Kandiah Guruparan, SpR)

Retrospective audit of consent for elective hysterectomy in order to assess whether the RCOG and GMC standards were maintained during consent.

Specialist Services

07/10/2011 Complete 18/04/2012 There was 100% compliance with Use of Addressograph / labeling in every page; proper form usage [form 1]; details of procedure explained; benefits discussed; risks discussed[4 risks]; discussion regarding anesthesia; legible writing. Improvement required in leaflets given to patients (42%); copy of consent form to patient [26%]; documentation in clinical notes and notes keeping.

Changes required

3349 Baseline Audit of Putting Feet First

Erin Lee, Band 7, Podiatry, Jane Coles, Band 7, Podiatry

A one-day audit of all diabetic inpatients, looking at the number of patients, their risk rating according to NICE guidelines and the current inpatient care. The audit aims to draw up specifications for the proper management of the diabetic foot in secondary care. 21/11/11 - sent email to request data collection tools. (DB)

Integrated Medicine

18/10/2011 Complete 17/08/2012 Results: 15% of patients over all 3 sites had their feet screened on admission with only 7% of these patients beeing referred to the specialist team. However at the time the audit was carried out on 8th November 2011 it was indicated that 26% of patients should have been referred to the specialist team. Recommendations: Standardise screening tool. Develop an appropriate referral pathway alongside the Diabetes team. Develop the use of the Diabetic foot list on the PMS system across all hospital sites. Audit inpatient foot screening November 2013. Business case for a inpatient podiatrist band 7.

Changes required

3350 Long Term Outcome of Muller Resection for Ptosis

Miss R Khooshabeh, Consultant, Ophthalmology (Neena Porter, SpR, Ophthalmology)

Looking at surgical success rate of posterior approach ptosis surgery from year 2000 at SMH and WH.


18/10/2011 Complete 25/05/2012 In this audit of over 300 cases, we have shown that posterior approach Muller resection consistently achieves a high success rate, with 95 – 99% of eyelids achieving any one of target height, symmetry or contour, and 92% achieving all three. Its main advantages are that it allows both intra- and post-operative adjustment, thus giving a more predictable result with less frequent contour abnormalities and lower re-operation rates compared with anterior levator advancement. We conclude that isolated subtotal resection of Muller's muscle is a safe and effective procedure and can be used in the majority of ptosis patients with moderate to good levator function.

No changes required to current practice.

3351 Endoscopy Staff Experience Survey 2011

Sue Kenny, SMH Endoscopy Unit, Deborah Dobree-Carey, WH Endoscopy Unit

To assess levels of staff satisfaction and identify any areas for improvement.

Integrated Medicine



3275 Evaluation of Child Protection Supervision

Gerry Linke, Named Child Protection Nurse

To evaluate staff satisfaction with the group child protection supervision sessions provided to support staff dealing with children and their families.

Specialist Services

01/08/2011 Complete 06/02/2012 Recommendations: Feedback the results of this survey to staff. Up date staff regarding the supervision policy/child protection process and all legal processes. Actions: Arrange a series of workshops to feedback the results of this survey to staff. At the workshops also up date the: supervision policy, child protection process and all legal processes.

Changes required

3352 Parkinson's Hospital Medicines Management Audit

Catherine Northey, Pre-registration Manager (Lex Tomkins, Pre-reg Pharmacist)

Investigation into whether patients with Parkinson's disease have their medications correctly recorded and administered.

Specialist Services


3353 An Audit of Pharmacy Medicines Reconciliation in Buckinghamshire Healthcare NHS Trust

Lisa Pazik, Lead Pharmacist Emergency Medicines

Audit to look at: no. of reconciliations completed within 24 hours of admission, number of medicines signed and dated, more than one reference source for each item on the drug history, POD quantities recorded, medicines not prescribed have been actioned & medicines discontinued have a reason stated.

Specialist Services



3354 Laparoscopic Treatment for Endometriosis Patient Quality of Life Survey

Mr Tunde Dada, Consultant (Vasileios Minas, ST5) Obs & Gynae

A quality of life survey for patients who have had laparoscopic surgery for endometriosis.

Specialist Services

21/10/2011 Complete 18/04/2012 Laparoscopic treatment of endometriosis results in significant symptom relief, regardless of stage. This effect appears to persist for up to 36-48 months following surgery. There was overall a statistically significant drop in QOL score from 47 to 27 following surgical treatment range 0-100, score=100 represents worst quality of life. Recurrence rates are higher with longer follow up and higher endometriosis stage. Local recurrence rates are similar to those reported in the literature. The number of reported symptoms is not a reliable factor in assessing severity of endometriosis pre-operatively. Recommendations: 1. Surgical treatment for endometriosis is operator-dependant, therefore it may be important for Trusts to be able to show own results. 2. Incorporate results in leaflet/care pathway (perhaps use as aid in counselling locally).

No changes forthcoming.

3356 Reaudit of WHO Surgical Safety Checklist

John Abbott, Deputy ADO, Surgery

Re-audit of compliance with the WHO Surgical Safety Checklist May and June 2012.


29/06/2012 Complete 16/11/2012 To re-visit the patient checklist in the intra-operative booklet for elective plastic and orthopaedic joint replacements as an audit of the clinical notes by the audit department within 6 months; matrons to spend some clinical time with medical teams who are reported to have poor engagement with the WHO process; new WHO to go live in all theatre areas as recently ratified by the Theatre Steering Board and the Surgical Divisional Board; repeat full audit in 12 months time with suggested review of the WHO policy.

Changes required

3357 Long Line Venous Catheter October 2011


To evaluate the results of the High Impact Intervention (HII) Central Venous Catheter tool used in the Saving Lives Infection Control programme. ITU and St Andrews only.

Specialist Services

01/10/2011 Complete 20/01/2012 Compliance was very good but forms completed incorrectly affecting results and giving an underestimated compliance of 88%.

No signed off action plans received. New procedure for next peripheral line audit - action plans will be created for the wards by the OPAT team.

3358 Trustwide Consent Audit 2011

To assess the extent to which appropriate consent is obtained from patients within the Trust. To assess the quality of consent obtained from patients within the Trust. To educate clinicians in the standards of consent expected by the Trust.

Trustwide 01/11/2011 Draft Report with Clinician


3359 Outcome of Pregnancies Complicated by Gestational Diabetes (BHNHST) Re-Audit

Mr Tunde Dada, Consultant, Deborah Bett, Diabetes Specialist Midwife, Dr Archana Ranganathan, SpR, Obs & Gynae

An audit of outcomes such as mode of delivery, birth weight, admission to NICU and number of babies treated. Audit against standards and comparison of results with audit in 2009 (2479)

Specialist Services

01/11/2011 Complete 14/06/2012 Results: 1. Higher induction rates although median GA similar (?significance due to smaller numbers). 2. Delay in IOL associated with increased CS rate. 3. Elective LSCS rates higher. 4. Overall perinatal outcomes are comparable to ACHOIS. 5. More adverse perinatal outcomes in women diagnosed after 36 wks. Recommendations: 1. Larger audit to compare outcome of GDM induced at 38 + and 39 + weeks. 2. ?Delaying IOL in VBAC to improve VBAC rates.

Changes required

3360 Review of the use of HPV testing in Colposcopy Clinic (BHNHST)

Miss Deborah Sumner, Consultant, Obs & Gynae

HPV testing has been introduced to try and help the management of colposcopy patients and hopefully allow discharge of patients from clinic. This is a re-audit to determine whether HPV testing has helped management and whether patients have been discharged from clinic. Previous audit was 2949.

Specialist Services

28/10/2011 Complete 18/04/2012 No recommendations for change were made. No recommendations for change were made.

3361 Audit of GP 6 Month Follow-up Appointment Post Stroke

Dr Burn, Stoke Consultant (Dr Alison Rowlands, ST1 GPVTS

Audit of GP 6 month follow up appointments post stroke to see what checks are carried out.

Integrated Medicine

28/10/2011 Cancelled 01/03/2012 Cancelled - junior doctor realised the planned methodology for this audit was flawed.

Not applicable - cancelled

3362 Pneumonia Mortality Review


Review of mortality in inpatients over 75 with a diagnosis of pneumonia, during December 2010 and January 2011, following an enquiry from the CQC.

Trustwide 26/10/2011 Complete Results and Recommendations required Changes required

3363 Multiple Territory Infarcts in MRS and Malignancy

Dr C Durkin, Consultant, Medicine for Older People (Dr K Nagaratnam, ST6, MfOP)

Retrospective analysis of patient records, PACS and pathological reports of patients who presented with stroke (multiple territory infarct) and a diagnosis of cancer that was either made pre or post cerebrovascular event.

Integrated Medicine

31/10/2011 Cancelled 06/11/2012 Cancelled. Dr did not provide any lists for audit. No contact since January 2012.

Project cancelled.

3364 Delayed Discharges from Urology

Paul Hadway, ST7, Urology

An audit looking at Urology patients discharged during August 2011 and identifying those whose discharge was delayed and the reasons why.


03/11/2011 Cancelled 28/08/2012 Audit not completed due to lost data. Project cancelled

3365 OPAT IV in the Community PES

Marie Coward & Sian Bates, IV Specialist Nurses

This PES is being carried out as part of the admission avoidance evaluation project. Patients receive iv antibiotic therapy at home rather than in hospital. The purpose of this survey is to obtain patient feedback regarding the service being provided Nov 2011-July 2012.

Integrated Medicine

02/11/2011 Complete 31/08/2012 Without exception, the service has received very positive reviews and has been very well received. Both the IV Therapy Team and the Adult Community Healthcare Team have performed very well with all patients reporting excellent, efficient and professional service. Some patients did not receive information at the point of discharge about the service, however, they indicated that they were fully informed when at home. Recommendations: 1. IV Therapy Team to ensure every patient on the service receives a questionnaire. A tick box will be added to the patient discharge summary. 2. Ensure that all patients receive written information about the service prior to discharge and reaffirm that this information is understood when at home.

Changes required


Jane Eastman, Jenny Grievson, Senior Physiotherapists



24/10/2011 Complete 03/04/2012 Recommendatons: Feedback the results of the audit to Orthopaedic consultants, anaesthetists, nursing staff and business manager, involved in the ERP; establish data set for next audit period with reference to ERP; compare 2012 benchmark LOS data for primary elective joint replacement project against prospective data as ERP becomes more established; continue to increase percentage of patients with a LOS of 4 days or fewer; establish pre-op education for all primary THR & TKRs.

Copies of the audit report were issued to individuals involved in the ERP. The data set was discussed with the ERP team and minor changes were made for the next audit period to tailor it to the ERP with particular reference to anaesthetics and recording a POMS defined morbidity. The data set for April to September 2012 is ready to be audited and will be analysed to determine the median LOS for primary elective joint replacement. It is hoped that this latest data will reflect a massive improvement in attendance at pre-op education.

3367 Prescription of Nifedipine for Spinal patients at Risk of Autonomic Dysreflexia

Mr M Belci, Spinal Consultant (Temitope Ayorinde, SHO)

To assess rate of prescription of nifedipine among patients at risk of autonomic dysreflexia. Compare to NICE guideline.

Specialist Services

07/07/2011 Complete 07/12/2011 Poor practice of prescribing antihypertensives for in-patients at risk of AD. This will increase the chances of discharging these patients without an antihypertensive. Inconsistent dosing regimen for Nifedipine among adults. Recommendations: Current NSIC guidelines need to be updated and should include guidelines aimed at: 1. Mandatory antihypertensive prescription PRN for patients at risk of AD. 2. Consistent dose regimen for adults. 3. Explicit description of how antihypertensives for AD should be administered. Particular emphasis should be made on the administration of Nifedipine as it is the most used for this purpose in the NSIC. 4. All relevant staff should be made aware of all existing local guidelines for the management of AD. 5. Method of prescribing Nifedipine should be reviewed. Its current prescription of ‘sublingual’ appears confusing especially to nursing staff who administer the medication. 6. Improve the practice of prescribing an antihypertensive for patients with injuries at or above T6 especially among high lesions and more

The Spinal SHO guidelines are in the process of being updated.There is more awareness now among the doctors especially SHOs and verbal reports from pharmacy suggest that an antihypertensive for AD is being prescribed more for relevant patients at risk. The paediatric and adolescent guideline for treatment of AD has now been made available in the training folder for all doctors in the unit.Prescription now includes bite and swallow compared to sub lingual as emphasised in the updated spinal SHO clinical guideline.Working on getting it on the

complete injuries PRN. 7. Improve the practice of providing additional instruction for when antihypertensive is indicated in this group of patients. 8. Consider the introduction of a section for stating the neurological level of patients on drug charts to enable pharmacy to alert doctors and remind them when a PRN antihypertensive prescription appears to have been missed for a patient being discharged.

Trust guidelines so that it would be available on the Intranet for other departments in the hospital.

3368 Percentage of Smokers who Accepted a Referral to Support services at Pre-op Assessment

Alison Byrne, Sister Pre-op Assessment

To establish whether the smoking status of patients is being established at pre-op assessemt and whether smokers are being referred/accepting referral to Smoking Cessation Services.


07/11/2011 Cancelled 02/05/2012 Results and Recommendations required Changes required

3369 Screening for Tuberculosis and Blood-borne Viruses in Patients due to start Anti-TNF Therapies

Dr Malgorzata Magliano, Consultant, Rheumatology (Dr Olaa Mohamed-Ahmed, FY1)

A retrospective, multi-centre audit to consider whether appropriate screening is taking place in Stoke, Wycombe and Amersham patients due to start anti-TNF therapy. The audit will also consider whether efforts to screen are effectively documented in the notes.

Integrated Medicine

07/11/2011 Cancelled 06/11/2012 Cancelled. Doctor left trust without completing audit. Project cancelled

3370 Pre-op Blood Test Protocol Compliance

Dr Caroline Pritchard, Consultant, Anaesthetics (Dr Jennifer Taylor, FY1)

To compare pre-op blood bank tests (e.g. Hb group and save) on elective surgical patients with those recommended by hospital guidelines.




3371 Time Delay between Prescription and Administration of the First Dose of IV Antibiotics in NSIC

Mr Mofid Saif, Spinal Injuries Consultant (Dr Wail Ahmed, SpR)

Prompt administration of IV antibiotics is vital in management of septic patients. This audit assesses the scale of the delay in administering first dose IV antibiotics in septic patients in the NSIC

Specialist Services

15/11/2011 Complete 15/11/2011 Results: The audit demonstrated a high percentage (42 %) of potentially harmful incidences of delay in administration of the 1st dose IV antibiotics in septic patients. Only in 83.3 % of the incidents, 1st dose of IV antibiotics was prescribed STAT. It also demonstrated the lack of documentation of time by nurses in 34% of incidences and by doctors 14%.

A Sepsis – Integrated Care Pathway (with adaptations for spinal patients) was agreed upon and came into practice. Had discussions with pharmacist to make sure that the IV antibiotics are available within reach of the wards, especially during weekends and out of hours time. Re-audit June 12. (3361) (AC)

3373 Outcome of Occlusion Audit

Mr Nigel Cox, Consultant Ophthalmic Surgeon (Rachel Gallaher, Head Orthoptist, SMH)

To determine the effectiveness of occlusion treatment at SMH




3374 British HIV Association National Audit 2011

Dr Veena Reddy, GU Consultant

National audit looking at timeliness of HIV diagnosis and impact of 2008 national

Specialist Services

17/11/2011 Complete 01/11/2012 We performed in the top quartile for most areas. It highlighted our lack of access to psychological services (no action that we can take). The only suggested action was to do a patient satisfaction

None required

testing guidelines, in particular: local action to promote testing, circumstances of diagnosis, previous history and missed opportunities for testing, time from first positive test to be seen in HIV service. A survey of local testing policy and practice. This was a national audit for which we submitted information on 100 case notes. BHIVA sends a report with a breakdown of overall results and Trust results.

survey which is occurring.

3375 Mortality Review April 2011 - September 2011



Trustwide 21/10/2011 Complete (no changes reported)

30/05/2012 The Medical Director is to review the notes of the 4 patients where death was potentially avoidable and 1 where it was probably potentially avoidable. The Chief Nurse and Director of Patient Care Standards is to review the notes of the 10 patients where fluid balance was identified as being poorly managed as well as the notes of the patient where the reviewer stated that death was not potentially avoidable but commented: ‘Unlikely but earlier fluid resuscitation may have been helpful’. The outcome of the above reviews will determine whether the cases should be declared as Serious Incidents. Outcomes and associated action required will be communicated to the appropriate staff within the organisation.

Changes required

3376 An Audit of Nursing Homes to See if Diabetics are Receiving Appropriate Care

Ledwina Mutandwa, Diabetes Specialist Nurse

A pilot of 8 nursing homes. Includes questionnaire on general care of diabetics at nursing home, diabetes quiz for all staff and audit of all diabetic patients to see if received appropriate care

Integrated Medicine

18/11/2011 Complete 09/03/2012 Results: The pilot study showed that diabetes care in nursing homes is not satisfactory. Blood sugar was not tested frequently and annual reviews were not carried out. Staff scored 78% on average in the diabetes quiz but scores varied from 43% to 95%. Basic questions to do with the patient's care were often answered incorrectly. Recommendations: To set up study days on diabetes for care home staff. Send resource packages and care plans to all homes. Identify link nurse in each home and arrange meetings with them. Provide referral pathway and contact numbers. May be necessary to train district nursing team. Extend surveys to all care homes.

4 study days have been carried out and more planned. Still working on care plans. Link nurses have been identified but difficult to maintain contact because of staff turnover. Referral pathway and contact numbers have been provided to all homes. Working with district nurses to find ways of getting them involved.Overall it has been a learning curve with positive out comes on care of people living with diabetes in residential homes.

3377 Infected Hip Mr G Biring, Deep infection Surgery and 21/11/2011 Complete 22/06/2012 Older patients with significant co-morbidity appear to The findings have been noted

Hemiarthroplasty Consultant, T&O (Ben Dean, Orthopaedic Registrar)

following a hip hemiarthroplasty for fractured neck of femur is an uncommon but serious complication. This audit will look at the natural history and bacteriology of the disease in patients with proven deep infection after hip hemiarthroplasty, with a particular focus on factors affecting the chances of successful debridement and implant retention (DAIR).

Critical Care be at greater risk of deep infection after hip hemiarthroplasty. Debridement and implant retention (DAIR) has a low chance of success in this complicated group of patients and this may be associated with the high incidence of coliforms as the infecting organism. More than one attempt at DAIR appears futile and a Girdlestone's Procedure is advised after one failed DAIR.

by the consultants and a re-audit will take place in a year or two.

3378 Mountain Bike Injuries

Mr Belci, Spinal Consultant (R F Shoaib, ST5)

Are we following correct guidelines with regard to recording of mechanism of injury and performing correct investigations?

Specialist Services



3379 Quality of Orthodontic Photographs

Helen Travess, Consultant, Orthodontics (Helen Veeroo, SpR)

Audit of the quality of intraoral and extraoral orthodontic photographs taken by medical illustration.


28/11/2011 Complete 25/07/2012 90% of clinical photographs should meet gold standards; less than 5% should fall into category ‘not clinically useful’. For clinical photographs taken at start of treatment, 63% met gold standard and 11% were not clinically useful. For clinical photographs taken at end of treatment, 78% met gold standard and 7% were not clinically useful. Recommendations: improvement in positioning for intra-oral buccal photos; check patient is smiling naturally; confirm position of frankfort plane; repeat if eyes closed; ensure nothing obscuring teeth; re-audit in 2 years.

Findings were fed back to medical illustration with suggestions as per the report.

3380 Reporting of Orthodontic Radiographs

Helen Travess, Consultant, Orthodontics (Helen Veeroo, SpR)

Audit of the reporting practices within the Orthodontic Department for radiographs.


28/11/2011 Complete 25/07/2012 58% radiographs were not reported in clinical notes. 43% had no form of report at all. Recommendations were to ensure that all radiographs are reported; use stamp to help remember to report each xray taken; even if tracing put in file refer to it in clinical notes; re-audit in 1 year.

Labels being printed to place in notes to complete radiography reports for each xray taken, including assessment of quality.

3381 Audit of Retinopathy of Prematurity Screening

Dr G Sarkar, Consultant Paediatrician (Dr Sae Run Nisa Rizwan, SpR LAS)

An audit to assess whether the Trust is complying with retinopathy of prematurity screening guidelines.

Specialist Services



3382 Audit of Cholecystectomies

Mr A McLaren, Consultant General Surgery

Audit of all cholecystectomies between 1st May to 31st October 2011 looking at complications.




3383 Isolation Precaution Sign Audit

Danielle Parrott, Student Nurse on placement with IPC department

Audit to determine if isolation precaution signs are being displayed in line with Isolation Policy.

Specialist Services

01/10/2011 Complete 02/12/2011 The results show fairly poor use of the isolation precaution signs. In the current infection control manual there is no mention of precaution signs in the isolation policy. This should be added.The link infection control nurses on each ward should emphasise, to the ward staff, the importance of maintaining the isolation precautions sign for both staff and visitors.The link infection control nurses should monitor compliance with the policy within their area and promote the correct way in which to complete the signs.The audit should be repeated to check to see that improvements have occurred.Matrons should include monitoring of the isolation precaution boards in their matrons rounds.

Precaution signs have been added to the isolation policy. The use of the isolation precautions sign has been highlighted in the IPC Times and to Infection Control Link Practitioners. ICLP have monitored use and promoted signs in their areas. Matrons are monitoring the signs in their rounds. Audit was repeated Jan 12.

3384 Surgical Site Infection Pre-op and Peri-op Audit - T&O Theatres Oct 2011


Observational audit T&O theatres only.

Specialist Services

01/10/2011 Complete 02/12/2011 Results: Only 40 % of the eligible patients were screened for MRSA in this audit. Only New Wing Theatres at Stoke Mandeville Hospital participated in this audit. 100% compliance with checking WHO surgical checklist was achieved. All patients were given prophylactic antibiotics where appropriate. 1 of 3 patients requiring hair removal had hair removed by shaving which is unacceptable. There was 100% compliance with maintenance of Normothermia. Recommendations: All areas with non participation must produce an action plan on how they are monitoring the compliance with this audit.Areas who did not produce an action plan and return an action plan at the time of completing the audit must produce and action plan to show how areas of non-compliance have been addressed.All areas with ‘No’ answers are required to sign off this action plan to confirm all actions have been completed and then return to the IPC.

IPC have been assured that all actions have been addressed.

3385 Home Oxygen Service Assessment and Review

(Suzy Robertson, Operations Manager, Medicine). Lesley Broad, COPD Nurse Specialist, Hazel Haines, Lead Nurse

A questionnaire to patients in order to assess and review the home oxygen service, which will provide baseline information on current usage by patients and an understanding of their prescription and needs.

Integrated Medicine

01/12/2011 Complete 02/02/2012 The report will be used to prioritise patients alongside the concordance report. There are no specific recommendations.


3386 Clinic Letter Survey

Mr Shaun Appleton, Consultant, Surgery (Dr Deborah Stevenson, F1)

Brief forms to be handed out at outpatients reception asking if patients would like to receive copies of their clinic letters.


06/12/2011 Cancelled 28/08/2012 Audit cancelled. Audit cancelled.

3387 A Review of Waiting List Booking Cards

Miss Geraldine Tasker, Consultant, Obs & Gynae

Gynaecology operating lists are generated by booking co-ordinators who require accurate and detailed information on the waiting list booking card in order to list a patient correctly. Cards are frequently inadequate resulting in extra workload for co-ordinators and could result in patients being placed on the wrong list, in incorrect time slot, alerts not shared and late cancellations.

Specialist Services

21/11/2011 Complete 06/02/2012 More attention to detail is needed. 1. Contact phone number is extremely helpful. 2. Relevant medical problems should be carefully documented, and if no problems identified, that should be stated. 3.Weight documentation should be mandatory. 4. Theatre time allowed should be the operating time – the booking co-ordinators will allow for the anaesthetic time according to type of theatre (15mins/patient for DSU and 30 mins/patient for NW list).

Recommendations communicated at academic half day in Feb 2012. Additionally an email was sent to clinicians in the department. Re-audit to commence in October 2012 – to ensure more detail documented on W/L cards.

3388 A Survey of Gynae-oncology Patients' Needs for a Planned Nurse-Led Clinic

Francesca Lis, Gynae-oncology Clinical Nurse Specialist, Jeanette Tebbutt, Lead Cancer Nurse

Feedback is required from patients In order to gauge potential uptake for a nurse-led gynae-oncology clinic, which will meet patients' requirements.

Specialist Services



3389 Rate of UTIs in Spinal

Debbie Green, Matron, NSIC, Jean O'Driscoll, Infection Control

To examine rates of catheter related UTIs in Spinal and compare with national rates. Analyse patients' notes to see if any trends. Prospective recording of numbers of catheters and all UTIs for 3 months in each spinal ward.

Specialist Services

07/12/2011 Complete 31/12/2012 No recommendations or action plan. No recommendations

3390 Spinal Outreach Service

Debbie Green, Outreach

Outreach visits spinal patients in other hospitals to talk to patients about care and to train staff. Audit Outreach service against policy in terms of delays etc and evaluate training with an experience survey.

Specialist Services



3391 BTS Paediatric Asthma National Audit November 2011

Sunil Raga, Consultant, Paediatrics (Dr Rizwan)

National BTS Audit of the Management of Paediatric Asthma - November 2011.

