Annual Report and Accounts - The Great Western Hospital

No. Audit Title
15. Non Invasive
Ventilation (NIV)
16. Vaginal Birth after
C- Section
17. The time taken by
Emergency
Department X-ray
to complete X-ray
requests made by
Acute Assessment
Unit (AAU)
18. Service
Improvement:
Chemotherapy
treatment on Day
Therapy Centre
(DTC)
19. Prescribing of Oral
Nutritional
Supplements
(ONS) for Adults
at Three Swans
Surgery.
20. Compliance to
Patient Group
Directions (PGD)
21. Audit of the
Prescribing,
Monitoring and
Administration of
Therapeutically
Monitored
Antibiotics
22. Evaluation of
Sedation Practice
on Intensive Care
Unit
Audit Summary/Learning and Action
might experience and what to do in that case. A large proportion of
patients did not know how long to continue new medicines for. 70%
patients were satisfied or very satisfied with the surveyed aspects of
information given. This represents a mis-match between what Health
Care Professionals and patients believe constitutes appropriate
information. Action plan includes developing a "Provisions of Medicines
Policy" detailing a list of MUST and SHOULD actions for provision of
information. "Patient information leaflet” must be given with all supplied
medicines. Electronic discharge summaries to be standardised.
Implementation of "Patient Medicines Information Helpline". Ward
Pharmacists to use available opportunities to speak to patients about
newly prescribed medicines and relevant information in a timely manner.
Re-audit is planned when actions have been implemented.
In general, NIV is being used appropriately. The key learning is to modify
NIV Nursing chart to include record of blood gases.
The audit has demonstrated excellent performance in the implementation
of recommendations for intrapartum care and antenatal records. The
works needs to focus on improvement in documentation of counselling,
management and planning required.
A low number (23%) of cases had a delay in having the X-rays performed.
The main reasons identified were- No nurse escort and/or Patient not
ready. There are discussions planned at inter-departmental steering group
and the results will be referred to AAU.
The key actions to improve service include- Promote patient information
regarding avoiding same day bloods unless there is a clinical reason to do
so, Poster to be produced, Proposal to separate out different
chemotherapy types to streamline process and C-PORT chemotherapy
capacity tool to be introduced to streamline pathway and increase
efficiency to maximise DTC capacity.
There are identified areas for improvement around “advice given to the
patients, recording of BMI’s, and documentation of treatment plan. Use of
ONS has risen since 2008. Targeted work around each individual patient
with recording of essential information and timely periodic review of
patients to ascertain continuation of ONS.
Areas for improvement include amalgamation of PGD policies and
agreement on training and competency for PGD’s across the merged
Trusts.
Overall, the results demonstrate improvements (of various magnitudes) in
the indicators of interest relating to antibiotic level monitoring. The plans
are to continue with the service and re-audit using the same methodology.
Actions include analgesia and sedation protocol discussion by a multidisciplinary
working group.
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