Specialist Services

01/12/2011 Complete 31/07/2012 Total cases audited 3148. Results very similar to 2010 audit. 98 percent received beta agonist bronchodilators with a quarter treated by nebulizer alone, and just over third by spacer alone, and just over third treated by a combination of nebuliser and other devices. Half the children also received ipratropium. Eighty two percent receivedcorticosteroids. 3% receiving IV aminophylline, 3% IV Magnesium and % IV Salbutamol and 4% being admitted to ICU. Area where care remains least well done is around discharge planning. only 44% of children are recorded as having their device use checked and only 41% are recorded as being given a written discharge plan. Since the evidence suggests that good discharge planning decreases future admissions this is an area that many units might target for improvement.

Changes required

3392 BTS Paediatric Pneumonia National Audit November 2011

Sunil Raga, Consultant, Paediatrics (Dr Rizwan)

National BTS Audit of the Management of Paediatric Pneumonia -

Specialist Services

01/12/2011 Complete 31/07/2012 101 institutions submitted data (up from 77 in 2011) reporting over 2800 cases (male 52.9%). The age distribution was very similar to that of previous years with 45% under the age of three years and 71%

Changes required

November 2011. under the age of five. Duration of admission was short with 45% staying less than 48 hours (40% 2010-2011) and 85% less than five days. On admission 99.1% of children had their oxygen saturation recorded in air and nearly 40% were hypoxic (oxygen saturation less than 92%). 30% of children had a fever greater than 39 degrees centigrade. Wheeze was noted in 40% of those under the age of five and 24% of older children. 43% of children were given a bronchodilator, 28% had intravenous fluids and 52% had some intravenous antibiotics. The commonest intravenous antibiotic was Augmentin, then Cefuroxime both given for one to two days. Overall antibiotic choice did not change between 2010-2011 and 2011-2012 with Augmentin being the most popular antibiotic in both time periods. Despite macrolides being suggested as only second line antibiotics in the 2011 guidelines, macrolide use increased to 27.2% of antibiotics given in 2011-12 compared with 20% in 2010-2011. Physiotherapy is not recommended in the management of pneumonia but 17% of children nevertheless received it (15% 2010-2011). Despite only three children in 2011-2012 having a significant complication, some 33% of children received an appointment for hospital follow-up and 11% had a chest X-ray repeated at follow-up. This would appear on an unnecessary high use of secondary care resources.

3393 Audit of Gastric Ulcer Follow-up (WH)

Dr Sue Cullen, Consultant (Naomi Warner) Gastroenterology

Patients who have a gastric ulcer visualised at endoscopy should have a follow up appointment within 12 weeks. Are these patients being followed up?

Integrated Medicine

12/12/2011 Complete 12/12/2012 As well as advice to stop anticoagulants prior to their OGD, patients should be advised to have clotting checked 3-5 days prior to the procedure to enable abnormal clotting to be corrected or the OGD rescheduled. If unable to obtain H. pylori result via Clo test, and no other obvious aetiology for ulceration (eg NSAID use), alternative test for H. pylori, or empirical therapy with re-scope should be considered.

Changes required

3394 The Role of CT Scan in the Management of Suspected Sepsis in Patients with Spinal Cord Injuries

Tom Meagher, Consultant, Radiology (Dr Wail Ahmed, SpR)

Early diagnosis of septicaemia is vital in management of sepsis in SCI patients. Audit to assess if CT scans reported accurately and, if positive, findings acted on appropriately. NICE guidelines exist. Aim to establish Trust guidelines for use of CT for diagnosis of sepsis.

Specialist Services

13/12/2011 Complete 16/10/2012 Specific radiological diagnosis was found in 14 % of cases and 67 % of these required surgery for treatment of sepsis. Correlation between clinical and radiological findings was found in 55 % of cases. No relationship was found between the severity of sepsis and specific radiological findings. CT- Chest/Abdomen/Pelvis is a valuable and expensive diagnostic tool with high radiation dose, however it is only useful in a limited number of sepsis cases in spinal cord injured patientsMultidisciplinary spinal/radiology meetings are extremely important for discussion of complicated cases and planning further management with consideration of early surgical intervention.

No changes required

3395 Re-admissions Audit


Audit of the notes of all patients re-admitted during April, May and June for a reason appearing to relate to the reason for their original admission.

Trustwide 13/12/2011 Design Results and Recommendations required Changes required

3396 Surgical Site Infection Peri-op Audit - Urology Dec 11/Jan 12


Observation audit - Urology only.

Specialist Services

01/12/2011 Complete 28/02/2012 One of the patients screened tested positive for MRSA. This patient was not given MRSA decontamination and the patient notes were not alerted. The failure to take the required actions following the positive MRSA result should be investigated and the outcome of the investigation fed back to the Infection Prevention and Control Team. If necessary, this should be reported as an adverse incident via the Datix system. 100% compliance for completing WHO surgical checklist. Some of the questions on the proformas for some patients were not answered. It is important all questions are completed.

These are discussed at the IPCC and we have been reassured by the AND all actions have been addressed.

3397 Emergency Department IV Fluid Prescribing in Surgical Patients

Dr Stewart McMorran, A&E Consultant (Dr Carly Grandidge, FY2, Medicine)

Audit against British Consensus guidelines on IV fluid therapy for adult surgical patients.

Integrated Medicine

15/12/2011 Cancelled Audit cancelled. Project cancelled.

3398 Outcome for Shoulder Replacement Surgery

Geoffrey Taylor, Consultant Orthopaedic Surgeon, Vicky Russell, Clinical Specialist Physiotherapist

Use Oxford Shoulder Score (a validated outcome measure) to measure function pre-op and 3 and 12 months post shoulder replacement. Also patient satisfaction survey at 12 months.




3399 Use of Tranexamic Acid in Traumatic Fracture Neck of Femur Surgery

Dr Sara McNeillis, Consultant, Anaesthetics (Dr Bijal Kothari, CT1, Dr Rebecca Medlock)

Audit looking at retrospective notes of traumatic hip fracture and use of tranexamic acid.


19/12/2011 Cancelled 21/02/2012 Project cancelled Project cancelled

3400 Audit of Contraceptive Implant Removals

Dr Elizabeth Vincent, Associate Specialist, Contraception, WH

Audit of contraceptive implant removals. Was counselling given before insertion? Have treatments been considered/tried prior to removal?

Specialist Services



3401 Audit of Adherence to the Guideline for Management of Reduced Fetal Movements in Pregnancy (SMH)

Dr Gemma Brierley, ST2, Obs & Gynae, Miss A Reddy, Consultant

Re-audit of 3065. Women & Children

02/01/2012 Complete Entered on database in error. See audit 3457. NA

3402 Surgical Site Infection Peri-op Audit - Ophthalmology, ENT & Oral Nov 11


Observational audit Specialist Services

01/11/2011 Complete 03/01/2012 Results: Pre-operative component: 11 patients out of 46 should have been screened for MRSA but one of the 11 wasn't screened. Peri-operative component: All patients undergoing a surgical procedure must have the WHO surgical checklist completed. 98% were. Some forms were completed incorrectly with "No" instead of "N/A". There was 100% compliance for monitoring normothermia. For 6 (13%) the glucose control question was not completed. Recommendations: 1. Staff should be reminded to screen all relevant patients for MRSA. 2. Staff should be reminded to complete the forms correctly, particularly when differentiating between "No" and "N/A" responses. 3. All elements of the tool must be completed. If the audit is not applicable in theatres then the must send a blank form back crossed through with not applicable documented. An action plan should be completed by all areas where there was any non-compliance. This should be returned to the IPCT office.

All actions have been addressed. Staff reminded to screen all relevant patients for MRSA. Staff reminded to complete the forms correctly and completely. Staff reminded that if the audit is not applicable must send a blank form back crossed through with not applicable documented.

3403 An Audit of Miss Shaikh's Strabismus Surgery Outcomes

Miss Asifa Shaikh, Consultant Ophthalmologist, Dr Christine Kiire, ST4, Ophthalmology

Audit against the Royal College of Ophthalmologists guidelines for the management of strabismus in childhood.




3404 Accuracy of CT Pneumocolon against Colonoscopy

Dr R Sekhar, Consultant Gastroenterologist (Dr Harjit Bains, ST5)

Audit against BSG guidelines.

Integrated Medicine

05/01/2012 Cancelled Audit cancelled. Doctor left Trust and no information supplied on whether it was ever carried out.

Project cancelled.

3405 Spinal Orthopaedic Clinic Patient Satisfaction Survey

Mr Edward Seel, Consultant Orthopaedic Surgeon

A brief questionnaire survey of patients' experiences in outpatients. Sheets will be handed to patients immediately after their OPA to be completed anonymously. The forms will be collected before they leave.




3406 Audit of Goal Planning & Needs Assessment Programme 2010/11 in NSIC

Dr Jane Duff, Consultant Clinical Psychologist, NSIC

Needs assessment & goal planning programmes provide measures of the clinical outcomes of rehabilitation. To measure service standards regarding completion of NAC and commencement of goal planning

Specialist Services

06/01/2012 Complete 31/07/2012 Results: Team were proactive in allocating and completing NACs with patients who were mobilised on admission.47% of patients had an NAC within 2 weeks of mobilisation.Of those that were delayed a significant number were not allocated a Keyworker. 70% of patients commenced goal planning within 2 weeks of the NAC. Evidence of GPM documentation in notes needs improvement, and implementation of Goal planning on IMS. Actions: Improvement in ensuring all patients have a Keyworker and therefore complete an NAC.

Action: set a standard for allocation of Keyworker.

Changes required

3407 Renal Tract Computed Tomography In Spinal Cord Injured Patients : Trends, Indications & Outcomes

Dr Tom Meagher, Consultant Radiologist

Renal tract stones affect up to 7% spinally injured patients and are common cause of infection and scarring. They present differently in spinally injured patients as they may not cause discomfort but can cause renal loss if not identified. Renal tract CT commonly used but frequency needs to be considered. Audit to evaluate accuracy of CT scans, increase in scans and incidence of ureteric calculi.

Specialist Services

06/01/2012 Complete 16/04/2012 There was a year on year significant increase in use of CT. CT is increasing in use in the spinal cord injured population, most frequently for the monitoring of stone disease. The incidence of ureteric stones supports early use of CT in patients with hydronephrosis. No recommendations other than to send report to Urology

Report sent to Urology. No other recommendations.

3408 National Cancer Patient Experience Survey

Rick Panigraphi, Jeanette Tebbutt

All patients diagnosed with cancer between Sep and Nov 11 are identified. Names sent to co-ordinators who then sent out questionnaire, analyse and report. Report produced summer 2012.

Specialist Services

06/01/2012 Complete 04/01/2013 Results: The Trust was the same or better than other Trusts for all questions except one. This question was "The patient was offered a written assessment and care plan". Actions: Each site specific tumour team do a yearly internal patient satisfaction survey which they then write an action plan and will incorporate themes from the national survey.Some of the issues around patient care are going to be dealt with by Lynne Swiatczak as part of a quality care working group.

Changes required

3409 Audit to Ensure Infection Control Manual in Every Clinical Area is Up To Date


Each clinical area to complete audit form which looks at each part of infection control manual in their area to see if complete and up to date.

Specialist Services

09/01/2012 Complete 22/05/2012 All infection control manuals checked and updated. No changes required.

3410 Workplace Health & Safety Audit 2011

Marion Carnell, Health & Safety Facilitator, Stoke Mandeville Hospital

Annual audit of compliance with legal requirements regarding workplace health and safety.

Trustwide 15/11/2011 Complete 03/05/2012 Annual process. No report produced by CA&E - figures given across in table format for Marion Carnell.

Changes required

3411 Cervical Disc Replacement (IPG 100, IPG143)

Mr Stuart Blagg Audit of new procedure against associated NICE guidance as requested by the NCP Committee. (NN022)




3412 Administration of Anaesthetic to Carpal Tunnel Decompression Patients

Tony Heywood Audit of new procedure as requested by the NCP Committee. (NN027)




3413 Thrombolysis for Acute Ischaemic Stroke

Dr Mathew Burn and Dr Chris Durkin (Dr Harjit Baines, SpR)

Audit of new procedure as requested by the NCP Committee. (NN028)

Integrated Medicine

04/04/2012 Ongoing data collection

Data is collected on all patients who have been thrombolysed, and has been since procedure started in December 2007. The database is maintained by Susie MacTavish. We also discuss all patients thrombolysed in a monthly clinical governance meeting. Our complication rate is as expected, with our activity and Door-To-Needle times better than the national average. Recommendations from 2012 audit: Ensure the neurological deficit score ids recorded at the 24 hours post-thrombolysis stage.

Changes required

3414 Audit of Smoking Prevalance Amongst Patients with Spinal Cord Injury

Dr A Prasad, Respiratory Consultant (Alyson Moss, Smoking Cessation Co-ordinator)

To determine smoking prevalence amongst patients with spinal cord injury in order to put appropriaite measures in place for effective management and better health outcomes for patients who smoke.

Integrated Medicine

11/01/2012 Cancelled 06/11/2012 Audit cancelled. No further information. Project cancelled

3415 Audit of Smoking Prevalance Amongst Inpatient Population of the Spinal Injuries Unit

Dr A Prasad, Respiratory Consultant (Alyson Moss, Smoking Cessation Co-ordinator)

To determine smoking prevalence amongst patients with spinal cord injury in order to put appropriaite measures in place for effective management and better health outcomes for patients who smoke.

Integrated Medicine

11/01/2012 Complete 08/06/2012 1. Smoking status of patient should be assessed at time of admission to NSIC and recorded on the IMS system. 2. All patients who smoked before injury should be asked if they plan to start again if they were able. Training session for NSIC Doctors and Nurses in NRT use, and referral to Bucks Smokefree Support Service (BSSS). 3. All current smokers should be offered NRT on and during admission to NSIC and a referral made to the BSSS unless they opt out. 4. Clinical Audit of NSIC outpatients to be repeated in September 2012.

Changes required

3416 Fetal Fibronectin Jackie Hall Audit of new procedure as requested by the NCP Committee. (NN030)

Specialist Services

18/04/2008 Complete 20/04/2010 A sample of 20 patients undergoing fetal fibronectin tests between August 2009 and February 2010 were included in the audit. The main results were: admissions were high in negative test results (57%); 28% of those with negative results were given steroids; 75% of PV bleeds had negative results, all were discharged with no steroids. In 3 cases tests were performed outside the gestational age marked by guideline. There was no record of intercourse prior to the test in any of the 20 cases.

No changes required. New Clinical Procedure audit.

3417 Laparoscopic Radial Prostatectomy (IPG 193)

Mr Neil Haldar Audit of new procedure as requested by the NCP Committee. (NN031)




3418 Endovascular Exclusion Stenting of Abdominal Aortic Aneurysms

Mr Andrew Northeast Audit of new procedure as requested by the NCP Committee. (NN034)


17/10/2008 Complete 05/04/2012 The results of the formal audit were forwarded to the committee on 30 July 2010. The procedure is continually audited and the results in April 2012 are: 54 interventions; current 30 day mortality 0% v national vascular database reported 3%; 6 (11%) re-interventions (all developed late leaks that were all re-stented successfully) vs published EUROSTAR 5 year re-intervention rate 58%; 2 required urgent re-intervention during their inpatient stay for major complications - no comparable national data available for this; 4 EVARS subsequently died but were outside the 30 day moratorium and of unrelated causes. All our major vascular procedures are continually audited at both a local and national level by submitting them to the National Vascular Database.

All major vascular procedures are continually audited at both a local and national level by submitting them to the National Vascular Database.

3419 Potassium-titanyl-phosphate KTP (Green Light) Laser Vapourisation of Prostate for Benign Prostatic Obstruction

Mr Jon Greenland Audit of new procedure as requested by the NCP Committee. (NN036)


17/04/2009 Complete 05/04/2012 An audit was carried out, the findings were discussed with Andrew McLaren at the end of last year, 2011, he was satisfied with the results and was happy for us to continue.

3420 Microwave Ablation of Varicose Veins

Mr Andrew Northeast Audit of new procedure as requested by the NCP Committee. (NN037)




3421 Hysteroscopic Sterilisation

Mr Tunde Dada Audit of new procedure as requested by the NCP Committee. (NN040)

Specialist Services

Not yet started


3422 Subtenons Local Anaesthesia for Intraocular Surgery Delivered by ODP

Richard Smith Audit of new procedure as requested by the NCP Committee. (NN041)


16/04/2010 Complete 12/08/2012 The procedure is inherently safe with an extremely low incidence of significant complications. Audit of the last 29 procedures - 13/07 - 13/08/2012. No patients found the administration of LA uncomfortable or painful; during the procedure 27 patients had no pain, 1 patient had mild sensation and 1 required additional subtenons LA. Surgeon had excellent access to operative site in 22 patients, and good in 5 patients. There were no complications or situations where someone else had to take over to complete the procedure. The quality of the blocks the ODP is undertaking is comparable to those undertaken by experienced anaesthetists. The feedback from nursing staff who have been present in the anaesthetic room when the blocks take place is that patients find Graham’s manner calm and reassuring, and that they do not find the procedure upsetting. Recommendation is that this procedure is safely carried out by the ODP and no longer requires a higher level of surveillance than would be expected for medical staff undertaking the procedure.

Changes required

3423 Audit to determine the percentage change in Elderly Mobility Scores for inpatients completing a course of physiotherapy at Buckingham Community Hospital

Susie Gaynard, Physiotherapist

Looking at the sensitivity of change of an outcome measure to see if it is appropriate for use in the ward inpatient setting.

Integrated Medicine

01/12/2011 Complete 22/02/2012 Results: 10/20 patients made an improvement of more than 50% in their Elderly Mobility scores. 12/18 patients improved from functional dependence to independent functional status on reassessment. 3/18 patients improved from dependant to borderline functional status. 3/18 patients remained at dependant functional status, but all patients made improvement from baseline assessment. All patients made an improvement in their outcome measure following rehabilitation. Recommendations: Use the Elderly mobility score as the standard outcome measure for inpatients at Buckingham Community Hospital. i


3424 Paediatric A&E Liaison Forms

Sydnella Terry, Paediatric Liaison Officer

Analysis of data collected at Wycombe EMC through the Renass reporting system from January 2011 when the new system, First Net, went live in October 2011.

Specialist Services

12/01/2012 Complete 03/03/2012 Report sent but no particular recommendations made as changing to Remass system.

Sydnella Terry reported that so far (September 2012) there has been little progress in improving documention of information on children. 2 meetings were arranged with A&E staff - first meeting they did not attend; the second highlighted the fact that there are many other issues with other specialities children are referred to whilst in A&E, who do not document information on the A&E system. Those reports are usually blank.

3425 Audit of Tetanus Prescribing in A&E (SMH)

Esa Rintakorpi, Lead Nurse, A&E, Abigail Ashby, ENP, A&E, SMH.

An audit of the prescribing of tetanus vaccination in A&E at Stoke Mandeville.

Integrated Medicine

12/01/2012 Complete 03/05/2012 The results demonstrate the need to revisit the present guidelines, to see if the advice given with regards to those patients with clean wounds needs revision, as this audit provides evidence that over-prescribing of Revaxis® is taking place. The recommendation is that the Trust guidelines are reviewed sooner than the planned revision date of September 2013. Once the guidelines are reviewed, the documented action plan for improved documentation, education for staff, and a new Summary Guideline can be implemented, all of which would lead to improved clinical practice, best practice with regard to Revaxis® use, unity and parity with regard to prescribing and implementing treatment amongst all disciplines, and the reduction of financial costs to the Trust.

Changes required

3426 High Intensity Focussed Ultrasound (HIFU) Ablation of Parathyroid Lesions

Mr Andrew McLaren Audit of first 10 procedures carried out as requested by the NCP Committee. (NN042)


01/04/2011 Cancelled 09/04/2012 Removed from New Procedures Approved List as kit not approved.

Project cancelled.

3427 Chest Wall Ultrasound

Dr Charlotte Campbell Audit of new procedure as requested by the NCP Committee. (NN044)

Integrated Medicine


29/01/2013 Project cancelled.Nnow National and Trust standard practice to use ultrasound.

Project cancelled

3428 Nurse Led Service for Fascio-iliaca Blocks for Preoperative Pain Control for Patients with Fractured Neck of Femur

Mary Miller, Lead Nurse, Pain Management

Audit of new procedure as requested by the NCP Committee. (NN046)




3429 Inguinal Sentinal Node Biopsy in Melanoma

Mr Peter Budny, Consultant, Plastics & Burns (Helen Katsarelis, CT1)

Quality control audit of new sentinel node biopsy as requested by the NCP Committee. (NN049)




3430 Improving the Prescription of Medication when the Integrated Care Pathway for the Dying is Commenced

Dr F Hami, Consultant (Mills/Gbinigie/Aires, Core Medical Training)

WH scored in the bottom 25% hospitals in the National Care of the Dying Audit for drug prescribing when starting a patient on the ICP. Subcutaneous drugs should be prescribed on a prn basis for 5 symptoms.

Specialist Services

16/01/2012 Complete 09/07/2012 Recommendations: 1. Cross-site education with posters and teaching.2. Ongoing audit of prescription of end of life medications. 3. Review reasons why certain medications aren’t prescribed. 4. Regular teaching slots for FY1s and FY2s at both sites.

There are regular teaching sessions on the ICP, where anticipatory prescribing is highlighted.Dr Hami teaches the FY1 and FY2 doctors on their mandatory teaching sessions.The audit will be repeated by a Junior in the next year.

3431 Audit of Screening Needs Assessment Checklist on St Patrick's Ward

Dr Jane Duff, Consultant Clinical Psychologist, NSIC

The screening needs assessment checklist is a way of assessing rehabilitation or changed health needs of readmitted patients. Check in each patient's admission file if admission anticipated to be 3 weeks or more. Full needs assessment checklist and goal planning to be commenced if indicated by screening assessment.

Specialist Services



3432 Transanal Haemorrhoidal Dearterialisation

Mr Andy Huang Audit of new procedure as requested by the NCP Committee. (NN038)




3433 The Management of Necrotising Fasciitis

Sudap Ghoona, Consultant (Jonathan Cubitt ST3, Paul PoynterSmith, Plastics)

Analysing management of necrotising fasciitis, looking at the presentation, investigations, management and outcome. Aiming to evaluate prognostic criterion.




3434 A Review of the Quality of Speech and Language Therapy

Michelle Holmes, SALT Audit to identify the quality of SLT case notes across the three hospital sites and will evaluate improvements which have been made since the previous audit completed 18th january 2011. It has been decided that new audits will be undertaken for each year rather than quarterly audits previously proposed. The areas assessed have been taken from the Trust guidelines and from what is though to be important by senior SLT staff. Historically, SLT managers have regularly assessed/audited the staffs' case notes and this project ensures that this situation continues.

Specialist Services

17/01/2012 Complete 31/03/2012 Results: Admin - 100% standards achieved in 47% cases. Clarity 100% standards achieved in 74% cases. Content/care give 100% standards achieved in 82% cases. Recommendations: Inform staff of the particular areas for improvement. Continue to use the same case note checklist format for future audits. Repeat audit in January 2013.

Staff informed of results. Due to be re-audited in Jan 13.

3435 Voice Therapy Patient Experience Survey

Julia Mee, Head of Therapies (Barbara Reynolds, Team Lead ENT)

To obtain patient feedback about their experience of voice therapy from booking an appointment to discharge from therapy. This will be used to inform change.

Specialist Services

13/01/2012 Complete 05/10/2012 19 patients returned completed questionnaires. All patients were satisfied, overall, with their care. All patients would recommend the service. Recommendations: 1. For the Voice Therapy Team members to continue to offer the high level of care to voice patients as was demonstrated by this audit. 2. Team members will take care to arrange voice therapy appointments with patients on the phone wherever possible to give patients maximum available choice of appointment times. 3. Team members will take care to explain the process of voice therapy and to explain the diagnosis and potential causes of voice and throat symptoms. 4. Team members will be encouraged to discuss patient expectation of voice therapy at the beginning of treatment also. 5. Team members will be encouraged to discuss discharge planning with patients so that they feel involved in this process.

Changes required

3436 Audit of Management of Head Injuries in Children against NICE Guidelines

Jenny Woodruff, ST3, Zahrah Neshat, Paediatrics

Audit of adherence by the paediatric team to NICE guideline CG56, Head Injury in Children, including: GCS documentation at presentation; CT scan criteria; Admission criteria; Neuro observations frequency and accuracy; Discharge information.

Specialist Services

19/01/2012 Complete 01/09/2012 Recommendations: 1. Sticker with CT scan criteria and a yes/no tick box. 2. Adjustment to neuro obs charts to include the frequency of observations, and a statement that a) sleeping children should be woken. b) if GCS drops inform a doctor.

Changes required

3437 Fast Track Physiotherapy Service Patient Experience Survey

Katie Glover, Advanced Physiotherapist

Survey of patients referred to fast track physiotherapy by Workplace Health with musculoskeletal problems.

Specialist Services

20/01/2012 Complete 04/02/2013 Results: 57% staff waited one week or less between their referral from Workplace Health and their first physiotherapy appointment. 89% staff were seen within 2 weeks.All staff were satisfied with the process of referral, 80% very satisfied.82% staff were given a choice of where they received their physiotherapy.All staff were satisfied with the timing of their physiotherapy appointments, 80% very satisfied.67% achieved less pain as a result of their physiotherapy and 53% achieved improved flexibility. Only 10% staff felt it had made no difference to their problem.92% staff whose job was affected by their problem, felt that the physiotherapy enabled them to carry out their job more easily than they would have done without the treatment.90% staff felt that the physiotherapy enabled them to carry out other activities more easily than they would have done without the treatment.All staff were satisfied with the Fast Track

Changes required

Physiotherapy Service, 83% very satisfied.Recommendations: Ensure staff requiring access to this service are referred promptly to WPH. Raise all BHT staff awareness that this service is available to them to access.Ensure referral pathway is maintained as efficient as possible.Waiting time for first appointment or telephone triage is within service standards.Continuation of the service on at least the three main BHT sites.

3438 Evaluation of Staff Knowledge of Diabetes Pre & Post the Think Glucose Campaign

Dr S Chatterjee, Diabetes Consultant, (Nicki Skillen & Mary Harding, Community Diabetes Nurses)

To measure the level of knowledge of diabetes of staff on the wards in the Community Hospitals. This information will be used to develop a training programme to improve the effectiveness of Think Glucose and patient care.

Integrated Medicine

21/07/2011 Complete 23/01/2012 Baseline audit only. No changes required.

3439 Evaluation of Head Injury Semantic Differential Scale

Dr Andy Tyerman, Consultant Clinical Neuropsychologist & Head of Service, Community Head Injury Service

Pooling of data for detailed psychometric analysis of the Head Injury Semantic Differential Scale which is used in the initial assessment of patients referred to the service.

Integrated Medicine

23/01/2012 Complete 26/11/2012 Not sure if results/recommendations will be forthcoming.

NA. No formal results/recommendations.

3440 Coding of Revision Hip Surgery

Mr B. Mann, Consultant, T&O (Dr Georgina Burcher, FY2)

Comparison of coding with outcomes for revision hip surgery. Looking to achieve 80% compliance with coding and outcomes.


24/01/2012 Complete 30/06/2012 Recommendations included: increase coding capture rate via education (Surgeons & Coders); type written operation notes; indicate diagnosis, implants removed & inserted (fixation method also important); ex-PBR claims are a significant source of extra income - now processed by Arthroplasty Fellow prospectively.

Changes required

3441 Use of Acitretin in Dermatology

Dr Mohsin Ali, Consultant Dermatologist (Dr Caroline Champagne, ST3, Dermatology)

Is Acitretin being prescribed safely in dermatology according to the BAD guidelines. Particularly focusing on its use in women of child bearing age and its effects on liver and lipid metabolism.

Integrated Medicine

25/01/2012 Complete 09/11/2012 Results: 100% of the women of child bearing age were tried or considered for an alternative to Acitretin. However in those where an alternative systemic agent was not documented as being considered it isn’t clear whether the doctor did consider alternatives and simply didn’t document these options. The precautions that should be taken in women of child bearing age were not clearly taken and certainly not documented. In most cases baseline bloods were performed but in the majority no fasting glucose levels were checked. In the majority of cases blood tests were not intensely monitored as per guidelines in the first two months. Of those patients who developed abnormalities in their blood tests almost all were correctly managed. Recommendations: Presentation of these audit findings at a departmental academic meeting to raise awareness of the issues and areas where practice does not meet the expected standards.Provide advice on better documentation of discussions with women of childbearing age regarding contraception. Also focus on the need for more intense blood monitoring during the first 2 months after treatment is initiated. Re-audit in one years time.

A pre-treatment checklist was produced as a result of the audit to use when prescribing Acitretrin.

3442 Retrospective Audit of Digoxin Loading Doses used to Treat AF within the Buckinghamshire Healthcare Trust

Lisa Pazik, Lead Pharmacist Emergency Medicine

Comparing actual prescribed and administered loading doses of digoxin for AF with those calculated from population pharmacokinetic data and assess the therapeutic effect of the loading dose.

Specialist Services



3443 Pain in Children Dr Robert Janas, SpR, Dr Stewart McMorran, Consultant A&E

A review of children aged 5-15 years presenting to A&E with moderate to severe pain.

Integrated Medicine

25/01/2012 Cancelled 11/10/2012 Audit cancelled. No response from clinician. Audit cancelled.

3444 Radical Retropubic Prostatectomy Patient Experience Survey

Hilary Baker, Macmillan Uro-oncolgy CNS

A patient experience survey to review the experiences of patients undergoing a radical retropubic prostatectomy for prostate cancer.




3445 What do Intrapleural Blocks mean for the Mastectomy Patient?

Dr Bunsell, Consultant, Anaesthetics (Sam Michlig, CT1, Bijal Kothari, CT1)

Looking at all patients undergoing mastectomy with and without intrapleural blocks to compare LOS and morphine usage.




3446 Lung Cancer Ongoing Patient Experience Survey

Jill Mowforth, Lung Cancer Specialist Nurse

To record patient satisfaction and experience of the diagnostic pathway for lung cancer and mesothelioma.

Specialist Services



3447 Surgical Site Infection Peri-op Audit - Gynae Feb 12


Observational audit gynae only, week of 13th-19th Feb.

Specialist Services

13/02/2012 Complete 27/04/2012 Results: 100% compliance MRSA screening. 100% compliance WHO checklist. Glucose monitoring was indicated for 5 (28%) patients but glucose control was maintained in only one. For 3 (17%) procedures this question was not answered. 3 patients were not given prophylactic antibiotics when they were indicated. In 8 (44%) cases hair removal should have been completed but wasn't. Recommendations: 1. All staff completing the audit must be competent in this. Training should be offered where required. 2. Staff to be reminded to complete all questions. 3. Trust antibiotic regime for relevant procedures to be available and used. 4. Where applicable hair should be removed appropriately following national guidelines using clippers and not shavers. 5. Staff need to be aware of the need for maintaining glucose control in diabetic patients and to answer all questions. 6. All patients where applicable must have the normothermia monitored and recorded.

Infection Control say that all recommendations addressed.

3448 Sharps Management February 2012



Specialist Services

01/02/2012 Complete 09/07/2012 Results: Overall compliance was 96%. Scores varied by ward/area from 78% “Yes” responses to 100%. 3 wards had an overall compliance less than 85%. Recommendations: 1. Non participation should be discussed at SDU/clinical governance meetings and relevant areas should complete the audit. 2. The report, results and issues highlighted for further focus should be discussed and disseminated to all relevant staff across the Trust. 3. Appropriate training for staff completing the audit tool should be provided to ensure returned data is robust. Ongoing training, promotion of good practice and compliance monitoring should continue. 4. Actions identified should be completed and closed as part of the audit cycle and actions must be signed off by the Divisional ADN’s. 5. The collation of data on reported sharps injuries should continue to inform further training and facilities.

IPC assure us that all actions completed.

3449 Audit of Acute Dietetic Referral Forms

Liz Pryke, Dietetic Manager

To investigate if newly implemented adult acute dietetic referral forms are being correctly completed by referring staff.

Specialist Services

31/01/2012 Complete 01/05/2012 Dates and names completed well on referral form. However MUST only 62%-65%, weight 54%-71%. Low response to questions on whethet patient lost weight, whether MUST action plan implemented. Referral forms only completed for 19%-33% cases. Recommendations: 1. Only 1 type of referral form be used. 2. Training to raise awareness of use. MUST training. 3. Decision to be made whether to continue using referral forms or stop using them as hardly used.

We are now only using 1 type of referral form across all acute sitesTraining is ongoing [monthly basis]We have decided to continue using the referral forms to allow us to prioritise appropriately, and we are re-enforcing the importance of them at ward level.

3450 Gastric Aspiration Volume in Enterally Fed Patient on ITU

Heike Melbourne, Specialist Dietitian

A survey of ITU doctors and nurses on knowledge of gastric residual volumes in enterally fed patients on ITU and a survey of practice amongst ITU doctors related to stopping enteral feeding prior to a procedure..

Specialist Services



3451 Transfer Form Audit Feb 12


Audit of transfer form completion.

Specialist Services

01/02/2012 Complete 31/05/2012 32/257 (51%) transferred patients had infection control and prevention issues handed over. 20/30 (67%) patients with infection control issues had the issues handed over. Recommendations: Staff member transferring a patient should ensure IC handover given. Document in patients notes if verbal handover for IC issues received. Audit report to be discussed at all Ward/ Unit meetings in addition to Clinical Governance, Ward/ Team Leader meetings. Staff completing the audit to ensure they know how to complete it correctly. All areas listed as non participating should complete an audit for their record.

Infection Control always assure us all actions completed

3452 Evaluation of Meals in NSIC

Samford Wong, Dietitian, NSIC

Questionnaire to patients and staff re meals provided. Repeat of audit of March 2011. New menu was introduced in May 2011 and a new regeneration system has been installed. Want to see if improved.

Specialist Services

31/01/2012 Complete 03/09/2012 Actions: Ensure nutrition screening on admission is implemented effectively in order to determine the risk of malnutrition, implementing the appropriate care plan, and repeat periodically according to nutrition pathway. Arrange education sessions for catering staff, nursing staff, medical staff . Review the quality (texture, temperature) of hospital food. To involve volunteer help in meal ordering; to make sure food is cut up and placed within their reach. Menu available to all patients. Breakfast / Lunch / Supper club – to let patient to have company and encouragement while they eat. AHP involvement (e.g OT) to provide the need of feeding aid, bedside water system.

Changes required

3453 An Audit of One Stop Breast Clinics 2011

Dr Kadir Hasan, consultant radiologist

A previous audit (2596) of waiting times in the one stop breast clinics (where patients have all necessary scans and see doctor at same appt) was carried out in 2008. This is a re-audit to see if improved. Data from patients seen 10/10/11 to 1/12/11.

Specialist Services

10/10/2011 Complete 23/04/2012 Results: Patients had a median wait of 30 minutes in the Radiology Department, excluding the time taken for the scans. However, 9 patients experienced extremely long waits of over 1 hour 15 mins, with a maximum wait of 2 hrs 6 mins. Problems occurred at all 3 waiting points (waiting for mammography, ultrasound and report) although the biggest problems occurred when waiting for ultrasound, with 7 patients waiting over 1 hour. Recommendations: 1. Equal distribution of number of patients booked into each clinic. 2. Book the follow up mammograms and patients for the family history clinics on a different day prior to the clinics to reduce workload in the one stop clinics. 3. Provide adequate staff in all clinics. 4. Install a second digital mammography unit to reduce waiting for mammography.

Moving to new unit in 2013. New equipment will be purchased. There has been more effort to book equal numbers of patients in each clinic and staff numbers have been improved to some extent.

3454 Metacarpal Fracture Audit

Mr T Heywood, Consultant Plastic Surgeon (Dr Kana Miyagi, LAS ST3, Plastics)

Metacarpal fracture is a common hand injury. There are concerns that we may be over treating these injuries with surgery. This audit will evaluate those cases which have undergone surgery and assess whether they met the current recommended criteria for surgery. There are no national guidelines at present.




3455 Endoscopy Unit PES 2012

Sue Kenny, Sister, WH, Deborah Dobree-Carey, Sister, SMH (Dr Sekhar, Consultant Gastroenterologist, SMH & Dr Sue Cullen, Consultant Gastroenterologist, WH

A patient experience survey in line with the Global Rating Scale, which will help to develop and assess a patient centred service.

Integrated Medicine

27/01/2012 Cancelled 05/11/2012 Audit cancelled. Project proposers did not get back to us.

Project cancelled.

3456 Health Visitor User Experience Survey 2012

Caroline Axten, Health Visitor Clinical Practice Teacher

To benchmark the level of satisfaction amongst clients with the current health visiting service. This information will be used to compare the level of satisfaction following the health visitor implementation plan year on year up to 2015.

Specialist Services



3457 Re-audit of Adherence to the Guideline for Management of Reduced Fetal Movements in Pregnancy

Gemma Brierley, ST2, Obs & Gynae

Audit of adherence to Trust Guideline 419.3 Management of Reduced Fetal Movements.

Specialist Services


3458 LFTs in Right Iliac Fossa Pain

Nigel d'Souza CT3 (Diallah Karim F1)

Biliary pathology can be a cause of right iliac fossa pain. Standard practice is to check LFTs in all patients with acute abdomens. This is a prospective audit to see how many patients admitted with right iliac fossa pain have LFTs checked and how many are abnormal.




3459 An Assessment of GP Gynaecology Referrals Under 2 Week Wait

Mr Tunde Dada, Consultant (Dr Cheryl Phillips, ST1 and Dr S McKelvie ST1) Obs & Gynae

An assessment of the quality and appropriateness of GP referrals under 2 weeks wait against NICE and Trust guidelines.

Specialist Services

09/02/2012 Complete 14/03/2012 Results: 1. Majority of referrals appropriate. 2. Examinations are not documented well – are they being done? 3. Appropriate tests not always documented/done prior to referral e.g. smears, Ca125. 4. Good access for GPs to US. 5. Occasionally poor referrals made with little information. Recommendations: 1. Update GPs on latest gynae cancer referral guidelines. 2. Target endometrial cancer referrals. 3. Adjust referral proforma. 4. More space for clinical details. 5. Test results to be included. 6. Information on PMH and co-morbidities. 7.To review rejected referral letters.

Junior doctor audit, no changes received 21/2/136 (CP)

3460 Integrated Care Pathway for the Dying Adult (WH) Re-Audit

Dr Faqa Hami, Consultant in Palliative Medicine

2011-2012 Re-Audit to compare the end of life care received by patients in the acute wards of Wycombe Hospital against the new ICP for the Dying Adult.

Specialist Services



3461 Isolation Precaution Sign Re-audit

Amy Burgess, Student Nurse, Infection Control

Audit to determine if isolation precaution signs are being displayed in line with Isolation Policy. Re-audit of 3383

Specialist Services

01/01/2012 Complete 13/02/2012 Results: Although many of the isolation boards were in place, none were completed completely correctly. Medicine and Surgery have improved in some areas since last audit, CSS stayed the ssame and NSIC and Women & Children were less compliant. Recommendations: 1. Display precaution chart instruction from Infection Control manual in wards. 2. IC department to advise link nurse on how to educate staff on correct method of hand hygiene according to particular infection. 3. Link nurse to educate staff. 4. IC to produce table of common infections and best method of hand hygiene to be displayed on ward. 5. Link nurse to encourage nurses to remove or wipe clean board between patients to avoid confusion. 6. Matrons and link nurses to monitor use and compliance of isolation boards. 7. Remind staff to de-isolate patients when isolation no longer necessary. 8. Audit to be repeated.

These are discussed at the IPCC and we have been reassured by the AND’s all actions have been addressed.

3462 Patient Hand Hygiene Audit November 2011

Infection Control Re-audit of audit carried out in August 11 to check to see if patients are encouraged to perform hand hygiene after bathroom/commode/before meals etc.

Specialist Services

01/12/2011 Complete 13/02/2012 Results: Prompted after assisted to bathroom 78%. Offered assistance with hand hygiene after bedpan/commode 79%. Individual hand wipe provided for the patient prior to meals 48%. Offered assistance to open/use the hand wipe prior to mealtime 44%. Offered an alternative method of hand hygiene facility prior to meals 73%. Patients read hand hygiene leaflet 10%. Assistance after bathroom/commode and before meals improved slightly since last audit. Provision of hand wipe worse compliance since last audit. However, smaller audit last time. Overall compliance very low. Recommendations: 1. Areas to produce action plan to show how compliance will be monitored. 2. Wards should ensure have adequate supplies of patient leaflet. 3. Wards should have system to ensure patients given leaflet on admission. 4. Winning poster on hand hygiene to be distributed for display. 5. Discussion and education re patient hand hygiene. 6. Include in IPC corporate induction. 7. Assess patient's abilities to perform hand hygiene and assist if necessary.

These are discussed at the IPCC and we have been reassured by the AND’s all actions have been addressed.

3463 Evaluation of Paediatric Training Sessions for Junior Doctors

Dr Atanu Dutta, Consultant, Paediatrics

Continual evaluation of training sessions run by the paediatric department for junior doctors.

Specialist Services



3464 Audit of the Management of Group B Streptococcus Mothers

Dr A Dutta, Consultant, (Dr Bolutito Akinbiyi, ST2) Paediatrics

An audit of the management of Group B Streptococcus mothers who have delivered live infants at Stoke Mandeville, in order to review current GBS guidelines and to compare with GBS Network/NICE guidelines and current local guidelines.

Specialist Services

15/02/2012 On hold Results and Recommendations required Changes required

3465 VTE Prophylaxis after Plaster Cast Immobilisation

Dr Jonathan Pattinson, Consultant, Haematology (Dr Ahmed Arif, F1, Haematology)

Audit of VTE Prophylaxis after leg immobilisation against NICE guidelines.

Specialist Services


3466 Hand hygiene Facilities Audit Jan 2012



Specialist Services

01/01/2012 Complete 16/04/2012 Overall compliance increased from 94% to 96% but 5 wards less than 85%. 69 areas took part.27/37 submitted complete action plans. Recommendations: 1. Those not taking part to complete audit. 2. Those areas with low compliance to reaudit. 3. Those areas with non-compliant wash basins to highlight on IPC work programme.

Infection Control say that all recommendations addressed.

3467 Clinical Evaluation of Spinal Interventions and Treatment

Mr Edward Seel, Consultant Spinal Surgeon

A clinical evaluation of spinal interventions and treatment through pre- and post- treatment questionnaires (Oswestry).


01/04/2012 Design Results and Recommendations required Changes required

3468 Community Heart Failure Service Patient Experience Survey

Tracey Apps, Community Heart Failure Specialist Nurse

A Patient Experience Survey to determine the effectiveness of the Community Heart Failure Service in the care they provide for their patients.

Integrated Medicine

30/01/2012 Complete 20/12/2012 Overall 98% patients were either "very satisfied" or "satisfied" with the service and treatment which they received from the Heart Failure Specialist Team. Recommendations: 1. Raising the profile of the hospital based Heart Failure Support Nurse. 2. Obtain more clinic space for 2013 in the North of the county. 3. Look into increasing the length of clinic appointments. 4. Appoint new administrator to improve contact to the service. 5. Remind patients of the BHF literature which they are provided with at their initial assessment as useful reference.

Changes required

3469 Transport Survey Ian Garlington, Director of Property Services

A Transport Survey is being carried out at Wycombe Hospital aimed at visitors, and at Stoke Mandeville Hospital aimed at patients visiting their first assessment clinic/outpatients clinic, to assess their current travelling arrangements and experience of hospital.

Trustwide 20/02/2012 Complete 16/07/2012 Reorganisation of Trust Departments - ongoing. No changes required

3470 CQUIN Discharge Summary Audit

Liz Hollman,Associate Director Healthcare Governance, Sharon Webb

CQUIN audit reviewing the quality of discharge summaries for 50 patients discharged from the Trust during November 2011

Trustwide 20/02/2012 Complete Recommendations: 1. Ensure that the following information is included on discharge summaries: full consultant and GP identification; mode of admission; route of admission; discharge destination and method; cognitive function; outpatient Consultant and hospital for outpatient appointment; results awaited; grade of doctor completing discharge summary. 2. Discharge summary template to be reviewed to ensure it contains all the necessary information.

Changes required

3471 Alcohol Related Liver Disease NCEPOD Audit

10/01/2012 Complete 01/12/2012 None No changes required

3472 Upper Gastrointestinal Cancers Patient Experience

Maureen Kiely, Barbara Reid, Upper GI Cancer Specialist Nurse

Evidence for peer review and to obtain patient feedback regarding the service

Specialist Services

22/02/2012 Complete 25/02/2013 The survey illustrates that the Upper Gastrointestinal team are giving the right amount of information guided by the patients’ requirements and level of understanding. The diagnosis was given in a caring

Changes required

Survey and quality of information provided.

and sensitive manner resulting in the patient feeling supported. In addition, the patients had trusted, and had a good rapport with both doctors and nurses.It was noted that not all patients were advised to have a relative or friend present to support them when receiving results, fortunately no patients were upset by this. Patients may be informed of potential diagnosis during the initial investigation stage. This may preclude a friend/relative being present at that time. Potentially, patients may not always remember the advice given due to raised anxiety levels or sedation given during procedures.The survey demonstrated that patients may not be aware of what a written treatment is. The 2012 Peer Review outlined 100% compliance in their findings out treatment plans in notes, for that reason, suggestive that patients may have received a written treatment plan. Overall the survey demonstrates that patients are content with the volume, consistency and the way diagnosis and information was delivered. There is a general consensus with the overall care throughout the colorectal cancer pathway, which suggests that the patient group is very happy with their care and treatment.

RECOMENDATIONSThe plan for this year is continue the good work already in place. To recommend from first contact where appropriate the benefits of having a relative or friend present during consultations, without causing undue anxieties. To continue giving all patients a written treatment plan, amending the plan to give clearer visibility to the document title and content. To ensure patients have an awareness of the document. Rea

3473 Audit of NSIC Pain Care Pathway

Imogen Cotter, Clinical Psychologist, NSIC

To Translate the MASCIP Guidelines for the Management of Neuropathic Pain in Adults following SCI into Clinical PracticeAim to implement a NSIC pain care pathway in June 2012 and to audit it 6-12 months after implementation.

Specialist Services



3474 Audit of Evidence Based Practice of Asthma Management in A&E

Dr Patrick Ukwale, Consultant, (Dr Edward Harvey, GPVTS1) A&E

An audit to measure the adherence to BTS guidelines in the management of acute asthma in the A&E setting.

Integrated Medicine

29/02/2012 Complete 31/05/2012 Recommendations: 1.Educate staff by presentation of CEM standards and current performance. 2. Encourage better documentation. Consider asthma proforma instead of CAS cards. 3. Standard referral forms to GPs with tick boxes to reduce time spent on paperwork. 4. Re-audit in 3 months time.

Changes required

3475 Audit of the Difficult Airway Trolley Equipment

Dr Bogdanov, Consultant, Anaesthetics (Dr Phillip Duggleby, SHO, Dr Tom Barge FY1, Anaesthetics)

A survey of all grades of anaesthetists assessing the frequency of use, training and confidence in using the different pieces of equipment on the new Difficult Airway Trolley, using the Difficult Airway Society guidelines on difficult intubations.



11/05/2012 Results: Confidence using equipment declines as frequency of elective use decreases; several pieces of ‘difficult airway’ equipment used infrequently on elective lists e.g. video laryngoscope, intubating LMA, flexi bronchoscope; juniors and middle grades need monthly use of equipment to maintain confidence; poor awareness of what equipment available in an emergency. Recommendations: 1. Encourage use of ‘non-routine’ equipment of elective lists, especially alternative laryngoscopes/ video laryngoscopes, more experience intubating through LMA with flexi bronchoscope and need for additional cannula/surgical cricothyroidotomy simulation. 2. Trainees record sheet - logbook for use of selected pieces of equipment, e.g. McCoy, video laryngoscope, 2nd generation LMA, intubating LMA; encourages ‘see one, do one, do two, do three etc’ training on elective lists; development of technical skills in low pressure environment. 3. Education of contents of difficult airway trolley, e.g. posters, e-mail, FRCA Teaching Group. 4. Re-audit in 1 month. 5. Consider standardisation of trolleys.

Changes required

3476 Audit of Screening of Patients with Dementia

Jo Birrell, Matron, Medicine for Older People

An audit to look at the screening given to patients with a diagnosis of dementia within the first three days of an admission. Replicating some of the methodology from project 3186.



3477 Audit of Dabigatran

Nik Bakti, CT1, Surgery

An audit with the Haematology Department to correlate dabigatran levels and post op wound oozing, a follow up to audit 3060.


27/02/2012 Cancelled 24/10/2012 Project cancelled by clinician. Project cancelled by clinician.

3478 Audit of the Transrectal Ultrasound and Biopsy of Prostate Service

Jill Roberts, Senior Staff Nurse, Urology

A patient experience survey with the aim of improving the service where required.




3479 Audit of the Paediatric EWS Chart (PEWS)

Kirsty Johns, Practice Development Nurse, Paediatrics

An audit of the correct use of the Paediatric Observation Chart and PEWS

Specialist Services

01/03/2012 Complete 30/06/2012 The audit shows that, across all areas caring for children within a hospital setting within the Trust, PEWS Charts are not being fully completed to provide a complete assessment of the child. PEWS Charts are not being completed in line with the Trust Guideline on Physiological Observations. This may be due to lack of awareness of the Trust Guidelines or lack of education in the use of PEWS. Despite children triggering a PEWS, doctors were not always informed. The lack of documentation regarding doctors being contacted or the rationale for performing reduced observations is also poor. Recommendations: 1. Review of the PEWS Chart. 2. Review of the Trust Guideline.3. Education of staff in assessment of the child using PEWS, the importance of documentation and the reporting of PEWS scores to Medical staff.

Changes required

3480 Intravenous Antibiotics in the Intrapartum Period

Tunde Dada, Consultant (Gillian Rivlin, FY2) Obs & Gynae

An audit of intravenous antibiotics during the intrapartum period in prolonged rupture of membranes in the term infant. To assess if antibiotics are being given in line with guideline. To assess record keeping in relation to decision and discussion about infant outcomes.

Women & Children

01/03/2012 Complete 14/03/2012 Reviewed the outcome of 20 cases: 12 Spontaneous labour; IOL; 1 emergency LSCS. 2 patients late or omitted IV ABx, all women given information but no evidence of being given written information. To be raised at Labour Ward Forum.

No action plan received, no changes received 21/2/13 (CP)

3481 Venous Thromboembolism Prophylaxis Audit Medicine

Jonathan Pattinson, Consultant Haematologist (Dr Ivie Gbnigie, Dr Junie Wong, CT2 Medicine)

As a follow up to audit 3090 and part of rolling VTE audit.

Specialist Services

03/03/2012 Cancelled 14/01/2013 Cancelled Cancelled.

3482 Exercise Tolerance Testing

Leonora Assirati, Student Cardiac Physiologist, Cardiology Department

An iInvestigation into the efficacy of exercise tolerance testing as an indicator of coronary artery disease in patients referred to the rapid access chest pain clinic

Integrated Medicine



3483 An Audit of 3rd and 4th Degree Tears

Tunde Dada, Consultant (Sarah Barker, ST2) Obs & Gynae

An audit of 3rd and 4th degree tears against CNST/RCOG Greentop 29 Guidelines for diagnosis, follow up and treatment, to be combined with a study also being carried out in Oxford.

Specialist Services

06/03/2012 Complete 18/05/2012 70% sustained in LW setting. 77% primigravidas. 72% babies between 3000-4000gms. 47% NBFD deliveries. 42% delivered by midwives. 57% second stages longer than one hour. 55% tears associated with episiotomies including all 4th degree tears. All tears were documented as identified. In all cases where documented, the correct sutures and technique were used (should be documented in all notes). All tears were repaired in theatre. All tears were sutured by appropriate member of staff. Recommendations: 1. Need to ensure appropriate medication (Fybogel and Lactulose) prescribed for all women upon discharge. 2. Need for proforma to be completed even if op note filled in.

Changes required

3484 Burns Outreach Service Patient Survey

Ann Fowler, Burns Outreach Specialist Nurse

A patient experience survey to assess the service of the Burns Outreach Specialist Nurse.




3485 National Emergency Survey 2012

Clinical audit department

A patient experience survey relating to A&E visits in Feb 2012.

Integrated Medicine


Results: BHT was rated same as other Trusts for most questions, better for none and worse for five, including length of time in A&E and overall A&E experience. Mean score for overall experience on scale 0 to 10 was 7.1.

Changes required

3486 Measuring Compliance With Accepted Standards For Perioperative Fasting

Dr Sara McNeillis, Consultant (Dr Rebecca Medlock, CT1), Anaesthetics

An audit to determine if patients are being fasted according to RCoA standards.


07/03/2012 Cancelled 28/08/2012 Junior doctor has left Trust - audit will not be completed.

Project cancelled

3487 Audit of the Shared Care Protocol of Disease-Modifying Anti-Rheumatic Drugs

Dr Magliano, Consultant, Rheumatology (Lee Aye ST1, Dhuv Panchal, FY1)

To see if shared care protocols are being adhered to.

Integrated Medicine

07/03/2012 Complete 07/06/2012 Recommendations: 1.Qualitative study into why GPs have not signed shared care protocol. 2. Patient survey into what is more convenient and practicable for centre of prescribing and safety monitoring. 3. More transparent database for flagging patients who have missed blood tests as part of safety monitoring. 4. DMARD proforma for when starting on shared care to ensure appointments and blood tests not missed for prescribing clinician.

A laminated pathway for staring DMARD has been placed in each doctor's room to remind them about the forms and documents which need to be filled in.

3488 Audit of Video Calls via SKYPE as an alternative to Peripetetic Home Visits following Discharge from NSIC

Debbie Green, Matron, Outreach, NSIC

If patients prefer some patients will receive SKYPE call instead of home visit after NSIC discharge. Starts in June 2012. Audit of staff and patient experience.

Specialist Services


3490 Are SEND Discharge Summaries being completed

Dr Gopa Sarkar, Consultant, (Dr Amy Garrett, ST4) Paediatrics

Record keeping audit of SEND discharge letters used by the Neonatal Unit at

Specialist Services

12/03/2012 Complete 11/02/2013 45 notes from babies admitted to the neonatal unit between January and February 2012 were reviewed against the standard set for completing the SEND discharge form. A previous audit of SEND had been

Changes required

appropriately? (SMH)

SMH. Compare the information in the SEND discharge letters with the information in the notes to see how up to date/complete the information in the SEND discharge letter is.

completed in 2010. Results - None of the 45 notes were fully completed, the mostly commonly missed information was discharge gestation - 6 of 45 were complete except for these details. Father's details were often missing from antenatal history although available in the nursing notes. Drugs were general well documented but some summaries missed drugs, in 2010 audit it was noted that SEND forms showed sodium chloride being used to flush IV medication instead of normal saline, in this audit that was only recorded on one occasion. The Parental communication and Social sections often contains phrases such as kept up to date, see notes and see yellow sheets without any other information. In one case with social concerns the social section showed "see notes" but no indication of concerns or people involved included in the summary. Discharge details generally well completed - 43 were signed, 2 by consultants the rest by SHO's or Registrars. No recommendations given.

3491 Neuro Rehabilitation Unit Record Keeping Audit

Lesley Fox, Neuro Rehab Physiotherapy Clinical Support Worker

Record keeping audit of Neuro Rehabilitation Unit notes.



3492 Colposcopy Clinic Survey

Cathie Hansen, Colposcopy Nurse

PES of colposcopy clinic at WH. As previous audit (2567), record results by colposcopist.

Specialist Services

06/03/2012 Complete 05/07/2012 Overall, the responses and comments made by the patients are very encouraging. As department has recently moved into new premises it was rvery encouraging that the Colposcopy Suite met the approval of the majority (96%) of patients. Recommendations: 1. Ensure that the telephone numbers are correct on all of the paperwork. 2. Investigate how it can be made it easier for patients to speak to the appropriate person. This poses some difficulty as some phones are shared with the ante-natal clinic. 3. Take on board comments made about the reception staff.

Paperwork has been checked and corrected. Reception staff have been spoken to about their manner.

3493 Preventing Surgical Site Infection – Peri Operative Audit for Spinal Elective & Emergency Procedures


Observational audit carried out for 1 week in March 2012

Specialist Services


3494 On the Day Surgical Cancellations

Caroline Pritchard, Consultant, Anaesthetics

To audit all on the day surgery cancellations that are documented as medically unfit, and review reasons.




3495 Audit of Proximal Femoral Fracture

Shivali Patel, CT1, Anaesthetics

Waiting for PPF. 20/3/12 Shivali Patel cancelled this audit as it is similar to another audit.


13/03/2012 Cancelled 20/03/2012 Audit cancelled - never started. Audit cancelled - never started.

3496 Thromboprophylaxis in Gynaecology

Tunde Dada, Consultant, (Samantha Lyons, FY2) Obs & Gynae

Audit against Trust Guideline 539.1 to see if high risk patients for thromboembolism are identified and the correct doses of fragmin are prescribed for the correct duration. To identify if VTE scores have been completed and calculated for patients who have undergone gynae surgery, both emergency and elective.

Specialist Services


3497 Gynae-Oncology Patient Experience Survey 2012

Francesca Lis, Gynae-Oncology Clinical Nurse Specialist, Cancer Services

A patient experience survey to assess the experience of patients with gynaecological cancer. (reaudit)

Specialist Services

15/03/2012 Complete 10/10/2012 The results of the survey show that patients find the service helpful and valuable. Many comments about how comforting they found it to have someone who understands the anxieties experienced during investigations, diagnosis and treatment, and appreciated being able to contact their Specialist Nurse without having to make an appointment. Negative comments focussed on the difficulties experienced in contacting their Specialist Nurse by phone. 2 patients said that they had not been given their diagnosis in a caring and sensitive manner; these had been given by doctors. Recommendations: 1. Offer women to come back to our new nurse led clinic on a Wednesday in CCHU for 30-45 minutes (Level 2 psychological support). 2. Distress Thermometer assessments to be recorded and printed from Infoflex, to put in the notes. 3. Offer women time with the CNS in the clinics alongside the consultant.

Changes required

3498 VTE Audit Day Surgery


Part of rolling VTE audit which looks at VTE assessment and prophylaxis in each division. This audit relates to day surgery.

Specialist Services


3499 Perineural Invasion in Cutaneous Squamous Cell Carcinoma

Mr P Budny, Consultant Plastics (Roman Mykula, SpR plastics)

Audit cases of cutaneous SCC with persistant invasion in last 4 years, treatment, recurrence, follow up.




3500 Audit of Information Given to Women Prior to Induction of Labour

Miss Felicity Ashworth, Consultant, (Dr Katherine Talbot, SpR) Obs & Gynae

A prospective audit on the information provided to women prior to induction of labour – against NICE Guidelline CG70, and Trust guidelines.

Specialist Services

12/03/2012 Complete 18/05/2012 Recommendation: Information leaflet on Induction of Labour should be revised in order to clarify - possible length of time before birth; potential increase in pain level; need for electronic fetal monitoring; partner not able to stay in hospital during period after admission for IOL and birth.

Information leaflet currently being revised.

3501 Hand Hygiene Observational Audit April 2011 to March 2012


Hand hygiene audits carried out on all wards monthly (audit 3107) and recorded in spreadsheet. To analyse spreadsheets to produce annual summary.

Specialist Services

01/04/2012 Complete 12/06/2012 Results: Overall hand hygiene/”bare below elbows” was carried out in 98% of opportunities observed during the year, a slight improvement on the previous year’s figure of 97%. This compliance varied between doctors and nurses, with doctors recording a compliance of 94% and nurses and HCAs, 99%. All staff groups have improved or maintained their compliance since 2010/11. Compliance by ward/area varied from 84% to 100%. Recommendations: 1. There must be a system in place to show that ward staff have seen the audit report. Even though the overall month’s result may be at the compliance level, staff who are responsible for the hand hygiene data must look at the month’s data. If the data shows certain areas are below the compliance level a mini action plan must be completed to show how these issues are being addressed. If the month’s compliance level is below the recommended level then weekly audits must be completed along with an action plan. This must show how low compliance is being addressed. 2. Areas of non participation throughout the year (not


highlighted in this audit) should be addressed on a monthly basis. 3. All hand hygiene results must be displayed at ward level for public information.

3502 Audit of Management of Term Breech Deliveries (SMH)

Mr Tunde Dada, Miss Nutan Misra, Consultants (Dr Uloma Okwuosa, ST5) Obs & Gynae

An audit of management of term breech presentations, with emphasis on delivery and early perinatal outcomes, against Trust and RCOG guidelines.

Specialist Services

02/04/2012 Complete 13/07/2012 Results: Very high caesarean section rate for breech. Vaginal breech - too few for sufficient conclusions. Detection and reduction of incidence ae the best measures for reducing C-section rate. Better counselling regarding ECV. Impact on training and skills. Recommendations: 1. Improve detection with portable scans in community. 2. Midwifery USS training. 3. Improve ECV uptake. 4. Reminders and stickers. 5. Improve documentation. 6. Improve training and skills - Videos at maternity study days. 7. Collect further data on outcome of vaginal breech deliveries.

Changes required

3503 Management of Miscarriage Patient Experience Survey (SMH and WH)

Mr Chris Wayne, Consultant (Dr Uloma Okwuosa, ST5) Obs & Gynae

A patient experience survey for management of early pregnancy loss.

Specialist Services



3504 Audit of Denosumab and Zolendronate Prescriptions for the Treatment of Osteoporosis

Dr Magliano, Consultant Rheumatologist (Agnes Fong, FY2)

Retrospective study of patients receiving Denosumab & Zolendronate between Feb 2011 and Feb 2012. Audit against Trust guidelines on indications for prescribing.

Integrated Medicine

02/04/2012 Complete 10/09/2012 Recommendations: Consider strontium before starting parenteral therapy. Consider denosumab before prescribing zoledronate. Patients to have serum Ca/Vit D checked and replaced prior to starting parenteral therapy. Clinical audit lead to make clinicians aware of guidelines.

Changes required

3505 NIHSS Scoring in Stroke Patients

Dr A Misra, Consultant, (Deborah Stevenson, Jennifer Brown, FY1) Medicine

Assessment of percentage of stroke patients with an NIHSS score pre and post introduction of proforma labels.

Integrated Medicine

26/03/2012 Cancelled 28/08/2012 Audit abandoned due to lack of time. Project cancelled.

3506 Investigations for Stroke Admissions

Dr A Misra, Consultant, (Jennifer Brown, FY1) Medicine

To determine how many patients admitted with suspected strokes in January had a CXR, lipid profile and random glucose on admission. If not on admission, when?

Integrated Medicine

26/03/2012 Complete 28/08/2012 Results: Of the 64 patients audited 37 (57.81%) had a formal random glucose sample taken; 21 (32.81%) had either a lipid profile or total cholesterol sample taken within 1 week of admission; 46 (71.87%) had a chest radiograph on admission. Recommendations: 1. A brief summary of admission investigations for suspected stroke to be added to trust intranet guideline. 2. A poster form of this summary to be displayed in relevant areas in EMC. 3. This summary to be emailed to all medical and EMC staff. 4. if chest radiograph is to be made a standard investigation for all stroke patients, this needs agreement with the radiology department. 4. Rre-audit after six months.

Changes required

3507 Audit of Management of Paediatric UTI

Dr Boon Tang, Consultant, (Dr Rachel Weerasinghe) ST1, Paediatrics

An audit to assess whether children presenting with UTI are assessed, treated and investigated appropriately against NICE CG54 and Trust guideline 380.3.

Specialist Services

03/04/2012 Complete 04/09/2012 In summary we need to improve our knowledge of the UTI guidelines to make sure unnecessary scans and OPD appointment are not requested. How we obtain and diagnose UTIs for the most part seems satisfactory, but we should improve our documentation. Recommendations: 1.To promote the use of the hospital guidelines when dealing with children with a suspected UTI. 2. To encourage better documentation when obtaining urine samples. 3. To educate colleagues as to when to perform a dipstick and how to interpret this result. 4. To emphasise that the imaging strategies are different for different ages and that all clinicians should review the guidelines when planning investigations and follow-up.

Will re-audit in December 2012.

3508 Assessing Knowledge of Nutrition Supplements used on the Wards

Jenny Ottaway, Specialist Dietitian

To assess nurses' and HCAs' knowledge of supplements, the differences between them, and dosages. Using questionnaire on 10 nurses/HCAs on each ward.

Specialist Services



3509 Audit of VTE Prophylaxis in Emergency General Surgery

Dr Pattinson, Consultant Haematologist (Adnan Rozario, FY1, Surgery)

Part of rolling VTE audit

Specialist Services


3510 Audit of Lower Limb Revision Surgery

Mr Biring, Consultant (Mr Rishi Chana, Arthroplasty Fellow), T&O

To audit the revision workload and profile casemix of cases undertaken by BHNHST. To include where patients have their primary surgery, how they are doing now and a cost benefit analysis.




3511 WHO Surgical Safety Checklist Obstetric Procedures

John Abbott, Operations Manager, Critical Care

Continuation of WHO surgical safety checklist audit.

Specialist Services

11/04/2012 Complete 01/05/2012 Of 20 sets of notes audited, 3 had a WHO Maternity Checklist present, 1 of these was not 100% completed.

Action plan completed with theatres. There is an amended process for emergency caesarean sections.

3512 Mortality Review October 2011 - March 2012



Trustwide 16/04/2012 Draft Report with Clinician


3513 Pain Management Following Open Reduction Internal Fixation (ORIF) of Wrist

Dr Carl Morris, Consultant, Anaesethetics (Dr Athanassoglou, SpR)

An audit of pain scores following ORIF wrists.


16/04/2012 Notes being pulled


3514 VTE Audit Orthopaedic

Jonathan Pattinson, Consultant Haematologist (Laura Watts, Dr Panchal, F1s

Part of rolling VTE audit which involved audits 3090, 3205, 3256, 3274 which

Specialist Services


16/04/2012 There have been substantial improvements in the numbers being fully compliant with the NICE guideline on VTE assessment and prophylaxis, very nearly but not quite meeting the audit standard of

Changes required

T&O) looks at VTE assessment and prophylaxis in each division. This audit relates to Trauma admissions. Re-audit of 3313

90%. This suggests that our interventions have been effective and should be continued to result in further improvements. However, there remains a major problem with prescription of mechanical prophylaxis which should be rectified in future. Recommendations: 1. Spread the intervention which has been trialled on the orthopaedic wards to other wards of the hospital where orthopaedic patients are found. In this intervention nursing staff are asked to check for a VTE assessment when accepting a new patient to the ward, and write reminders to the doctors on the nameboard and in the notes. 2. Continue discussions with IT about changing the computer system where patient lists are compiled so that there is a box or reminder next to each patient name for when the VTE assessment has not been completed. This has started, but is likely to be a long term intervention. 3. Consider changing the admission proformas so that the VTE assessment stands out more, for example by putting a red box around it. This should reduce the number of instances where the admission proforma is being used but the VTE assessment is not being filled in.

3515 Audit of Emergency Caesarian Section

Miss Aparna Reddy, Consultant (Timothy Williams, FY2) Obs & Gynae

Continuous audit against CNST standards, Trust Guideline 463.4 and NICE CG132.

Specialist Services


3516 Antibiotic Prophylaxis Prescribing for Hip & Knee Arthroplasty

Mr Mann, Consultant, T&O (Adam Sykes, CT3)

A retrospective audit of the prescription of antibiotics for hip & knee arthroplasty surgery during March 2012 against Trust guidelines. A prospective audit of June data will also be undertaken.


19/04/2012 Complete 03/12/2012 Recommendations included: educating the SHOs; further education for the anaesthetists; revision of the T&O Junior Doctors Handbook; revision / re-formatting of the antibiotic guidelines.

The Junior Doctors' Handbook and the antibiotic guidelines have been revised.

3517 Audit of HIV testing of children of HIV positive patents

Veena Reddy, Associate Specialist, GUM

A retrospective audit of HIV testing of children of HIV positive parents. To identify children who have not been HIV tested from an at risk vertical transmission population. Audit against BHIVA recommendation - do not forget the children.

Specialist Services

19/04/2012 Complete 07/06/2012 GUM services should: 1. Proactively manage the cohort of possible parents. 2. Proactively manage ongoing cases with a view of the ‘ticking clock’ working in partnership with parents to agree the process of testing, whilst acknowledging/alleviating the parents' fears. 3. Raise the issue; stress that this is routinely discussed with all HIV-positive parents and that it is routine for all children of HIV-positive parents to be tested. 4. Explain the facts on the possibility of a positive diagnosis, depending on the child’s age. 5. Plan for all outcomes, which include the support and information needs of the child if told the parent’s diagnosis.6. Support more complex cases and cases of absolute parental refusal with a more intensive multidisciplinary approach and develop the relationship needed to ensure that child is tested. We have a dedicated HIV social worker who supports our parents through some of the dilemmas associated with testing children 7. Have clear thresholds to escalate referrals to the next level of responsibility when necessary. A set protocol, however, would not be appropriate. An individualised approach is required. If a child is sick then considerations to escalate to safeguarding would be appropriate. As clinicians we have a duty to signpost and facilitate best practice.

Every new patient to the service has the children’s questionnaire completed at baseline and the issue addressed. The cohort of not tested have been reviewed and revisited again with each patient- raising awareness and offering support to facilitate testing. We have not overridden any parents wishes.

3518 Transfusion – National Audit of Labelling and Correction on Group and Save Samples

Donna Beckford-Smith, Terrie Perry, Transfusion Nurses

The national comparative audit of the labelling of blood samples for transfusion starts on the 1st of May and runs for 3 months. The aim of the audit is to audit 3 rejected samples per week.

Specialist Services



3519 Antenatal Day Assessment Unit (DAU) Audit

Miss Nutan Mishra, Consultant (Lizzie Bartlett, FY2) Obs & Gynae

An audit of the referral patterns to the Antenatal DAU in relation to guidelines, highlighting inappropriate referrals and workload. Comparison of results to those of 2011 audit.

Specialist Services

01/02/2012 Complete 18/04/2012 More patients are being seen in DAU than during 2011. Only 6%-7% inappropriate referrals, which are commonly self-referrals. More patients are discharged from DAU than any other outcome showing DAU are successfully managing patients who have needs not met by primary care, but who are not unwell enough to be admitted. Referrals are from a variety of different sources showing that generally, healthcare professionals are aware of DAU and its role. Recommendations: 1. Find out how aware GPs/A&E/other relevant health care professionals are of the role of DAU and how to refer. 2. Inform SHOs of the role of DAU on induction. 3. To continue a similar audit yearly for 5+ years to ensure DAU is being utilised as it is intended and to ensure the inappropriate referrals are kept to a minimum.

Changes required

3520 Re-audit of Prescription of Intravenous Fluid and Electrolytes in Emergency Surgery

A Goede, Consultant, Surgery (Charis Manganis, FY1, General Surgery)

Prospective re-audit of fluid prescription and administration in emergency surgery, based on British Association for Parenteral and Enteral Nutrition (BAPEN) guidelines: British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients. (Re-audit of 3239)



3521 Management of Hypertension in Pregnancy against NICE and Trust Guidelines

Miss Nutan Mishra, Consultant (Dr M Walia, GPVTS, Dr Samantha Scammell) Obs & Gynae

Continuous audit of hypertension 1st December 2011 to 31st March 2012. For Labour Ward Forum.

Specialist Services

01/04/2012 Complete 14/06/2012 Results: 1. Good documentation of management of severe PET in the patient notes. 2. Management according to trust guidelines and CNST. 3. No differentiation from PET/HTN in the delivery book. 4. PET proforma not being used at all. 5. Good understanding of Severe PET classification amongst the staff on labour ward. Recommendations: 1. Proforma to be completed and inserted in the patient notes. 2. Correct documentation in delivery book. 3. Severe PET teaching for students.

New guideline completed (September 2012).. To be launched at APEC study day 13/9/12. Posters to be created posters for dating scan area. Check list for community midwives developed by JM/JH.

3522 National Paediatric Diabetes Audit 2011-2012

Dr A Dutta, Paediatric Consultant, SMH, Dr M Russell-Taylor, Paediatric Consultant, WH

A national system for routine data collection, analysis and feedback of diabetes related data. Data from Apr 2011 to Mar 2012.

Specialist Services



3523 Appropriate Use of D-Dimer in Suspected Pulmonary Embolism Compared to BTS Guidelines

Dr Chris Wathen, Consultant, Respiratory Medicine (Dr Muaad Abdulla, FY1)

To compare the use of d-dimer in suspected PE against BTS guidelines.

Integrated Medicine

24/04/2012 Complete 30/08/2012 Results: 46% (21/46) patients had correct use of D-Dimer prior to CTPA for possible Pulmonary embolus, in accordance with risk guidelines outlined by the British Thoracic Society. Recommendations: 1. Clinical probability (using BTS guidelines) or a proforma should be included in the notes; 2. d-dimer should not be requested in patients aged over 80, and those with recent obstetric/surgical histories; 3. d-dimer tests to be requested only with the approval of senior doctors and only in cases where the risk of pulmonary embolus is low or intermediate; 4. A regular review of the appropriate use of d-dimer for acute medical presentations; 5. Re-audit.

Changes required

3524 Management of Shoulder Dystocia

Miss Hall, Consultant, (Dr Laura Lewis GPVTS 1) Obs & Gynae

To follow up previous audit and compare performance to NICE and Trust guidelines. (Previous numbers 2270, 2354, 2960,3227).

Specialist Services

27/04/2012 Complete 14/06/2012 Results: 1.The proformas are often not completely filled in, we must improve upon this – fill in every section, if it doesn’t fit neatly into a box free text is acceptable. 2. We often don’t have any documentation of time of calls for help or order of manoeuvres. 3. The record of postnatal discussions is incomplete in the majority of cases. 4. We are very poor at completing Datix forms and the trust requires that they are completed for every case. Recommendations: 1. Datix forms must be completed. 2. Proforma must be completed fully. 3. Record details of the postnatal discussion in maternity notes as well as ticking the box on the proforma.

Changes required



Part of IPC audit plan Specialist Services

01/05/2012 Complete 02/08/2012 Results: Reg obs Only 2 wards took part. 100% compliance. Ongoing obs 3 wards took part. 100% compliance. Recommendations: 1. The Infection Control team will liaise with the ITU Senior Staff to review the audit to ensure that work that is already being carried out is not repeated. 2. Wards that have not participated should complete this audit.

Infection Control assure us that all actions completed.




01/05/2012 Complete 22/08/2012 Results: Urinary Catheter Care – Insertion. 98% full compliance was achieved. 5 areas had elements of non-compliance and should have produced action plans. However, only one of the areas did.Urinary Catheter Care – Ongoing Care: Overall, all applicable elements were performed in 90% cases. 7 areas had elements of non-compliance and should have produced action plans. However, only 2 of the areas did. Recommendations: 1. The tool must be adapted to include “Not applicable” options for all elements. 2. The tool to include a question on if the UCAM form completed on each patient with a catheter for more than 24 hours. 3. All patients with an existing catheter or a catheter inserted must have a form commenced. 4. All staff who undertake catheter insertion and ongoing care must have appropriate training to ensure patient safety is maintained.

Infection Control assure us that all actions completed.

3527 Long Term Condition SLT Team Outcome Audit

Ali Greenwood, SALT Provide therapy for acquired neurological conditions. Look at success of

Specialist Services

24/04/2012 Complete 06/06/2012 Aims of therapy were achieved in 80% of cases. Where they were not achieved, the client had declined further assessment or therapy. Recommendations: 1. Continue to ensure that

Continued to ensure that outcome measures sheets are recorded in patient case notes on discharge. This will be

interventions using Kent Outcome measures on 15 patients from Aug 11 to Jan 12.

outcome measures sheets are recorded in patient case notes on discharge. 2. Provide team training for goal setting. 3. Review other outcome measure systems. 4. Audit a larger sample of discharged patients’ case notes to include communication impairments. 5. Audit samples from both North and South Buckinghamshire LTC teams. 6. Complete Action Plan on the above in discussion with LTC speech and language therapy teams, South and North, by September 2012.

audited over the next month as part of the larger casenote audit covering the whole department.Setting goals within our current system of outcome measures has been informally discussed and clarified within the Long Term Conditions Team. However, the team are keen to review/investigate other systems of measuring outcomes which might be better suited to communication impairments, in particular, aphasic difficulties. As the Long Term Conditions Team has a number of major projects in progress this financial year, it was proposed to continue with the current measures until the following year.A larger sample of casenotes, to include North and South teams, will be audited as part of this year’s casenote audit. This will record inclusion of outcome data in casenotes but will not audit outcomes of therapy. Audit of therapy outcomes will follow any changes in outcome measures proposed/used in the next financial year.

3528 Effectiveness of the Clinicians’ Companion Software for Patients with Parkinson's Disease

Chloe Cripps, SALT Specialist Services


3529 Outcomes for Teletherapy with Dysphasic Patients

Julia Parsons, SALT Outcomes measured after treatment. Trial treatment starting May 2012. Start measuring outcomes at end of 2012.

Specialist Services



3530 Effects of Pre-operative Cardiac Assessment in Abdominal Aortic Aneurysm Patients

Dr Aneil Malhotra, Registrar, Cardiology (Charles Miller, SHO)

To gather data from AAA patients before and after Cardiology Assessment was introduced to determine whether outcomes have improved.

Integrated Medicine

30/04/2012 Cancelled 23/08/2012 Project did not start due to initial problems. Project cancelled

3531 What Proportion of First Time Seizures are Referred for a Neurology Review

Dr Briley, Consultant, Neurology (David Ledingham, FY1)

To review the notes of patients presenting with seizures for the first time to ascertain whether the patients are referred to a specialist in the managemnet of epilepsy to ensure early diagnosis and treatment in line with NICE guidelines.

Integrated Medicine

30/04/2012 Cancelled 06/11/2012 Doctor never started audit. Project cancelled

3532 Negative Appendicectomy Rates

Marwan Farouk, Consultant, Surgery (Nigel D'Souza, CT3)

To check negative appendicectomy rates and rates of microscopic inflammation of appendix.


03/05/2012 Complete 21/01/2013 Trust NAR 16.8% - 25.4%. This was found to increase after ultrasound scan, however caution is urged with this finding as it is appreciated that the patients going straight to theatre without ultrasound are likely to be more ‘obvious’ cases of appendicitis.

Changes required

3533 Ultrasound in Appendicitis

Marwan Farouk, Consultant, Surgery (Nigel D'Souza, CT3, Kirsty Steele, David Grant)

To look at sensitivity and specificity of ultrasound for appendicitis and compare with published results.


03/05/2012 Complete 21/01/2013 The appendix was not visualised in 66.4% of ultrasound scans. Ultrasound ‘contributes’ to diagnosis or management in only 44% of scanned patients. It was found to be most useful in females over 16 (58%). Recommendations: Ultrasound may be useful in females over 16 presenting with RIF pain, its role mainly in excluding other diagnoses. In other groups ultrasound is less valuable. More weight should be put on clinical suspicion; this would require close monitoring of NAR. There may be a role for CT, other studies have shown reduced NAR but it would expose patients to significant radiation.

Changes required

3534 Thyroid Function Tests

Dr Sudesna Chatterjee, Consultant (Dr Sarah Ng, FY1) Diabetes and Endocrinology

To assess the number of TFTs requested during acute medical intake and whether they are requested appropriately. If they are abnormal, are they acted upon appropriately.

Integrated Medicine

20/04/2012 Complete 24/06/2012 45.84% of thyroid function tests in acute medical inpatients are not justified or have unclear indications. This leads to the wastage of a significant amount of financial resources which could be put to better use. Tthyroid function tests were requested in 22.5% of medical patients. Only one in 10 of these patients at the most could have abnormal thyroid function, as indicated by the abnormal TSH value. Clinical information is commonly not written on the request card or clinical indications not given clearly, which makes it difficult for the laboratory to decide the most appropriate thyroid function test to perform to yield the most cost-effective test which yields the highest diagnostic result. Abnormal thyroid function tests are often difficult to interpret in acutely unwell patients and should be retested once the patient has recovered, usually within 3-6 months. A TSH concentration above the reference range with FT4 within the normal reference range suggests subclinical (mild) hypothyroidism. In these patients, TFTs need to be repeated in 3-6 months after the initial results to exclude transient causes of a raised

Changes required

TSH. Only then can a diagnosis of subclinical hypothyroidism be made. Two months is the minimum period to achieve stable concentrations after a change in thyroxine done. Thyroid function tests should not normally be requested before this period has elapsed. Discharge summaries should include information to the GP regarding the abnormal thyroid function tests, the initial indication for requesting it, and also the action plan required for further testing and possible commencing of treatment. Manifestations of thyroid disease are often subtle and interpretation of thyroid function tests in unwell inpatients are often difficult. Our audit reinforces the principle that TFT results very rarely influence the management of acutely unwell medical inpatients, and should not be performed routinely in this group of patients. Recommendations 1. Present audit findings to educate junior doctors regarding appropriate indications for thyroid function testing, the limited usefulness of thyroid function tests requests in acute illness, importance of providing clinical information to aid the laboratory in performing testing, timeframe to repeat thyroid function tests, and the importance of good communication to general practitioners through clearly written discharge summaries for follow-up of abnormal thyroid function tests diagnoised in hospital. 2. Set up hospital guidelines on the Bucks Healthcare Intranet. 3. Include recommendations in Bucks Trust Clinical Guidelines handbook.

3535 Use of Oxycontin / Oxycodone Analgesia in Hip and Knee Primary Arthroplasty

Mr Gurdeep Biring, Consultant, T&O (Mr Rishi Chana, Fellow)

To look at the use of local anaesthetic and oxycontin / oxycodone analgesia in hip and knee primary arthroplasty to determine role in enhanced recovery post-operative regime.




3536 Fascia Iliac Blocks as a Replacement for Morphine in Fractured Neck of Femur

Alistair Graham, Consultant T&O (Andrew Jones, Lydia Hanna, FY2)

Monitoring analgesia and response to analgesia in patients with #NOF using fascia iliac blocks as a morphine replacement. Auditing against current pain control standards.




3537 Personal Child Health Record Record Keeping Audit

Elaine Tranter, Corinne Hibbert, Dawn Smith, Community Midwives

Record keeping audit of babies' Personal Child Health Record ("Red Book").

Specialist Services



3538 Extra-Cardiac Findings on Cardiac MRI

Dr M Hart, ST4 Assesses the prevalence of extra-cardiac findings from cardiac MRI and evaluates their clinical significance.

Specialist Services


08/05/2012 186 cardiac MRIs checked. 193 ECF detected. 39% had one or more clinically significant ECF. High prevalence of extra-cardiac findings on MRI which could impact on patient's treatment/life, therefore it is crucial to look for extra-cardiac findings when reporting cardiac MRI. Recommendations: 1. To follow up on clinically significant extra-cardiac finding to ensure appropriate clinical management. 2. Present results and educate department in the importance of looking for extra-cardiac findings. 3. Reaudit in 12 months.

Changes required

3539 Audit of Analgesic Requirements and Satisfaction Post 3 Index Operations

Matt Size, Anaesthetics consultant (Hosnieh Djafari Marbini (ST5)

To assess pain relief peri-operatively in 3 index operations, noting use of opioids and central & peripheral nerve blocks. Then looking at patient pain scores and how quickly satisfaction reached in recovery.


08/05/2012 Complete 21/01/2013 All patients should have a pain score of below 4 on waking in the Recovery Room and no patient should return to the ward with a pain score of 4 or more (Royal College of Anaesthetists). Pain scores were 4 or more for 6% patients on waking and for 4% patients on leaving recovery. It is difficult to analyse from case notes alone what could have been done to ensure all patients had lower pain scores post-operatively. There are several cases where a peripheral nerve block was performed, which may have been sub-optimal, and it is also difficult to appreciate retrospectively factors such as workload in the recovery room at a particular time. This might be a further avenue for research for a prospective study, or also to evaluate patients for longer post-operatively, as well as to ask for pain scores pre-operatively, which are not routinely recorded.

Changes required

3540 Audit of Length of Stay on Postnatal Ward Post Delivery

Dr Sanjay Salgia, Consultant, (Dr Elizabeth van Boxel, ST1) Paediatrics

An audit to assess delays in the discharge of babies from Rothschild Ward.

Trustwide 30/11/2011 Complete 14/07/2012 Areas for improvement: Paediatrics: 1. Senior involvement and decision making - ?Avoiding erroneously given IV abx. Avoiding delay in discharge to arrange FU for renal pelvis dilatation. 2. Burden of administrative work on postnatal SHOs - Subtracts from time available to perform baby checks (particularly at weekend) and arrange complex follow up. 3. Review of non-antibiotic related guidelines - Not always easy to find – different versions of the same guideline! Obstetrics: 1. Coverage with intrapartum antibiotics - Insufficient maternal IV abx accounted for 24% of delays. 2. Communication between Paediatrics and Obs/ Midwifery - Avoid erroneously given IV abx. Anticipate problems such as need for apnoea monitor. Microbiology: 1. Suspected sepsis guidelines: lower threshold for treatment than some others in network? 2. Communication with microbiology – ability to access and interpret results.

Changes required

3541 IMS Documentation of Admission Neurology Examination

Mr Saif, Consultant (Dr Helen Banks, Rehabilitation registrar)

Audit to assess completeness of neurology examination for new patients admitted to NSIC and use of IMS proforma to document findings. Audit of last 40 patients admitted.

Specialist Services

11/05/2012 Complete 29/05/2012 Results: Complete ASIA assessment (Sensory exam, sensory level, motor exam, motor level, overall level, AIS score, anal reflexes, Frankel grade) for only 13% of patients. No neuro exam documented in IMS for 4 patients (10%). 75% of neuro assessments took place on the day of admission. Remainder were carried out within 2 days of admission. 86% of assessments carried out by SHOs. Recommendations: 1. Ensure interpretation sections filled in. 2. Improve examination and documentation of reflexes. 3. Ensure additional components of neurology exam are completed and documented. 4. Consider changing training for new SHOs to further highlight the importance of full assessment and documentation.

This will be re-audited but none of the other recommendations actioned.

3542 Local Maternity Survey February 2012

Audrey Warren, Head of Midwifery

Local maternity survey, based on the National Maternity

Specialist Services

09/05/2012 Complete 11/12/2012 1. 77% of women said they were not given information about the NHS Choices website. 2. 57% of women rated their care during pregnancy as

Changes required

Survey 2010, for all mothers who gave birth in February 2012.

excellent or very good. This was 75% in 2009. 3. 14% of women gave birth in a Birth Centre. 4. 22% of the women were left alone when it worried them at some point. 5. 76% rated their care during labour and birth as excellent or very good. This was 81% in 2010. 6. Feeding - Midwives had discussed infant feeding, at least to some extent, with 72% mothers during their pregnancy. 53% babies were exclusively breastfed (or fed expressed breast milk). 18% (40) mothers responded that their babies had been fed only formula milk and 25 of these mothers said that they had not put their baby to the breast at all. 7.Care at home - 11% felt they were not given active support and encouragement to feed their baby. 59% saw a midwife either once or twice after they went home. 32% would have liked to see a midwife more often. 8. 68% of women felt that during their stay in hospital they were always treated with kindness and understanding.

3543 Audit on the Management of Hyperglycaemia in ACS Patients

Dr Punit Ramrakha, Consultant, (Dr Gillian Rivlin) Cardiology

Re-audit of blood glucose monitoring in patients with suspected ACS and adherence to ACS protocol. (re audit of 3236)

Integrated Medicine

14/05/2012 Cancelled. Project cancelled.

3544 Operative Vaginal Delivery

Mr Chris Wayne, Consultant (Dr Raveendran Ruben, Dr Shiraush Patel) Obs & Gynae

Ongoing audit of operative vaginal delivery (last audit 3229).


3545 Management of Hyperemesis Gravidarum

Mr Tunde Dada, Consultant, (Faye Boundy, Ahmed Arif) Obs & Gynae

To assess management of hyperemesis gravidarum and whether it is done according to Trust guidelines (452.3).

Trustwide 18/05/2012 Complete 16/10/2012 Results: Good adherence to guidance in initial investigation and management of HG. Consider ways to reduce length of hospital stay. Limited data to evaluate re-admission rates/ severity of condition. Recommendations: 1. Review at 2 hours and again at 6 hours. 2. Decision on admission / discharge based on specific criteria. 3. Implementation and re-audit with prospective study.

Changes required

3546 Management of Massive Post Partum Haemorrhage

Miss Sangeeta Suri, Consultant (Dr Edward Harvey, Dr Rebecca West ST1) Obs & Gynae

Ongoing audit of incidence of massive obstetric haemorrhage (>1500 ml) between Audit against CNST, BHT guideline 550.1 and NICE. (previous audit 3308).

Specialist Services


3547 Colorectal Patient Experience Survey 2012

Clare Bossom, Colorectal Clinical Nurse Specialist, Cancer Services

A patient experience survey to assess the experience of patients with colorectal cancer. (reaudit)

Specialist Services

19/05/2012 Complete 24/02/2013 Recommendations: The plan for this year is to continue the good work already in place. To address the issue of making patients aware of what the Keyworker role is, and to take this further by highlighting to them their Keyworker name in written format. To liaise with the Colorectal MDT lead, to filter down to all the medical team the importance and benefits of having a colorectal nurse present, when relaying a diagnosis of cancer to patients. MDT members will be advised on how to contact colorectal nurses on both hospital sites. To recommend from first contact where appropriate the benefits of having a relative or friend present during consultations, without causing undue anxieties.

Changes required

3548 Speech & Language Therapy Annual Statistics - Usage

Debbie Begent, Acute SLT Service Manager

Looking at patients seen etc. Waiting times are recommended by

Specialist Services

18/05/2012 Complete Acute referrals at Wycombe Hospital increased significantly even before the Hyper Acute Stroke Unit opened. There was an increase in staff of 0.3 WTE but this has not been enough to cope with increased

All recommendations being carried out. Staff redistributed to cope with changed demand. More statistics being recorded.

and Waiting Times Royal College. demand. The Long Term Conditions Team at Stoke Mandeville have a steady referral rate and an increase in referrals. The Long Term conditions team at Amersham/Wycombe have had a reduction referral rates. Despite being without a Clinical Lead for 6 months have managed to keep waiting time breaches minimal. There is a steady increase in the referral rates to the Voice team and LSVT. Recommendations: 1. Monitor statistics and re-distribute staff as required in response to changes in the Trust. 2. LSVT will be newly established at Stoke Mandeville, keep separate referral statistics for LSVT in the North of the Bucks. 3. Separating statistical collection to monitor acute stroke vs medical referrals. 4. Separating statistical collection to reflect the increase in Head and Neck Cancer referrals and Voice Team to discuss further efficiencies possibly in administration systems. 5. Continued collection of statistics in order to monitor referral and response rates so that we can be flexible in an organisation that is changing and developing.

3549 PROMS Outcome Measure Mid Term after Knee Replacement

Mr Johnstone, Consultant T&O (Peter Smitham, SpR)

Audit TKR over 5 years using PROMS outcome measures. Compare with national PROMS database which is just done 6 months after surgery.




3550 Physio Outcomes in Gynaecology

Rosi Haunton-Barron To look at outcomes for all obs, gynae & urology patients referred to physio in 2011/12.

Specialist Services

23/05/2012 Complete 01/06/2012 Recommendations: 1. To reduce the initial appointment assessment time to ½ hour for Drams, 3rd and 4th degree tears and Pelvic Girdle Pain. 2. With Mr Greenland’s consent – to prescribe medication for Over Active Bladder through the GP if felt it would be beneficial thus reducing the number of patients referred back to the consultant. 3. Review of patients’ follow up appointments with consultants.

Initial appointment assessment time reduced to ½ hour for Drams, 3rd and 4th degree tears and Pelvic Girdle Pain. Medication prescribed for Over Active Bladder through the GP so number of patients referred back to the consultant reduced. Reviewed patients’ follow up appointments with consultants so some discharged earlier.

3551 Audit of Interventional Radiology

Jael Ramcharitar Audit of complications following intervensional radiology procedures.

Specialist Services

23/05/2012 Complete 21/09/2012 Report has been reviewed by the SDU Lead, who has put together an action plan that will be taken forward with the support of the Medical Director.

Changes required

3552 Audit of VTE Prophylaxis in Burns & Plastics Surgery

Dr Pattinson, Consultant Haematologist (Robyn Perkins, FY1, Plastics)

Part of rolling VTE audit

Specialist Services


3553 Obesity Management in NSIC - Staff Questionnaire

Samford Wong, NSIC Dietitian

Examining staff opinions and practice on weight management for SCI patients. Questionnaire also sent to doctors in several other trusts.

Specialist Services



3554 Awareness of Guidelines on Management of Delirium in T&O

Ramesh Chennagiri, Consultant T&O (Dr Chris Griffin, Dr Esther Trafford FY1 T&O)

Following a neck of femur fracture delirium is as prevalent as 50%. Research suggests delirium is poorly recognised and inefficiently managed. Audit of recognition and assessment of delirium at admission in T&O patients over 65.


25/05/2012 Cancelled 07/02/2013 Project cancelled, may be reactivated. Project cancelled

3555 Surgical Site Infection Peri-Op Burns & Plastics June 12


Part of IPC audit plan. Carried out in week 11/6/12 to 17/6/12.

Specialist Services

01/05/2012 Complete 01/09/2012 A report wasn’t compiled due to only 4 observations being completed. This was discussed with Jean O’Driscoll who was going to follow up the issues with low compliance.

Not applicable

3557 Improving Current Practice for Treatment of Weber B Fractures

R Chennagiri, Consultant (Howard Chan CT2, Cat Fortescue CT1 T&O)

Review practice for current treatment of Weber B fractures and identify areas for improvement. Audited against RCS standards.




3556 Haematology Cancer Patient Experience Survey

Marie Pennell, Haematology Clinical Nurse Specialist, Cancer Services


Specialist Services

27/05/2012 Complete 15/02/2013 Results: 91% of respondents were very satisfied and 9% were satisfied with the care provided and reported having confidence and trust in the clinical nurse specialists. The audit indicated very positive

Changes required

Reaudit of 2889. responses to the support received from the CNS. 100% of the respondents were given contact details of the key worker.4 out of 19 patients did not completely understand their treatment plan and 2 out of 17 patients were not given a written summary of the treatment plan. 1 patient said they did not see CNS very often.Recommendations: Ensure all patients are given a written summary of the treatment plan.Check patients understanding using a different form of words in order to give the patient the opportunity to say they did not understand.All patients need to be provided with information on support groups and self-help groups by CNS.Plan a holistic assessment clinic and give patients the opportunity to meet with the CNS at a set appointment time.

3558 Patient Hand Hygiene Audit April 2012

Infection Control Re-audit of audits carried out in August 11 and Nov 11 to check to see if patients are encouraged to perform hand hygiene after bathroom/commode/before meals etc.

Specialist Services

01/04/2012 Complete 30/05/2012 Assistance on hand hygiene is being offered to 65% of patients after using the bathroom but some patients do not need this. Staff are makingsure the patients are receiving hand wipes with their meals, the audit results indicate 78% of patients asked said they were receiving the hand wipes. The audit results demonstrate that only 29% of patients received the ‘Hand Hygiene Benefits Everyone’ leaflets. All patients should receive this leaflet as part of their healthcare management. This means that 71% of people said that they had not received or read theleaflet. Recommendations: Areas of low compliance to re –audit to check all actions have been addressed. Areas of non compliance to complete audit and action plan to ascertain compliance. Recommendations and areas of low compliance to be discussed at next IPCC meetings. Staff to assess individual patients ability to perform hand hygiene for themselves and ensure assistance given where required.



National Inpatient Survey of sample of 850 patients seen in July 2012.

Trustwide Not yet started


3560 No. of USS Slots Required for DVT Clinic

Dr Richard Hughes, Consultant Radiologist (Dr Yvonne Obura, FY1)

Collecting data on number of patients who present in DVT clinic but cannot have USS on same day due to lack of availability.

Specialist Services

09/05/2012 Complete 04/12/2012 Recommendations:The FY1 is aware of how many USS slots are available for the day and when the earliest slot is if none are free on the day.All referrals are made to the FY1 on-call. The registrar directs all such referrals to the FY1 for booking of an USS slot.Patients are only seen in the DVT clinic following a scan. They should therefore be assessed in EMC, receive dalteparin if applicable and be referred to the clinic once an USS slot has been established.Re-assessing the protocol as to the clinical need of having a re-scan. Holding conclusion as to whether the service requires more USS slots pending implementation of the above recommendations.

Changes required

3561 Investigating the Impact of a Pharmacist at Pre-Admission Clinics on Peri-Operative Medicines Management

Saadia Khalid Lead Pharmacist, Surgery (Brenda Ogbuji, MSc student Pharmacy)

Pharmacy will be providing an enhanced service to pre-assessment clinics at WH for elective total knee replacement patients. This will start in May 2012. Audit will involve collecting data from before and after pharmacist introduced and will be looking at specific data, such as medicines reconciliation and management of medicines in the peri-op period.

Specialist Services

01/06/2012 Complete 15/10/2012 When nurses alone handled medicines reconciliation of patients in the PAC, a large proportion (62%) of patients had medication discrepancies upon admission. The most common of these was the omission of some of the patient’s home medications. The involvement of pharmacists in the PAC led to more correct and accurate medication histories being obtained for the patients which can help to reduce medication discrepancies upon their admission to hospital. It also improved the level of pharmaceutical service received by elective surgery patients.

Changes required

3562 WHO Maternity Checklist Audit

Miss Aparna Reddy, Consultant (Dr Neha Singh, FY2) Obs & Gynae

An observation audit of the use of the WHO Maternity Checklist to be carried out in New Wing Theatres, and complemented by an audit of 20 sets of case notes.

Specialist Services



3563 Audit of Last Minute Cancellations of Procedures in Ophthalmology

Dr Allaaeldin Abumattar, Associate Specialist, Ophthalmology

An audit to compare the Trust's last minute cancellation rate to the DH nationally tolerable rate and to address any avoidable reasons accordingly.


06/06/2012 Complete 01/10/2012 Results: Main causes of loss - a. DNA / cancelled by patient. b.Patient illness and pre-existing medical condition. C. Operation not necessary / required / cancelled by surgeon. d.Administrative errors. e. Data Missing. Recommendations: 24-48 hours before admission a reminder / check by telephone (or any alternative) to identify patients who are unable or too unwell to attend their surgery { potential DNA} giving the hospital chance to substitute these patients. This “waiting list last minute validation” is to check whether patient is still able and willing to undergo the procedure and whether they have received all the details, arranged transport.

Changes required

3564 Survey of Patients' Views on the Use of a Computerised Visual Aid to Explain Prolapse

Mr Tunde Dada, Consultant, (Dr Alvaro Bedoya-Ronga, ST6) Obs & Gynae

A survey to assess patients' views on the use of the computerised visual aid and leaflets in order to explain prolapse and its treatment.

Specialist Services

Complete 14/06/2012 CVA is a useful tool to communicate with patients, helps patients to understand their prolapse and the surgery and is at least as good as the leaflet. It is being used routinely. Recommendations: Encourage and increase the use of CVA. Develop procedure specific leaflets.

Changes required

3565 Management of Neonatal Jaundice

Dr Gopar Sakar, Consultant, (Dr Katharine Irving, ST1, Dr A. Ray Narayaran, ST5) Paediatrics

An audit of notes in order to determine the management of neonatal jaundice against Trust and NICE guidelines.

Specialist Services

06/06/2012 Complete 10/10/2012 1. Implement NICE charts for monitoring bilirubin levels across the neonatal & paediatric department for all gestational ages. Discontinue use of current Trust charts and remove these from wards. 2. Print the summary sheet from the Trust guideline “Appendix 1” (see page 3 of this document) on the reverse of the two term NICE charts (37-week and ≥ 38-week) that will be used in the postnatal ward. This summary sheet to be completed by all staff (midwives, nursery nurses and junior doctors) for every jaundiced baby, and to be included in the patient records and hand-held notes. 3.Compile a file of documentation and information specifically for “Jaundice” to be kept in the nurse’s station or Doctors office in the postnatal ward. This file should be for general use by all including midwives, nursery nurses and doctors. It should comprise sections containing at least: a. Guidelines on management and assessment: The NICE guidance summary and our Trust protocol; - NICE bilirubin charts for various gestational ages (with the “Appendix 1” summary sheet photocopied

Not all recommendations need to be implemented. Guideline 693.3 updated October 2012. The NICE treatment graphs (Appendix 5) need to be interpreted with common sense judgement and discussion with the paediatric team is mandatory if treatment is triggered by the charts. Patient information leaflet.

on the reverse page as described above); b. A parent education leaflet, which should be given to all parents with jaundiced babies (available from NICE guidance website)- GP letter template for jaundiced babies that should be completed at discharge from the ward. c. Master copies of all documentation should be given to SCBU secretary Jan for safe keeping. This file could be developed by one of the SHOs working in the unit currently. Failing this, Katharine Irving will complete this task. 4. Distribute list of recommendations to postnatal ward and SCBU management staff. Points to be discussed with midwifery and neonatal staff. Dr Sarkar to organise these meetings and dissemination of information. 5. Re-audit in 1 year following implementation of recommendations discussed to complete cycle. This should take place around September – October 2013. Dr Sarkar to supervise this.

3566 Critical Care Mortality Review


Review of February 2012 mortality in Critical Care, SMH, following an alert. Notes to be reviewed using mortality review tool.




3567 Paediatric Consent Audit

Miss Jo Hicks Review of the consenting of 50 paediatric patients who underwent a procedure from 1st September 2011 to 30th April 2012.

Specialist Services

01/06/2012 Cancelled Cancelled Cancelled

3568 Pain Audit in New Wing Recovery

Barbara Leach, Senior Acute Pain Nurse

Audit of pain scores after anaesthetic and pain scores leaving Recovery. To improve patient experience and post-operative care and achieve shorter length of stay in Recovery.


11/06/2012 Complete 01/11/2012 The recommendation was to improve the recording of pain scores on wards. Action will include running Pain Assessment Study days. Pain nurses will also get involved in student nurse education in acute and chronic pain study sessions.

Changes required

3569 Audit of Post-Operative Endophthalmitis

Mr Khurram Rahman, Associate Specialist, Ophthalmology

To analyse the incidence rates of post-operative endophthalmitis (severe eye infection following eye surgery) in the Ophthalmology Unit at Stoke Mandeville Hospital between 2008 and 2011. A re-audit of 2478.


11/06/2012 Complete 09/10/2012 Results: The endophthalmitis rate in the Trust is slightly higher than national average; the culture positive rate in both vitreous and esp. aqueous is low; vitreous biopsy gives a better yield than vitreous tap. Recommendations: to continue with post operative prophylaxis as before; to consider using intracameral cefuroxime.

As the large multicentre European study was flawed, the decision to change to using intracameral cefuroxime was left to individual practitioners.

3570 Audit of Clinical Management of Pre-Term Labour before and after introduction of Fetal Fibronectin Testing

Miss Suri, Consultant (Ayesha Choudhary, Amar Maroo) (Dr Katherine Talbot) Obs & Gynae

Audit of Clinical Management of Pre-Term Labour before and after introduction of Fetal Fibronectin Testing.

Specialist Services



3571 Mouth Care in ITU Dr Panikkar, Consultant Anaesthetics/ICU (Dr David Bruce, FY1 ITU)

Mouth care is important on ITU because patients are often ventilated and at high risk of infection. Audit of all patients on ITU on set date (estimate of 8-10 patients) looking at duration of stay so far. Auditing against Trust guideline 355.2. Also questionnaire to ITU nurses & doctors.




3572 Chemotherapy Patient Experience Survey

Annie Richards, Matron for Cancer & Haematology

Obtain patient feedback regarding the service and information provided. Reaudit.

Specialist Services



3573 Peripheral Line Care June 12

OPAT Team Part of IPC audit plan. To be carried out by OPAT team.

Specialist Services

13/06/2012 Complete 07/09/2012 Results : Insertion: All 4 elements of tool complied with for 68% observations. Continuing Care: VIP forms were completed for 88% patients with IV lines. All applicable elements were complied with in only 20% cases. Recommendations: 1. To individualise more of the elements in the insertion audit, to avoid discrepancy in assessment process and help focus any further training needs. 2. Areas that were involved in the audit and showed non compliance will have individual action plans to complete, with results being returned to the IV team.3. Medical staff must be informed of the results as they play a significant role in the element of insertion. 4. The importance of filling in documentation should be emphasised through educational processes. Education/ training continues to ensure that insertion and continuing care of peripheral cannula devices is provided for all healthcare workers involved in this skill.

Changes required

3574 Audit on the Process of Induction of Labour

Miss Felicity Ashworth, Consultant, (Dr Meena Bhatia, SpR) Obs & Gynae

A prospective audit on the process of induction of albour against Trust guidelines.

Trustwide 12/03/2012 Complete 30/06/2012 Recommendations: 1. IOL only bay. 2. IOL specific staff on Roths in am. 3. No rest day with Propess (primps). 4. Consider out patient-IOL (NICE guidance). 5. Update of leaflet regarding timings. 6. Improve explanation women receive about why they are being induced, what the process involves and delays they can experience.

Changes required

3575 Survey of Information Given to Patients on Ward 5B MFOP

Dr D Walshe, Consultant, (Dr Ana Phelps, SpR) MFOP

A survey on the information given to patients and patients' relatives/carers on admission and discharge to Ward 5B SMH, MFOP.

Integrated Medicine



3576 Documentation of Anaesthetic Risks

Dr Louise Dodd, Consultant, Anaesthetics (Dr Deborah Stevenson, FY1)

Audit to investigate how many patients are informed of all anaesthetic risks for GA/spinal/epidural.


19/06/2012 Complete 28/08/2012 Recommendation: Make changes to the anaesthetic chart to include a ‘risks explained’ section with tickboxes for each type of anaesthetic, giving the relevant risks in order to act as a reminder of the need for discussing risks with the patient prior to surgery and as an aid to saving time in the documentation of this discussion. In order to facilitate this and ensure support from the department this would ideally be done after surveying consultants on their opinion of these changes, and on which specific risks should be included.

Changes required

3577 Underlying Causes of Insulin Administration Errors

Louise Meakes, Lead Nurse, Diabetes, Satinder Bhandal, VTE Lead Pharmacist

To audit the causes of insulin administration errors. The learning

Integrated Medicine

20/06/2012 Complete 28/09/2012 Results: 11/14 errors (78%) were identified as primary active failures. 7/14 errors (50%) involved a lapse in memory or attention; lack of staffing was identified as a risk factor in 9/14 errors (64%), and a

Changes required

outcomes of this audit should be cross transferable to other medical administration errors.

heavy workload was cited in 7/14 errors (50%). Agency staff made 5/14 errors (33%). Recommendations: clear knowledge of the medicines policy so all staff know of their role and responsibilities with regard to insulin administration; clear usage of the self administration of insulin policy; clear messages with regard to the role of agency staff; education in a structured and ongoing manner incorporating the safe administration of insulin and variable rate intravenous insulin infusion e-learning packages; dedicated quiet space to prepare medication; charts to be tagged together; reduction in the use of agency staff and the employment and investment of high quality regular staff to improve retention rates; robust supervision of staff to maintain skill set and competency.

3578 Personal Protective Equipment July 2012



01/07/2012 Complete 12/11/2012 Results: 167 of the 836 questions (20%) were incorrectly completed with a tick rather than number of observations out of 10. 158 of the 836 questions (19%) were considered to be not applicable to that ward/area. For the other 511 questions, average compliance was 97%. Compliance by question varied from 85% (Q11) to 100% (Q10). Compliance by area ranged from 79% to 100%. However, many questions were incorrectly completed in some area, therefore their compliance will not be accurate. For all 801 correctly completed, applicable questions, compliance was 97%. 34 areas had some non-compliant responses so should have produced action plans. Only 5 areas (15%) produced an action plan. Recommendations: Staff who complete the audit must answer the questions correctly and use not applicable rather than no where necessary. The results of audit are to be reviewed by the Associate Directors of Nursing and the relevant actions identified need to be completed in an action plan and returned to the Infection Prevention & Control Team.

Changes required

3579 Nutritional Knowledge of Paediatric Staff Survey

Dr Baneera Shrestha, Consultant, Paediatrics, Samford Wong, Dietitian

A survey of the knowledge of staff working in a paediatric setting of "nutrition matters" prior to implementing training.

Specialist Services

26/06/2012 Complete 14/11/2012 Total number of respondents was 53 - maximum possible score on survey was 17. Number of responses from Dr's was 12 who had a average score of 64.7%. Number of responses from Nurses was 36 with an average score of 47.1%. 5 Dietitians responded with an average score of 73.5% Results summary - 73% of staff aware of the nutritional screening tool, 98% of patients were weighed on admission, 40% of child's height not measure and approx 1/3 of patients growth chart not plotted on admission. There were some areas of poor knowledge identified including energy requirements of children, fluid requirements and indictors of overnutrition and undernutrition. Conclusions/recommendation - Need for further eduction in health professionals, feedback back is required to ward staff, need of stadiometer, make charts available via intranet, ward folders, put nutiritional screening tool and care plans on intranet and involve hospital management in education/training for AHP's with an MDT approach. No action plan

Changes required

3580 Audit of Risk Factors and Outcomes Following Colonic Stenting

Mr Huang, Consultant, General Surgery (Catherine Bradshaw, CT2, Charles Evans, SpR)

Audit of radiological and surgical outcomes of patients with an obstructing lesion of colon/rectum using colonic stents, against NICE guidelines and national standards.


27/06/2012 Complete 01/10/2012 This was a retrospective review of 21 patients who underwent SEMS treatment for large bowel obstruction in Buckinghamshire Hospitals NHS Trust between 2008 and 2012. 25 procedures were included in the audit and the success rate was 44%. Currently awaiting results of 2 large RCTS a) ESCO – 103/144 patients recruited, no adverse events to date and b) CReST – recruiting since 2009.

Changes required

3582 Effectiveness of Bowel Preparation in SCI Patients Prior to Colonoscopy

Maureen Coggrave, CNS (Ruth Penn, Research Nurse)

Similar audit carried out in 2010. (audit 2204). As a result of that audit a bowel prep protocol was introduced in Sep 2011. This audit is to assess whether this protocol is being followed.

Specialist Services

27/06/2012 Complete 16/11/2012 RESULTS: The bowel preparation medications and enemas followed the protocol in 13/27 (48%) cases. The endoscopist categorised the quality of bowel preparation as satisfactory in 4/27 (15%) cases, sub-optimal in 12/27 (44%) cases and poor or very poor in 11/27 (41%) cases.The procedure was completed effectively in 8/27 (30%) cases and not completed effectively in 19/27 (70%) cases. CONCLUSIONS:There has been no significant improvement in the outcome of bowel prep.Protocol not prescribed in majority of cases.Very poor compliance with protocol when prescribed.Inadequate IMS & patient notes make compliance with prep difficult to assess.Ineffective procedures cost inconvenience and money.RECOMMENDATIONS:Review protocol – medications and clarity.Improve use of protocol.Educate staff about protocol.Ensure protocol is accessible – upload to spinal drive, format for IMS & provide laminated copies to wards.Empower patients with improved preparation information – could Endoscopy send out with appointment?Liaise with Endoscopy to define rating to improve assessment of prep.Develop follow-up guidelines for ineffective procedures.Repeat mini audit in 6 months.

Changes required

3581 Audit of Category 3 and 4 Heel Pressure Ulcers

Sam Goodman, Pressure Ulcer Nurse

To establish if there are any themes within the development of heel ulcers in the Trust. Will audit all category 3 and 4 heel ulcers over 6 month period.

Integrated Medicine



3584 Patient Outcome after Zone 3 Extensor Tendon Repairs Comparing Immobilisation Regime with SAM Regime

Elizabeth Mawby Physiotherapist, Nicola Hyde, OT Hand therapy

Comparing outcomes Apr-Jun 12 using BHT guidelines treatment regime involving immobilisation and comparing with outcomes Jul-Sep using SAM (short arc motion) rehab regime. Guidelines have already been changed to SAM regime.

Specialist Services



3585 Audit of Speech & Language Therapy Outcome Measures on Medical Wards at WH

Nicola Cook, Specialist Speech & Language Therapist

To establish whether outcome measure tool is being used and what the outcomes and variances were by retrospective random selection from SLT department inpatient referral and discharge registration book.

Specialist Services

01/01/2012 Complete 31/03/2012 Results: Outcomes were recorded for 80% of the patients (standard=100%). 92% outcomes recorded were fully achieved. Actions: All SLTs to consistently complete outcomes for acute patients; to be highlighted at the acute team meetings. Clarify administration process at the acute team meeting. Re-audit in one year.

At acute team meeting in May 12 it was highlighted that all SLTs should complete outcomes. Also the administration process was clarified.

3586 Review of Stroke Patient Portfolio

Todd Kaye, Clinical Specialist Physiotherapist, Neuro and Rehab and Susie MacTavish

Retrospective questionnaire investigating patient opinion of Stroke Patient Portfolio to aid in the enhancement and any possible improvements for publication of version 2.

Specialist Services



3587 Audit of Screening of Prolonged Paediatric Jaundice

Dr A Dutta, Consultant (Dr Naomi Jefferis) Paeds

An audit of management of prolonged jaundice in a paediatric setting.

Specialist Services

01/06/2012 Complete 14/07/2012 The total cost of the prolonged jaundice screen at BHNT is £271.65 per patient. BHNT are currently not following NICE guidelines. Unnecessary investigations are being requested. Financial savings can be made, benefiting both patients and the paediatric department if current guidelines are revised in line with NICE 2010 or other local hospitals ie: JRH. Recommendations: Change parameters of direct bilirubin,for obtaining expert advice regarding babies, to a direct > 25 micromol/litre (currently 20). No need to request TSH and T4 as thyroid problems should have been detected via the blood spot screen. Extend this audit to gauge adherence to current BHNT guidelines. Current cost = £271.65. Proposed cost= £44.57 ( +/- £49.24). If only essential Ix, saving of £227.08 per patient. If essential and additional Ix, saving of £177.84 per patient. Total savings to Trust Proposed guidelines, saving of £44,280.60.

Changes required

3588 Junior Doctors' Record Keeping Audit 2012


Annual Trustwide record keeping audit carried out by junior doctors.



3589 Emergency Burns Care - A Survey of Appropriateness of Referrals

Gail Miller, Sister, Suzanne Nunn, Burn Care Adviser, Plastics and Burns

An audit of the appropriateness of referrals to the local burns service from Eds both pre and post implementation of training from Burn Care Advisors.


05/07/2012 Complete 19/02/2013 An initial audit of referrals from emergency departments to one burn service was carried out pre and post implementation of burn care traning. The results indicate that 30% of referrals were inappropriate before training yet 40% remained inappropriate after early implementation of training. Several factors to take into consideration are: Training predominately for nursing staff whereas it is the A&E doctors who will often refer patients to the burns service. New rotation of doctors between the first and second audit. Still staff to be trained. The results highlight the importance of the Burns Care Advisor's continued role in the training and education of referring services. period

Burns Care Advisors have set up burns link nurse framework across their catchment areas. Initiated the development of burns information folders in varied clinical areas. Produced a minor burns injury information leaflet. Commenced a burns first aid information leaflet. Initiated a standard burns pack.

3590 Contact Lens Related Keratitis

Mr K Rahman, Associate Specialist, Ophthalmology (Raj Mukhopadhyay, SpR)

Contact lens related keratitis is one of the most common causes for eye casualty appointments. The patients receive variable treatment regimens and risk factors are not assessed uniformly. This audit will compare standards of care with the current evidence.


10/07/2012 Complete 01/10/2012 The number of patients seen with contact lens related keratitis in our population was very similar to the standard (2.5%). In a significant proportion of patients, history was not detailed regarding type of contact lens, hand hygiene and smoking. Recommendations were made to note the risk factors in every case of keratitis. It was felt that it is difficult to obtain a definitive diagnosis at the initial visit. It was recommended that these patients would benefit from a corneal opinion. Feasibility of a rapid response cornea clinic would be explored for managing these patients quickly and take a significant load off the casualty. The treatment protocol, though variable, reflected the variations described in the literature. There is no consensus on the correct treatment modality and again, it was felt that a corneal opinion would be valuable. The final visual outcome was excellent. Our patients fared much better than standard. However, this might also be biased because the notes of patients needing admission and hence with more severe disease were not always kept at casualty. A re-audit at an interval of one year was suggested to evaluate the effect of the recommendations of this audit.

Changes required

3591 Incidence and Impact of Radiolucence in Oxford Unicompartmental Knee Replacement

Mr G Matthews, Consultant, (Dr Ross Muir, CT2) T&O

Retrospective audit of x-rays, operation notes and follow up.




3592 Audit of ACHT Service Specification GP Satisfaction Survey

Jackie Allain, Operational and Clinical Lead, ACHT

An audit to assess whether the GP Service Specification is delivering the promised level of service.

Integrated Medicine



3593 Community Nursing Team for Children with Learning Disabilities Client Experience Survey

Ane Poll, Clinical Nurse Specialist for Children with Learning Disabilities

Client Experience Survey to obtain feedback on the service provided by the Community Nursing Team for children/young people with a learning disability.

Specialist Services



3594 Diabetes and Endocrinology PES

Dr Sudesna Chatterjee, Consultant Diabetes and Endocrinology, SMH

A Patient Experience Survey carried out to assess the level of patient satisfaction with the Diabetes and Endocrinology Outpatient Clinics at Amersham, Stoke Mandeville and Wycombe Hospital.

Integrated Medicine



3595 Maternity Notes Record Keeping Audit

Mr Tunde Dada, Consultant and Hannah Hunter, SoM SMH

An audit of maternity notes record keeping

Specialist Services



3596 Isolation Precautions August 2012



01/08/2012 Complete 12/11/2012 There were 7 “No” responses in total, leading to an overall compliance of 99%. Recommendations: Monitoring of the isolation precautions boards, which should be available and completed when a sideroom is being used for an ‘infected’ patient, should continue when matrons’ rounds are taking place. Areas of non participation must address any ‘no’ answers within their area.

Changes required

3597 Suprapubic Stomas in SCI Patients

Debbie Green, Matron, NSIC, Jean O'Driscoll, Infection Control

Cancelled. Specialist Services


3598 Rapid Incremental Closed Reduction of Cervical Facet Fracture Dislocation in SCI

Wail Ahmed, Spinal Injuries SpR

Retrospective review of the effect of closed reduction of cervical fracture dislocations on patients' neurology and complications. Of the procedure. Also assessed success and failure rates and reasons for failure.

Specialist Services

26/07/2012 Complete 26/07/2012 Our rapid incremental closed reduction success rate was 39 %.Out of the seven patients who had successful reduction, three had improved motor level by 1 level, two by 2 levels and one by 4 levels.Most patients who underwent successful closed reduction had one stage surgical stabilization (ACDF), whereas most patients who underwent unsuccessful closed reduction had two stage surgical stabilization ( Posterior ORIF + ACDF).No recommendations or actions.

No recommendations or actions.

3599 Lumbar Puncture Success and Documentation

Dr Sarkar, Paediatric Consultant (Andy Marshall, Paediatric registrar)

Lumbar punctures are used to diagnose meningitis but are often unsuccessful in neonates. To audit current success rates before trying to make changes to procedure to improve success.

Specialist Services

27/07/2012 Complete 13/12/2012 90 patients included in audit, 6 had repeat LP's performed. Results - Audit standard was to have 100% documentation of LP, 50% of LP's successful and samples to be sent to lab within 30 minutes of procedure and to be analysed within 30 minutes of arrival at lab. Results showed the following documentation rates from notes - date and time recorded 83% of the time Indication 3%, consent 48% of the time, aseptic technique being used 86% of the time, number of attempts at performing LP 80% of the time, appearance of csf 80% of the time and the grade of doctor recorded 93% of the time. LP were successful 34% of the time. In 5% of the time samples were sent to the lab in under 30 minutes and 81% of the time they were processed in under 30 minutes of arrival in the lab. Recommendations - 1. a sticker has been proposed to increase documentation of LP's within notes. 2. To improve success rates the introduction of LP manikin and ultrasounds for previous bloody LP's 3. Highlight importance of samples getting to lab quicker to junior doctors and improve communication with porters 4.

Changes required

Proposed LP logistics guideline giving advice on how LP's should be dealt with administratively. All recommendations under review by consultants Andy to advise once finalised 14/12/12 (CP)

3600 Palliative Care PES 2012

Rachel O'Donnell, Palliative Care CNS Team Leader

An audit to determine if patients with palliative care needs benefit from the current palliative care service.

Specialist Services



3601 Paediatric Occupational Therapy Group PES July 2012

Alison Lyle, Community Paediatric Occupational Therapist

PES of parents of children attending community Occupational Therapy groups and talks. Re-audit of audit 3309.

Specialist Services



3602 Medical Occupational Therapy Record Keeping

Rebecca Bull, OT Audit 30 sets of notes, auditing against Trust & professional record keeping standards.

Specialist Services

31/07/2012 Complete 15/01/2013 Results: OT entries generally very good with regard to patient details, dated, signed. 88% timed, 68% designation of author. Recommendations: Consider name stamp with designation, use of felt pens/stickers. Consider extending audit to cover other areas.

Changes required

3603 Antibiotic Prescribing for Sore Throat and Laryngitis in Children presenting in Emergency Department

Dr Stewart McMorran, Consultant (Dr S. Tiwari, ST6) Emergency Medicine

An audit of the prescribing of antibiotic prescription rates for paediatric patients presenting with sore throat and pharyngitis in the Emergency Department.

Integrated Medicine

Cancelled 11/12/2012 Project cancelled. No response from doctor. Cancelled

3604 Re-Audit of Patient Readmissions within 28 days following Discharge from Medicine

Dr Mitra Shahidi, Consultant, Respiratory Medicine (Dr Quentin Jones, ST3)

Audit to look at the reasons for readmission of patients within 28 days following discharge from Medicine. Results will be compared with those of the previous audit, 3184.

Integrated Medicine

06/08/2012 Complete 06/02/2013 Results: similar statistics to 2010; re-admissions of related conditions is a common problem, particularly in the elderly; respiratory complaints, acopia and cancer were the main causes of related readmission; the majority of readmissions – both related and unrelated are often secondary to chronic conditions; community support packages are not being utilised. Recommendations were to make staff aware of support/care packages in the community; adapt medical discharge summaries to include details of care packages; reduce avoidable admissions for palliative patients.

Changes required

3605 Postnatal Bladder Care

Mr Ian Currie, Consultant (Dr Leyan Ham-Ying GPVTS, Dr Matthew Mayer GPVTS) Obs & Gynae

Audit of postnatal bladder care against Trust Guideline 687.

Specialist Services

Complete 16/10/2012 Results - 82% of decisions regarding catheter use were appropriate and well documented. Inconsistent levels of documentation regarding time and volume of 1st void. Insufficient data to comment reliably on management of retention, but signs are promising. Recommendations: 1. Standardise documentation paperwork. 2. Promote importance of early bladder care and relevance of 1st void. 3. Posters/Morning meeting/Staff bulletin/Education.

Changes required

3606 EPAU Guidelines Audit - Management of Miscarriage

Mr Chris Wayne, (Dr Emily Moss, Dr Abigail Taylor GPVTS) Obs & Gynae

Audit of management of miscarriage against EPAU Trust guideline 640.2.

Specialist Services

Complete 14/11/2012 Referral source - following guidelines.Number of patients presenting with a history of fewer than 3 miscarriages has reduced. Still too many patients presenting at < 6 weeks gestation. Too many patients having to stay overnight to wait for a scan. Recommendations: MDT discussion as to where to direct patients who are <6 weeks gestation. Suggest booking appointment and scan at 6 weeks.

Changes required

3607 Antibiotic Prophylaxis in Gynaecology Surgery

Mr Tunde Dada, Consultant (Dr Mohammed Ahmed GPVTS, Dr Deborah Stevenson FY2) Obs & Gynae

Audit of antibiotic prescribing in Gynaecology Surgery.

Trustwide Complete 16/10/2012 Recommendations: 1. Clarification of definition of ‘emergency surgery’. 2. Review need for antibiotic prophylaxis in hysteroscopic surgery. 3. Simplification of guideline, e.g. table format. 4. Recirculation of policy amongst gynaecologists and anaesthetists. 5. Re-audit and include Abx administration time relative to procedure. 6. Stream Guideline (e.g. Flow chart, RCOG pelvic floor advice…). 7. Further audit into management of retention. 8. Patient satisfaction / feedback survey. 8. Re-Audit after 6-12 months of changes.

Changes required

3608 Emergency Gynaecology Admissions

Mr Tunde Dada, (Dr Arnold Babumba GPVTS, Dr Nicola Solomon FY2) Obs & Gynae

To review the current trust guideline for emergency gynae admissions (427.1). To evaluate the effectiveness and efficiency of seeing acute gynaecology patients in the Emergency Gynae Clinic as opposed to A&E.

Specialist Services

Complete 14/11/2012 Most patients are seen in A&E (1/3 in EGU). A&E waiting times on average 2 hrs (up to >4 hrs). EGU patients get a scan the same day, but A&E have to wait (usually overnight). Proforma needs improvement (time of referral, arrival, and time seen not being recorded). Recommendations: 1. Proforma needs revision (currently using EPAU proforma). 2. Staffing and facilities need to be addressed. 3. Guideline needs updating to include a standard of care. Re-audit. (Discussion at AHD referred to Reading model where unit has more slots and is open all day. Our unit currently open only in afternoons and has only 4 slots to see patients and 2 scans per day. Doctors too thinly spread over EGU and A&E with 1 dedicated nurse and oncall registrar).

A&E patients stay in hospital longerBut no significant difference between number of operations for A&E/EGU patients?Longer stay due to delay in obtaining scan

Changes required

3609 Management and Investigation of Children Diagnosed with Sensory Neural Deafness, April 2007 to March 2012

Dr Sawhney, Consultant, Paediatrics (Dr Edward Gaynor, SpR, Dr Manju Kanga, Associate Specialist, Community Paediatrics)

Audit of the Management and Investigation of Children Diagnosed with Sensory Neural Deafness, April 2007 to March 2012 against local guidelines. Aim is to create a pathway for the Trust.

Specialist Services

Data Collection


3610 Availability of Snacks to Prevent Hypoglycaemia for Patients with Diabetes on Medical Wards

Liz Pryke, Dietetic Manager, Karen Orriss, Dietitian

To assess the knowledge of staff on the wards regarding suitable snacks; development of a poster to remind staff about snacks and the importance of providing snacks.

Specialist Services

17/08/2012 Complete 14/12/2012 After nurse training the results show that the number of Hypoglycaemic events have been reduced significantly between meals and at bedtime but the number at breakfast have only slightly reduced. No recommendations.

No recommendations

3611 Time Delay between Prescription and Administration of the First Dose of IV Antibiotics in NSIC

Mr Mofid Saif, Spinal Injuries Consultant (Dr Wail Ahmed, SpR)

Prompt administration of IV antibiotics is vital in management of septic patients. This audit assesses the scale of the delay in administering first dose IV antibiotics in septic patients in the NSIC. Re-audit of 3371.

Specialist Services

01/08/2012 Complete 21/08/2012 Re-audit demonstrated a lower percentage (24 %) of potentially harmful delays in administration of the 1st dose IV antibiotics in septic patients compared to 42 % in the first audit. 91 % of 1st dose of IV antibiotics were prescribed STAT compared to 83.3 % in the first audit. No absence of time documentation by nurses was detected compared to 34% in the first audit, whereas absence of time documentation by doctors remained at 14%, similar to the first audit. This re-audit demonstrated overall improvement in the performance and implementation of sepsis guidelines. Recommendations: 1.To incorporate the Sepsis Pathway into IMS. 2. The next audit should include all management of sepsis including IV antibiotic use. 3. All doctors and nurses should be encouraged to comply with the Trust Sepsis Integrated Care Pathway and use it in every sepsis incident.

Changes required

3612 Fractured Neck of Femur Operations Delayed due to Classification as Medically Unfit

Dr Jeremy Drake, Consultant Anaesthetist

An audit of the delay in procedures for patients with fractured neck of femur due to being classed as medically unfit with the aim of reducing the current cancellation rate.


21/08/2012 Complete 26/11/2012 There are no major themes indicating that we could reduce delays by instigating specific measures. Delays will continue to be reviewed and discussed at the monthly hip fracture meeting.

No changes required

3613 Skin Cancer Nurse Led Diagnosis Clinic Patient Experience Survey

Lindsey Lane, Skin Cancer CNS

To assess service provided by skin cancer CNS during period leading up to and immediately following diagnosis.

Specialist Services

22/08/2012 Complete 01/02/2013 Results: 92% patients were told their diagnosis face to face. All were given their diagnosis in a caring and sensitive manner. 96% definitely had confidence and trust in the Specialist Nurse. There had been improvements in most areas since the previous audit in 2010. Recommendations: All clinical staff who interact with cancer patients should attend the advanced communication course. When a patient is given their diagnosis it is important that the value of the MDT discussion is emphasised.

Changes required

3614 Infection Control Environmental Audit Community & Integrated Care


Part of IPC audit plan. Infection control audit of kitchens and patient equipment. Carried out by division. This audit is for CIC.

Specialist Services

29/08/2012 Complete 14/12/2012 Of the 7 areas audited all achieved the minimum compliance of 85%. The action plan must be completed by ward managers to address the areas of non-compliance. All actions must have a completion date and the final plan returned with all actions closed to ensure the audit cycle is completed.

Infection Control assure us that actions completed

3615 Acute Hand Infections: Topography and Microorganism Profile in A&E and Plastic Surgery

Mr Eric Tan, ST5, Plastics (Lucy Farrimond, FY1, Plastics)

An audit to determine the most common site, level and microorganism responsible for hand infection. Results will be compared with those of JHSA 2010: 35A/25-28. The audit will include 200 A&E hand infection cases and 100 cases treated by the Plastic Surgery team at Stoke Mandeville Hospital.




3616 Expediting Discharges in Medicine for Older People

Dr Simmie Manchanda, Consultant, (Dr Nathalie Fennell) MfOP

A retrospective audit of last 100 discharges from MfOP, recording when pre-existing care arrangements were documented and multidisciplinary team made aware; when patient became medically fit; when assessed by physiotherapy, occupational therapy and social work, and total length of hospital stay. Aim to design an intervention to reduce length of hospital stay.

Integrated Medicine



3617 Perioperative Transversus Abdominal Plane (TAP) Blocks vs Rectus Sheath Blocks for DIEP Flaps

Mr Eric Tan, ST5, Plastics (Rhona Sproat, CT1) Plastics

Retrospective audit of notes of DIEP flap patients looking at intraoperative and postoperative analgesia requirements.




3618 A Survey on the Availablity of Drinking Water for Rheumatology Patients

Dr Richard Stevens, Consultant Rheumatologist (Dr Simon Clough, FY2)

A survey to determine what proportion of ward based patients are safely and independently able to drink and have a drink within easy reach.

Integrated Medicine

10/09/2012 Complete Results and Recommendations required Changes required

3619 Lip Lacerations Hugh Wright, SpR Plastics (Rhona Sproat, CT1 Plastics)

Audit of current management of lip laceration, cost of management and cancellation of theatre time. No standards exist hence large variation in practice and probable potential for improvement.




3620 Preventing Surgical Site Infection - Peri Operative Audit for General Surgery and Vascular Procedures September 2012



01/09/2012 Complete 26/11/2012 Results: 53 procedures were audited. 100% patients had MRSA screening. 100% had WHO surgical checklist completed. !00% given antibiotic prophylaxis where indicated. 100% used clippers if hair removed. Glucose monitoring was maintained where relevant. Normothermia was maintained where relevant. Overall 100% compliance so no recommendations necessary.

Not required

3621 Sharps Handling & Management September 2012



01/09/2012 Complete 22/01/2013 Non participation should be discussed atSDU/clinical governance meetings and relevantareas should complete the audit.The report, results and issues highlighted forfurther focus should be discussed anddisseminated to all relevant staff across the Trust.Ongoing training, promotion of good practice andcompliance monitoring should continue. Actions identified should be completed and closed as part of the audit cycle and actions must besigned off by the Divisional AND’s.The collation of data on reported sharps injuriesshould continue to inform further training andfacilities.

IPC assure that all completed.

3622 Laryngectomee Valve Changes

Barbara Reynolds, Speech & Language Therapist - ENT Team Lead

To count the number of laryngectomee valve changes that took place in Wycombe SLT between Sep 2011 and Sep 2012.

Specialist Services



3623 DNA Rates in Voice Therapy


Monitoring DNAs. In a previous audit DNA rates fell when contacted by phone to arrange appointments.

Specialist Services



3624 Waiting Times for Initial Voice Therapy Appointments Post ENT


Waiting time not monitored at the moment. Patients may be more responsive if wait reduced. Plan to discuss referral criteria with ENT consultants at end 2012 and review waiting time before and after this.

Specialist Services



3625 Diabetic Ketoacidosis Audit

Dr Chatterjee, Consultant Diabetes (Kirsty Beckett, FY2)

RE-audit of 2843 at both hospitals. Audit against DKA treatment standards.

Integrated Medicine



3626 Initial MRI in Patients Referred to NSIC

Tom Meagher , Consultant Radiologist (Luis Lopez de Heredia, Clinical Scientist, Radiology)

Access to initial MRI for patients with traumatic SCI is essential to plan management, investigate complications and identify neurological deterioration. Determine numbers of patients with traumatic SCI that had initial MRI 2006/2012. Audit standard 80%.

Specialist Services

12/09/2012 Complete 17/12/2012 The percentage of new traumatic SCI patients admitted to the NSIC with an initial MRI scan loaded into PACS was only 40%, considerably lower than the audit standard of >80%. In a mini pilot study from the list of patients that had no initial MRI scans loaded into PACS, 10 patients were randomly selected for control purposes. The IT-Radiology department was asked to find/request the original MRI scans of these patients from the referring hospitals. 3 out of these 10 patients had an initial MRI scan from their referring hospitals which was not uploaded into PACS. Although, this was done in a small sample group, it suggests that there are a substantial number of patients (30%) missing their original MRI scans. Recommendations: Talk to the spinal consultants and the IT department to upload all the scans so they are available on PACS. Re-audit 6-12 months.

Changes required

3627 Orthodontic Patient Experience Survey

Sylvia Tan, Specialty Doctor, Orthodontics

To monitor patient experience within Orthodontic department.


14/09/2012 Complete 31/10/2012 Recommendations: 1. Tto discuss findings/outcome of audit at next departmental meetin. 2. Iincrease staff capacity at reception desk to greet patients. 3. Ensure all notification letters are being sent to correct address by constant updates of patients’ contact details by reception staff. 4. Recognise patients' parking problems – to feedback to clinical lead. 5. Rrewrite some questions in the questionnaire for the next audit as many of the questions were multiple question. 6. Discuss with colleagues and staff in the department on where best to distribute the questionnaires for the next audit as giving them out at the clinic and returning them to reception could possibly have affected staff behaviour as it would have been obvious to them that they were being assessed. 7. Re-audit in 3 years.

Changes required

3628 Initial Experience of Selective Laser Trabeculoplasty - First Six Months

Miss Anna Mead, Consultant, Ophthalmology

Selective laser trabeculoplasty is a technique used to lower the intraocular pressure in patients with glaucoma. The laser was first acquired by the Ophthalmology Department in February 2012. The aim of this audit is to look at the outcome of treatments with the laser to date and to define a departmental protocol for treatment.


17/09/2012 Complete 04/12/2012 Recommendations included: treatment protocol; better note keeping; better follow-up; re-audit in 1 year.

Changes required

3629 Audit of Intestinal Failure Management

Mr A Goede, Consultant (Reju Joy, CT1, General Surgery)

Collection of data for presentation to the Intestinal Failure Committee, of intestinal failure patients requiring TPN for more than 14 days over 3 year period in preparation for national peer review visit in October.


14/09/2012 Complete 25/10/2012 This was collection of data for presentation to the Intestinal Failure Committee rather than an audit so no recommendations for change were made.


3631 The Use of X-Ray in Upper Limb Laceration

Mr Peter Budny, Consultant (Iain MacLeod, CT2), Plastics

To evaluate the use of x-rays in arm/hand lacerations to establish whether we over use them in investigations, and to reduce harmful radiation usage.




3632 Audit of Investigations in Children with Hearing Loss

Dr Ruth Hill, Specialist in Neurodisability and Paediatrics

Audit of compliance with guidelines for aetiological investigation of infants with congenital hearing loss identified through newborn hearing screening.

Specialist Services

25/09/2012 Complete 29/01/2013 15 out of 21 cases met the 1st criterion and were offered aetiological investigations. 20 out of 21 cases did not meet the national guideline standards for investigations. In all 20 cases the recommendation to offer written information on the investigations was not met. An aetiological cause for the hearing loss was made in 25% of cases. Recommendations- All parents of deaf children should be given written information on the investigations as found on National Deaf children's society web site, re-audit in 2 years.

Changes required

3633 Knowledge and Understanding of PSA Testing Patient Survey

Mr Bdesha, Consultant (Rebecca Geyton, Le Ha, FY1) Urology

A patient survey of experience and understanding of PSA testing.




3634 Assessment of Left Ventricular Ejection Fraction by Cardiac MRI and Echocardioography

Eric Woo, Consultant (Kartika Selvam, SHO) Radiology

A retrospective assessment of left ventricular ejection fraction by cardiac MRI and echocardioography.

Specialist Services



3635 Audit of GP Direct Access Gastroscopy

Dr Weldon, Consultant (Lucinda Shaw, ST2) Gastroenterology

An audit to assess the information provided by GPs on the Direct Booking Gastroscopy Request Form and to determine the proportion of patients being incorrectly referred to gastroscopy for dyspepsia.

Integrated Medicine

28/09/2012 Complete 16/10/2012 5 patients met the criteria for referral (for 2 week wait). 6 patients met the criteria for direct access endoscopy (>55, trial of appropriate pharmacological agents for an appropriate length of time). 19 (63%) did not meet the criteria for referral of patients to endoscopy due to either age (<55 should not be scoped) or due to insufficient trial of pharmacological agents. Recommended interventions to GPs: 1. Review medications for causes of dyspepsia e.g. NSAIDs, orticosteroids. 2. Test for (and treat) H. Pylori infection. 3. Breath test or stool antigen test Metronidazole or amoxicillin, with clarithromycin. 4. Diet and lifestyle changes. 5. Avoid known precipitants - head up, weight loss, smoking cessation. 6. CBT- rule out cardiac/ musculoskeletal/ biliary causes for symptoms. Recommendations for department: 1. Re-design GP Direct Access referral forms to include NICE Guidelines. 2. Re-audit to assess if changes have been made to referrals. 3. Assess waiting times for 2 Week Wait referrals.

Dr Gorard emailed GPs in Stoke Mandeville and Wycombe catchment area 1/10/12. Local guidelines sent out as a reminder. Awaiting feedback from GPs.

3636 Patient Satisfaction Survey Following Implementation of Distress Thermometer in Psychological Assessment

Francesca Lis, Gynae-oncology Clinical Nurse Specialist

A patient experience survey to obtain information from patients with gynaecological cancer. This will be a pilot phase prior to introducing a nurse-led holistic assessment clinic in order to put in place any changes or to continue.

Specialist Services



3637 BTS Emergency Oxygen Audit

Jenny Ricketts, Consultant Nurse, Critical Care

An annual BTS audit of Emergency Oxygen presribing and delivery throughout the Trust. (see previous audits 2495 and 3283)

Integrated Medicine



3638 Gamma Nailing for Proximal Femoral Fractures

Mr Ramesh Chennagiri, Consultant, T&O (Aleem Hussein, FY2)

A restrospective assessment of implant failure rate of intra-medullary gamma nails in treatment of proximal femoral fractures in the Trust from 2009 to 2012.


02/10/2012 Complete 22/01/2013 The overall failure rate between 2010-2012 was 7.52%. The failure rate before May 2010 was 10.52%. The failure rate after May 2010 (set and jig changed) was 5.45%. Change of jig (May 2010) for proximal sliding screw led to a significant decrease in implant failure rate. Recommendations: Change of practice (jig verification); identification of further intra-operative risk factors for implant failure; radiological assessment of all nails placed in audit period; criteria for technical competence.

Changes required

3639 Initiation and Monitoring of Azathioprine in Dermatology Department

Dr Emily Davies, SpR, Dermatology

To audit the initiation and monitoring of Azathioprine in Dermatology Department against BAD guidelines between January 2012 to Sept 2012

Integrated Medicine



3670 Intermountain - T&O Patient Pathway

Mr Ramesh Chennagiri, Consultant, T&O (Georgina Williams, CT)

To answer fundamental questions about the role of follow-up in order to design a new booking system and set of outpatient templates, with the aim of improving the quality of patient contact, the confidence of patients and commissioners in our service, efficiency of the service, and optimising use of consultant staff.


04/10/2012 Complete 21/12/2012 93% outpatient follow-up appointments are made for the correct clinic; 74% are made for the correct time. Incorrect timings are related to a lack of capacity within the clinics rather than administrative error. Recommendations: trail for appointment booking forms, e.g. an ordercomms tab; combine with a system to flag those appointments made outside appropriate timeframe; consultants to have more control over their clinics, e.g. access to CRS and to checking their appointment availability before requesting appointment dates.

Changes required

3671 Thames Valley Cancer Network Enhanced Recovery Programme Project for Gynae-oncology Patients

Miss Geraldine Tasker, Consultant, (Neveen Khan, ST6), Obs & Gynae

A baseline audit and patient satisfaction survey of enhanced recovery for patients undergoing hysterectomy for endometrial cancer, before implementing ERP principles. A TVCN/TSSG Gynae Cancer led project.

Specialist Services



3672 Urology Cancer Patient Experience Survey (BHNHST)

Hilary Baker, Joe Kearney, Krystyna Caine, Uro-oncology Clinical Nurse Specialists

A survey to obtain feedback regarding the service and information provided to patients with urological cancer. (Previous survey see database number 2891).




3673 Antibiotic Prophylaxis in Surgery

Dr Waghorn, Consultant Microbiologist, Trust Antimicrobial Pharmacist

We have guidelines relating to antibiotic prophylaxis at surgery. Audit to look at 12 different types of surgery and compare with guideline. 15 cases from each surgery area to be audited for a 6 month period every year. This audit Jul-Dec 2012. Re-audit of audit 3333.

Specialist Services


Changes required

3674 BTS Paediatric Pneumonia Audit 2012-13

Dr Craig McDonald, Consultant (Dr Ralph Robertson) Paediatrics

Annual BTS audit of Paediatric Pneumonia November 2012 - January 2013.

Specialist Services



3675 Splinting the Nail Bed after Repair

Mr Heywood, Consultant, Plastics (Rachel Clancy, ST3)

An audit and a patient survey to determine a) if splinting the nail bed after repair improves outcome and b) whether using the nail as a splint introduces infection.




3676 Standards for Paediatric Services - Facing the Future

Dr Michelle Russell-Taylor, Consultant

National audit directed by RCPCH to look at their aspirations for the future and where units are at present for just 2 standards, 1 and 2.

Specialist Services



3677 Medical Management of Thyroid Eye Disease

Dr Sonia Mall, ST6 Specialty Registrar, Ophthalmology

Retrospective audit of patients who have had medical treatment for thyroid eye disease to assess whether the current protocol of treatment has been followed.




3678 Distal Radius Fracture - Early Discharge to Physiotherapy after Surgery

Mr Ramesh Chennagiri, Consultant, Orthopaedics (Lynn Bath, Musculoskeletal Clinical Lead Physiotherapist)

Currently these patients have a mean of 3.5 follow up appointments in fracture clinic. The aim is to reduce this to 2 FU appointments by discharging these patients to physiotherapy after follow up at 7-14 days post op, with a FU booked at 8 weeks to be cancelled by physio if not required.




3679 Nutrition Status of Patients with Fractured Neck of Femur

Liz Pryke, Dietitian, Lynsey Spillman, Dietitian

An audit to look at the nutrition status of inpatients with fractured neck of femur.

Integrated Medicine



3680 BTS Paediatric Asthma Audit November 2012

Dr Craig McDonald, Consultant (Mark Bamber CT5)

Annual BTS audit of Paediatric Asthma November 2012.

Specialist Services



3681 Audit of Management of Placenta Previa

Mr Tunde Dada, Consultant (Dr Shilpa Gandhe, SpR), Obs & Gynae

An audit to ascertain whether patients with placenta praevia are being managed correctly with regards to length of stay and follow-up process, including scan.

Specialist Services



3682 Preventing Surgical Site Infection - Peri Operative Audit for Trauma & Orthopaedic November 2012



01/10/2012 Cancelled Cancelled Cancelled

3683 Enuresis Clinic Patient Experience Survey

Ellen Hope, Team Lead SCPHN (School Nursing)

To assess patient experience of enuresis service.

Specialist Services

16/10/2012 Complete 28/11/2012 Parents generally very satisfied with service. One or two comments re lateness of referral. Recommendations: To keep GPs up to date regarding the enuresis service. To enable children to be referred appropriately and timely into the enuresis service.To maintain the excellent service provided to clients across the trust and maintain up to date knowledge for the clinic nurses.Arrange to update enuresis training 2013 and budget for one nurse to attend ERIC conference 2013.Training for staff on feedback from ERIC conference.Ensure clinic nurses monitor equipment regularly at each clinic visit to avoid batteries running low.

Changes required

3684 Audit of Caesarean Section under GA 2010/11

Dr Nicola Hanson, SpR, Anaesthetics

A continuous audit of caesarian section under general anaesthetic.

Specialist Services



3685 UK IBD Audit (Round 4) 2012-13

Dr Ravi Sekhar, Consultant, Gastroenterology

National audit to assess the processes and outcomes of up to 50 consecutive prospectively identified admissions for ulcerativecolitis. Re-audit of IBD service provision against the IBD Standards.

Integrated Medicine



3686 Cancer Target Times in Tertiary Referrals

Dr Geraldine Spain, ST5, Obs & Gynae

To assess whether any of the patients referred to tertiary centres for treatment have breached their dates, if so, is there anything that can be done about this.

Specialist Services



3687 Review of Serious Incidents for Revalidation

Jackie Smith, Patient Safety Manager

A review of Serious Incidents for revalidation purposes.



3688 Stoma Care Service Patient Experience Survey

Collette O'Brien, Stoma Care Nurse

Assessment of service - may help to prove case for further nurse.

Specialist Services



3689 Audit of GP Direct Access Endoscopy

Dr Weldon, Consultant Gastroenterologist (Raman Goyal, FY2)

To reduce inappropriate endoscopy requests. To audit to see how many are inappropriate and if reasons explained.

Integrated Medicine



3690 Male Lower Urinary Tract Symptom (LUTS) Clinic Evaluation

Pamela Ging, Prostate CNS

To audit the patient experience of the Nurse led male LUTS clinic.




3691 Mortality Review February 2012


A review of 50 deaths in February 2012 requested by the Healthcare Governance Committee following an increase in mortality rate for this period.

Trustwide 19/10/2012 Cancelled 14/11/2012 Project cancelled, usual 6 month review to be done instead.

Project cancelled.

3692 Assessing Infection Rates in Patients with Inflammatory Arthritis on anti-TNF Drugs

Dr M Magliano, Consultant (Dr Kuljeet Bhamra, SpR and Dr Shilpa Selvan, SpR) Rheumatology

Comparing occurrence of infection in patients with inflammatory arthritis on cetolizumab against etanercept and adalimumab.

Integrated Medicine

18/10/2012 Results and Recommendations required Changes required

3693 Detection of Small for Gestational Age Babies by Ultrasound

Dr Sarulatha Palaniappan, SpR, Obs & Gynae

An audit of the detection of small for gestational age babies by ultrasound.

Specialist Services



3694 Risk Factors for Laparoscopic Cholecystectomies

Mr S. Appleton, Consultant, General Surgery (Dr Gijsbert Vanboxel, CT2)

Retrospective telephone audit of laparoscopic cholecystectomy patients 2011-12. Surgical site infections identified, audit will look at the risk factors.




3695 Consent for NJR Mr Ramesh Chennagiri, Consultant (Dr Ed Bray)

An audit to accurately identify the percentage of patients who are consented for the use of their personal details on the NJR and ensure it is being reported accurately.


24/10/2012 Complete 22/02/2013 In 2012 Wycombe hospital quoted an NJR consent rate of 96%. In this audit 47 sets of patient notes were reviewed and no patients had been consented for the use of their personal data in the NJR. One set of notes contained the NJR consent form but there was no signature. This suggests that those filling in the NJR database post op are stating that the patient has been consented without checking the notes. Recommendations: Reiterate the responsibility of those completing the NJR database form post op to complete it with accurate information to ensure compliance with the Data Protection Act 1998; increase the number of patients being consented for the use of their data on the NJR by using a number of media to highlight the lack of consent to the orthopaedic department, e.g. emailing all doctors involved in consenting patients, use of posters in the admissions area where patients are consented to remind and highlight the requirement for consent; provide access to consent forms in the surgical admissions area to ensure that it is as easy as possible for consent to be taken; educate the admissions nurses regarding the requirement for the forms to be in the admissions pack with the usual consent form

Changes required

3696 A Re-audit of Waiting List Booking Cards

Miss Geraldine Tasker, Consultant, Obs & Gynae

Re-audit of 3387 (2011) to assess the thoroughness of documentation using the same methodology.

Specialist Services


3697 Vaginal Birth After Caesarian Section

Heidi Beddell, Consultant Midwife, Obs & Gynae

Audit against CNST standards to assess compliance with Trust/NICE VBAC guideline.

Specialist Services



3698 Audit of the Management of Latent Phase of Labour

Heidi Beddell, Consultant Midwife, Obs & Gynae

Audit of compliance with the Trust Guideline on Latent Phase of Labour (503.2).

Specialist Services



3699 Audit of Wart Treatment in Genito-urinary Medicine

Dr Veena Reddy, Dr Graz Luzzi (Rosemary Binks, Deputy Sister, Lynne Fearn, Senior Staff Nurse)

A retrospective audit of wart management against Shaw Clinic guidelines 2011 (based on BASHH).

Specialist Services



3700 A Comparison of Visual Outcome of Macular Hole Surgery with Standards

Mr Richard Bates, Consultant, Ophthalmology (Dr Raj Mukhopadhyay, ST3)

A comparison of visual outcome of macular hole surgery with Trust standards.


29/10/2012 Complete 21/12/2012 The audit found that of the 56 macular holes operated over the last 3 years, 100% closed after primary surgery. This is better than the national average of around 90-95%. Visual improvement was on average 3 Snellen lines - in line with national average. Visual outcome was marginally better than the previous audit in 2000. Conclusion was therefore to continue current practice.

Continue current practice.

3701 Trauma & Orthopaedics 3 Monthly Complications and Deaths Review

Mr Gordon Matthews, Consultant, T&O

An audit of mortality and morbidity following T&O procedures during July, August and September 2012.


30/10/2012 Complete 14/11/2012 Notes pulled for M&M meeting. No changes required

3702 Audit of Effectiveness of the Enhanced Recovery Programme in Patients Admitted for Colorectal Surgery

Glynis Howat, Surgical Care Practitioner, Dr Siegfried Wagner, FY1, General Surgery

An audit of patients who have been recruited into the enhanced recovery programme for laparoscopic colorectal surgery. Data will be collected regarding their postoperative recovery and in particular on feeding, analgesia and mobilisation.




3703 Audit of Decreased Conscious Level in Children

C G Rastogi, Consultant, Dr Abhijit Mazumdar, Paediatrics

Follow up to 3197. Concentrating on 1. documentation of the clinical history features; 2. documentation of the observations of heart rate, respiratory rate, blood pressure and temperature on presentation to hospital; 3. documentation of GCS measurements within the recommended frequency; and 4. documentation of capillary blood glucose taken within 15 minutes of presentation to hospital.

Specialist Services



3704 Audit of Management of Early Inflammatory Arthritis

Dr M Magliano, Consultant (Dr C Yong, SpR, Ursula Perks, Research Nurse) Rheumatology

An audit of compliance with the BSR guideline on the management of early inflammatory arthritis.

Integrated Medicine



3705 National Parkinson's Audit 2012

Dr Syed Hasan, Consultant, MFOP

This is a national audit designed to help Trusts evaluate their Parkinson's service against the NICE Guideline and National Service Framework for Long Term Neurological Conditions, compare their Parkinson's service to others around the UK, highlight strengths and weaknesses in current service and develop an action plan to improve services.

Integrated Medicine


3706 The Effectiveness of Joint Voice Clinics in Accurately Diagnosing Vocal Fold Pathologies

Michelle Holmes, Deputy Manager, SALT

The equipment in joint voice clinics can sometimes identify conditions missed by other assessment. This audit will identify how many patients between July 12 and Jan 13 had original diagnosis altered as a result of attending clinic. This will act as baseline for future audits.

Specialist Services



3707 A Review of Quality of Speech & Language Therapy Casenotes

Michelle Holmes, Deputy Manager, SALT

Identify quality of notes and compare with previous audit

Specialist Services



3708 TB Patient Experience Survey

Margaret Holland, TB Nurse

Patients' views of TB service.

Integrated Medicine



3709 Upper GI Cancer GP survey

Maureen Kiely, Upper GI Cancer Nurse

This is to get feedback from GPs regarding the effectiveness of communication following MDTs.

Specialist Services



3710 VTE Assessment in NSIC

Mr M Saif, Consultant (Dr K Collins and Dr F Qureshi)

VTE assessment audit.

Specialist Services

01/07/2012 Complete Results: Only 50-80% of patients had VTE assessments. 85% done within 24hrs of admission. 85% done by admitting doctor. Recommendations: 1. Separate VTE tab on IMS. 2. Reminder cards on each computer. 3. Raise awareness of VTE assessment. Brief introduction to VTE assessment in new SHO IMS training (from Dec 2012). Monthly feedback to all clinicians on percentage VTE assessments done. Suggest monthly prize / accolade for doctor doing most VTE assessments.

Changes required

3711 Survey of Paediatric Patient Orientated Eczema Measure Scores

Dr Mohsin Ali, Consultant, (Dr Emily Davies, SpR), Dermatology

A survey of Patient Orientated Eczema Measure (POEM) in patients attenting the Paediatric Dermatology Clinic October 2012 to March 2013.

Integrated Medicine



3712 National Trabeculectomy Audit

Mr Bruce James, Consultant

Re-audit of trabeculectomy to perform view of intraocular pressure one year after surgery carried out in 2010. Needed for revalidation.




3713 National Maternity Survey 2013

Audrey Warren National survey of mothers giving birth in Jan/Feb 2013.

Specialist Services



3714 Audit of Operative Vaginal Delivery

Mr Tunde Dada, Consultant, Obs & Gynae

Continuous audit of operative vaginal delivery for CNST.

Specialist Services



3715 Audit of Caesarean Section


Continuous audit of caesarean section for CNST.

Specialist Services



3716 Audit of Vaginal Breech Delivery and other Operative Procedures


Continuous audit of Vaginal Breech Delivery and other operative procedures for CNST.

Specialist Services



3717 Audit of Management of Shoulder Dystocia


Continuous audit of shoulder dystocia for CNST.

Specialist Services



3718 Audit of Management of Obstetric Haemorrhage


Continuous audit of management of obstetric haemorrhage for CNST.

Specialist Services



3719 Audit of Oral Drug Therapy for Patients who are Nil by Mouth

Reet Nijjar, CT1 Anaesthetics

Are patients getting medications e.g. usual medicines, painkillers pre-operatively on emergency lists when nil by Mouth.




3720 Mortality Review April - September 2012



Trustwide 14/11/2012 Data Collection


3721 Telephone Questionnaire for all Joint Replacement Patients

Jenny Carro, Ward Manager, T&O

A telephone questionnaire carried out for all joint replacement patients on day 7 following discharge from hospital. Part of the Enhanced Recovery Programme.




3722 Management of Diabetes Peri-Operatively

Dr Henrietta Brain, Consultant, Diabetes & Endocrinology (Dr Daniel Conaway, F2)

An audit of the management of diabetes peri-operatively against

Integrated Medicine



the new peri-op diabetes guidelines. To include a prospective audit of all day cases with diabetes admitted to WH on a defined day as well as a retrospective audit of 30 major elective operations on patients with diabetes across a defined time period across specialties, including general surgery, orthopaedics, gynae and vascular.

3723 Audit of Missed Fractures

Dr Stewart McMorran, Consultant A&E SDU Lead

A retrospective audit of missed fractures in A&E SMH over a three month period following a SUI.




3724 Diabetes Specialist Nurse Patient Experience Survey

Una Vince, Diabetes Specialist Nurse

A patient experience survey of the service offered by Diabetes Specialist Nurses.

Integrated Medicine



3725 Quality of Orthodontic Extraction Letters

Helen Travess, Consultant, Orthodontics (Helen Veeroo, SpR, Orthodontics)

Audit of orthodontic extraction letters sent to dental practitioners compared to national guidelines.




3726 Early Supported Discharge Team SALT, Service Users Survey

Debbie Begent, Acute SLT Service Manager

Survey of patients' experience of SALT early supported discharge team.

Specialist Services

01/04/2012 Complete 21/11/2012 Results:100% of respondents would recommend this service to other people.76% of responses were ‘highly satisfied’. A couple of issues which require some reflection are; different perceptions of the patient’s involvement in planning and the gap in service between ESD and community/long term service.A theme emerged about less improvement with cognition, than physical recovery.Recommendations:ESD Team to check with individuals that they feel involved in the decision making process, some people are happy to be guided by the professional, others prefer more involvement.Work with community services to improve transition of care.The team have already identified training required in cognitive rehab and put forward a flexible funding bid.

Changes required

3727 Endoscopy Patient Experience Survey 2013

Suzy Robertson, Operations Manager, Endoscopy (Janet Hercules, Administrative Manager, Sue Kenny, Sister, Endoscopy Unit, SMH & Deborah Dobree-Carey, Sister, Endoscopy Unit, WH)

Re-audit - an experience survey of patients attending for endoscopy. The questionnaire has been designed in line with global rating scales for excellence.

Integrated Medicine



3728 Endoscopy Staff Experience Survey 2013

Suzy Robertson, Operations Manager, Endoscopy (Janet Hercules, Administrative Manager, Sue Kenny, Sister, Endoscopy Unit, SMH & Deborah Dobree-Carey, Sister, Endoscopy Unit, WH)

To assess levels of staff satisfaction and identify any areas for improvement.

Integrated Medicine



3729 Central Venous Catheter Audit Dec 12

Marie Coward, Sian Bates, IV therapy team




3730 International Comparison of Non-Traumatic Spinal Cord Injury Rehabilitation Outcomes

Mr Belci, Consultant Spinal (Salman lari, SpR Spinal)

A Retrospective Case Review of Patients with Non-traumatic Spinal Cord Injury between 2009 and 2011

Specialist Services



3731 Tip Apex Distance in Dynamic Hip Screws

Mr R Chennagiri, Consultant, T&O (Yeuyang Li, FY2)

To assess tip apex distance over a 3-month period in all dynamic hip screw operations performed at Stoke Mandeville.


27/11/2012 Complete 21/01/2013 Results: TAD acceptable 28 (75.6%); TAD unacceptable 9 (24.3%). Audit results from Jan-Apr '08 TAD: acceptable 24 (69%), unacceptable 11 (31%). Recommendations: Ensure adequate X-Rays, aiming to get best possible AP and lateral views; posters in scrub areas in Theatre 4 and 5; audit TAD regularly – quick and easy to collect data; possibly compile prospective data of cut-out rate and compare with TAD audits.

Changes required

3732 A Comparison of Endoscopically vs Radiologically Placed Stents for Oesophageal Cancer

Tom Chapman, Registrar (Helen Tyrrell CT1)

A comparison of endoscopically versus radiologically placed stents for the relief of dysphagia in oesophageal cancer. No nationally agreed standards exist.

Integrated Medicine



3733 Audit of Primary Retinal Reattachment Rates

K Manuchehri, Consultant Ophthalmologist

Audit of Primary Retinal Reattachment Rates




3734 Audit of Use of STAMP on Paediatric Ward

Carol Clarke, Paediatric DietitianLiz Pryke, Dietitian Manager

To determine whether patients are being nutritionally screened within 48 hours of admission and STAMP (paediatric nutrition screening tool) is being computed with resulting careplan.

Specialist Services



3735 Staff Evaluation of First Response Service

Tricia Bratby, Lead Professional, Gerry Linke, Named Nurse, Child Protection

A staff evaluation of the First Response Service, a new single point of contact for all enquiries to the Children and Families Service (Social Care).

Integrated Medicine



3736 Audit of Mortality in Inpatients on Ward 8/9 at Wycombe Hospital

Dr A K Misra, Consultant, Ashneet Sidhu, Clinical Attache, MFoP

An audit of inpatient mortality on Wards 8/9 at Wycombe Hospital.

Integrated Medicine



3737 TB Audit for Health Protection Agency

Margaret Holland, TB Nurse

Health Protection Agency require some TB notes to be audited by Jan 7th.

Integrated Medicine



3738 The Use of, Storage and Requirements for Medical Gases supplied in Cylinders on Wards

Liz Sutton, Procurement Pharmacist (Wura-Ola Akinrinsola, Pre-Reg Pharmacist trainee)

Counting cylinders on wards and noting how they are stored and finding out what they are required for. There are Health & Safety Standards related to this. Manual count & inspection and questionnaires to staff.

Specialist Services



3739 Audit on the Application of Ozurdex in Buckinghamshire Healthcare NHS Trust

Dr Siegfried Wagner, FY1 General Surgery

Data from the notes of patients who have been administered Ozurdex treatment for ophthalmic disease to be collected. Data to include the clinical indication, visual acuity and results.




3740 Audit of Management and Follow-up of Paediatric Allergy and Anaphylaxis

Dr Baneera Shrestha, Consultant, (Dr Laura Lewis, GPVTS) Paediatrics

An audit of the Management and follow-up of paediatric patients presenting with either allergy or analyphylaxis, against RCPCH care pathways.

Specialist Services



3741 Workplace Health & Safety Audit

Marion Carnell, H&S Facilitator, Stoke Mandeville Hospital

A re-audit of compliance with legal requirements regarding workplace Health & Safety.

Trustwide 06/12/2012 Data Collection


3742 Ensuring Patients Are On Correct Medication Pre-Angioplasty

Ghazala Yasin, Sister, Cardiac Day Unit (Nicola Bowers, Cardiac Research Nurse)

An audit of patients coming in for angioplasty to see if they have been taking the correct medication and to determine reasons for non-compliance.

Integrated Medicine



3743 Re-Audit of the Use of Emergency Contraception (EC) and Record Keeping

Dr Jackie Moncur, Speciality Doctor, GU Medicine

Re-audit of the use of EC to ascertain whether this, especially the IUD, is being use appropriately, whether women are being offered a choice of EC and to determine how many women present for EC within 72 to 120 hours. Also to check full detailed documentation of decisions/recommendations are being kept.

Specialist Services



3744 Audit of Adherence to NICE Guidelines for CT Scans in Head Injury Patients

Mike Kazer, Consultant, (Dr David Robertshaw, FY2) Emergency Medicine

An audit to assess whether patients presenting to the Emergency Department with a head injury are appropriately having a CT head scan in accordance with NICE guidelines for head inuury (CG56).

Integrated Medicine




Jane Eastman, Senior Physiotherapist, T&O



09/10/2012 Complete 30/01/2013 Recommendations were to feedback the results of the audit to Orthopaedic consultants, anaesthetists, nursing staff and business manager involved in the ERP; establish data set for next audit period with reference to ERP; compare 2012 benchmark LOS data for primary elective joint replacement project against prospective data as ERP becomes more established; continue to increase percentage of patients with a LOS of 4 days or fewer; establish pre-op education for all primary elective joint replacements.

Changes required

3746 Hand Hygiene Facilities Audit Jan 2013



Specialist Services



3747 Preventing Surgical Site Infection - Peri Operative Audit for Urology Jan 13




Results and Recommendations required Not required

3748 Re-audit of Use of the Customised Growth Chart in the Identification of Small For Gestational Age Babies

Jackie Baxter, Clinical Governance Midwife, Obs & Gynae

A re-audit of 3327 of the use of the customised growth chart in the identification of small for gestational age babies. Prospective audit of 100 maternity case notes during the month of November 2012.

Specialist Services



3749 Preventing Surgical Site Infection - Peri Operative Audit for Ophthalmology, ENT and Oral November 2012





3750 National Chemotherapy Patient Experience Survey

Jeanette Tebbutt, Lead Cancer Nurse, Cancer Services

Survey of all patients having chemotherapy between May and August 2012. Survey produced by Quality Health. Trust to send list of patients and Quality Health to organise sending of questionnaires, 2 reminders and analysis.

Specialist Services



3751 National Cancer Patient Experience Survey

Jeanette Tebbutt, Lead Cancer Nurse, Cancer Services

Survey of all patients diagnosed/treated (?) between Sep and Nov 2012. Survey produced by Quality Health. Trust to send list of patients and Quality Health to organise sending of questionnaires, 2 reminders and analysis.

Specialist Services



3752 The Accuracy and Acceptability of Squint Surgery

Richard Smith, Consultant, Ophthalmology

A review of the records of all patients operated on for squint between November


31/12/2012 Complete 19/02/2013 Results: In general, treatment algorithms seem to be correct and there was no systematic tendency to undercorrect or overcorrect in any sub-group. Results compare favourably with available national

Changes required

2011 and November 2012 (approx 59 patients), looking at the preoperative and postoperative measurements and patient satisfaction. The results will be used to refine the algorithms for estimating the amount of muscle adjustment required to achieve a particular amount of correction.

comparators. Recommendations: Aim for undercorrection in children with global developmental delay.

3753 Re-audit of Insulin Administration Errors

Louise Meakes, Lead Nurse, Diabetes,

Re-audit of 3577. Integrated Medicine


3754 Infection Rates Following Surgery for Fractured Neck of Femur: Staples vs Sutures

Mr Edward Seel, Consultant, T&O (Dr Sarah Milliken, FY1, T&O)

To compare infection rates following surgery for fractured neck of femur in those closed by sutures vs those closed by staples.




3755 Infection Prevention & Control Knowledge Survey 2012


A questionnaire to assess staff knowledge of Infection Prevention & Control. An online survey was used.

Specialist Services

01/05/2011 Complete 12/01/2013 Only 366 staff members completed survey. There were several areas where there were too many incorrect responses. Recommendations: This survey must be disseminated to all relevant staff and to be discussed at relevant meetings e.g. ward meetings, clinical governance meetings. More emphasis on publicising the survey during the time leading up to the period that it is to be undertaken in order to obtain more responses. This survey highlights how important mandatory training is and this is reflected in some of the percentages to the questions. It is vital that staff are allocated time to complete their mandatory training to help provide correct IPC practices and provide a safe and clean hospital has outlined in the Trust’s 5 patient promises.

Changes required

3756 Rapid Incremental Closed Reduction of Cervical Facet Fracture Dislocation in SCI

Wail Ahmed, Spinal Injuries SpR

Retrospective review of the effect of closed reduction of cervical fracture dislocations on patients' neurology and complications. Of the procedure. Also assessed success and failure rates and reasons for failure. This is a continuation of audit 3598.

Specialist Services



3757 Validation Check of Safety Thermometer Returns

Christine Nuttall, Cheryl Pepper

A validation audit of data returned for the Safety Thermometer, December 2012.


25/02/2013 Results and Recommendations required Changes required

3758 Audit of Non-obstetric Emergency Care

Mr Tunde Dada, Consultant (Dr Rufaro Ndokera, FY2) Obs & Gynae

Audit of assessment/admission of pregnant patients presenting to A&E against Trust guideline 411.6.

Specialist Services



3759 Audit of Use of Oxytocin in Labour

Mr Tunde Dada, Consultant (Dr Kat Fu, Dr Richard Smith GPVTS) Obs & Gynae

Audit of use of oxytocin for the purpose of induction and aumentation in labour, against CNST and RCOG guidelines.

Specialist Services



3760 Staffing Levels on the Labour Ward

Lucy Duncan, Matron, (Jennnifer Taylor FY2 ) Obs & Gynae

Audit of staffing levels of midwives, consultants, registrars and SHOs on the Labour Ward SMH.

Specialist Services



3761 Audit of Continuous Fetal Monitoring during Uncomplicated Pregnancies

Mr Chris Wayne, Consultant, (Mariam Abbas Syed, GPVTS) Obs & Gynae

Audit of continuous fetal monitoring during uncomplicated pregnancies, against Trust guideline 425.6.

Specialist Services



3762 Paediatric Cystic Fibrosis Clinic Patient Survey

Marianne Tomlin, Paediatric Dietitian

Parent satisfaction survey of CF clinic. At this clinic patient sees physio, CF nurse, dietitian, consultant.

Specialist Services



3763 Outcomes after EPL Repairs of Hand

Laura Sutherland, OT Plastics Hand therapist

Looking at outcomes after EPL repairs comparing 2 different therapy regimes, static vs early active movement (EAM). Currently no standards.

Specialist Services



3764 Sharps Audit Feb 13


Sharps Audit Feb 2012. Part of IPC audit plan.

Specialist Services



3765 Transfer Form Audit Feb 13


Transfer Form Audit Feb 2013. Part of IPC audit plan.

Specialist Services



3766 Preventing Surgical Site Infection - Peri Operative Audit for Gynaecology Feb 13


Preventing Surgical Site Infection - Peri-operative Audit for Gynaecology, Feb 2012. Part of IPC audit plan.

Specialist Services



3767 Patient Experience and Understanding of Neutropenic Sepsis

Dr Robin Aitchison, Consultant, Haematology (Jonathan Chambers, CT1)

Patient questionnaire to be used on chemotherapy unit to assess understanding of neutropenic sepsis and experience in previous admissions.

Specialist Services


3768 Audit of the Management of Induction of Labour

Miss Gita Suri, Consultant (Sarah Barker, ST3) Obs & Gynae

An audit of the management of IOL against NICE guidelines.

Specialist Services



3769 Analysis of Shoulder Stabilisation Surgery with reference to Failure Rate and Complications

Mr Geoffrey Taylor, Consultant, Vicky Russell, Clinical Specialist Physiotherapist

An audit of shoulder stablisation surgery with reference to failure rate and complications.




3770 Paediatric Septic Screen Audit

Dr Shrestha, Consultant, Paediatrics (Kushalinii Ragubathy ST1)

Audit against NICE guidelines on the management of the febrile child.

Specialist Services



3771 Paediatric Health Assessment Patient Experience Survey for Children in Care

Cherry Gregory, Designated Nurse, Children in Care

Patient experience survey to establish children's view of health care assessment by Paediatrician, completed when entering care, and 6 monthly/annually thereafter until they leave care.

Specialist Services



3772 Sentinel Lymph Node Biopsy Patient Experience Survey

Peter Budney, Consultant Plastics, Lindsey Lane, Skin Cancer CNS

This is a new service, patients can be referred from other hospitals. Want to ensure patients have a smooth journey from referral.




3773 Survey of Staff/Patient Perceptions of Rehabilitation in Spinal Physiotherapy

Katie Wilson, Spinal physio

Some patients/staff have perception that rehab only occurs in spinal gym whereas it should be a continuous process. This is a patient and staff survey in rehab wards (George, David, Joseph ) assessing perceptions of rehab.

Specialist Services


3774 Membrane Sweep Audit

Heidi Beddall, Consultant Midwife

To assess compliance with the membrane sweep guideline based on NICE antenatal quality standard. 6 monthly guideline audit.

Specialist Services



3775 Maternal Request for Caesarean Section

Heidi Beddall, Consultant Midwife

This audit is an ongoing review of the number of maternal requests for caesarean section, the reasons for requests, number of maternal request caesareans performed and birth outcomes of this group of women.

Specialist Services



3776 Clinical Risk Assesment in Labour

Helen Beddall, Consultant Midwife

To ensure that the maternal risk assessment tool is completed at the onset of labour and to ensure that management plans are documented and adhered to (re audit).

Specialist Services



3777 Re-audit of Malnutrition Universal Screening Tool (MUST)

Liz Pryke, Nutrition & Dietetic Service Manager

To audit most wards across Trust (acute & community) to ensure that MUST forms are being completed properly. Last audited April 2011. Planning to audit Feb 2013.

Specialist Services



3778 The Success of Surgical Canine Exposures in the MOBB Region

Mr Bahattin Bagdadi, Specialty Doctor, Oral and Maxillofacial Surgery

A regional audit to check the success rate of canine exposure procedures.




3779 Audit of Adult Community Acquired Pneumonia (BTS)

Dr Mitra Shahidi, Respiratory Consultant, Fiona McCann, Consultant, ITU

To assess adherence to local and BTS guidelines regarding the management of pneumonia and to identify any areas for improvement.

Integrated Medicine



3780 Audit of Management of Pulmonary Emboli

Dr. Lucy Houghton, FY1

To assess whether confirmed Pulmonary Emboli cases could be managed as outpatients and to look at current length of stay.

Integrated Medicine



3781 Analgesia Prescription for Patients with Long Bone Fractures in A&E

Stewart McMorran, SDU lead, A&E (Neil Dawson, ST4)

Retrospective CAS card review against College of Emergency Medicine guideline for the management of pain in adults.

Integrated Medicine



3782 NEWS Track and Trigger Observation Tool Audit

Jenny Ricketts, Consultant Nurse, Critical Care

Audit to assess whether the NEWS Track and Trigger Observation tool is completed correctly as per Guideline 26, physiological observations of adult non obstetric inpatients.

Trustwide 18/02/2013 Design Results and Recommendations required Changes required

3783 IV Tharapy Team Service User Survey

Marie Woodley, Sian Bates, IV Therapy Specialist Nurses

Survey of doctors and senior nurses to identify knowledge, use, barriers to referring patients for IV therapy at home and other aspects of OPAT services.

Integrated Medicine


3784 Neuro Rehabilitation Unit Record Keeping Audit

Lesley Fox, Neuro Rehab Physiotherapy Clinical Support Worker

Re-Audit of record keeping audit of Neuro Rehabilitation Unit notes.

Integrated Medicine



3785 Quality of T&O Operation Notes

Mr Kankate, Consultant T&O (Ying Teo, SHO, T&O)

Re-audit of trauma operation notes to compare with national guidelines.




3786 Environment Audit NSIC & CSS Oct 2012


Audit of environment. Specialist Services



3787 Retrospective Analysis of Lung Cancer and Mesothelioma Admissions Between March 2012 and October 2012

Dr Prasad, Consultant, Respiratory (Jill Mowforth, Hayley Steiner, Lung Cancer Specialist Nurses)

A review of patient clinical records to identify trends and patterns in patients admitted to hospital with lung cancer and mesothelioma.

Integrated Medicine


3788 Gynaecology Outpatients Clinic (Wycombe) Patient Experience Survey

Denise Read, Deputy Sister

Survey of patients' views of gynaecology outpatients service.

Specialist Services



3789 FIM/FAM Audit 2010-1013

Karen Earp, Advanced Physiotherapist

A reaudit of patient outcome post rehabilitation from stroke.

Integrated Medicine



3790 Completion of Drug Charts in NSIC

Dr Ibrahim Ussef (Naulizio Belci, Consultant and Dot Tussler, Head PT EICEE Chair)

A reaudit of drug chart completion against trust guideline.

Specialist Services



3791 Elective Abdominal Aortic Aneurysm Surgery, 2008

Geraldine Delacy, General Surgery

Data for National Vascular Database to be published in public document in June 2013.




3792 Physiotherapy PES

Helen Hine, Band 6 physio, SMH

To review therapy service to establish if we are meeting patients' expectations and needs.

Specialist Services


3793 Paediatric Pre-Op Assessment Clinic

Sue Smith, Tracey Fox-Clinch, Deputy Sisters

Planning to set up pre-op assessment clinic for children so they can meet play specialists, nurses before surgery. Would like parent feedback on the needs of this facility.

Specialist Services


3794 Schwartz Rounds Focus Groups

Dr Liz Pounds, Clinical Psychologist (Zoe Chessell, Assistant Psychologist)

Two focus groups (regular attendees and speakers) to measure the value of Schwartz rounds - a local staff support initiative at NSIC

Specialist Services



3795 BASHH Management of Young People in Sexual Health Settings

Dr Luzzi (Dr Roberts/Dr Law, Brookside)

BASHH Management of Young People in Sexual Health Settings

Specialist Services

Complete 24/02/2013 Our Trust came out well in report. None required

3796 HPA HIV Diagnosis Audit

Dr Veena Reddy/Sunita Duggal

Audit carried out by Health Protection Agency using information gatheried from Shaw Clinic. Lost opportunities for HIV diagnosis.

Specialist Services

Data Collection


3797 BHIVA audit Dr Luzzi/Dr Veena Reddy

Patients dropped out of system.

Specialist Services

Awaiting Report/Action Plan


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