Annual Report and Accounts 2012/13 - Royal Devon & Exeter Hospital

68 4. Annex D
Royal Devon and Exeter NHS Foundation Trust
Quality Report 2012/13
Local Clinical Audit Title
& Aim
Local hip surveillance in
children with Cerebral
Palsy (CP)
Aim: to improve the
identification and
management of hip
displacement in children with
a diagnosis of Cerebral Palsy.
Actions
Compliance with the local guideline was poor and it was felt current research had moved
on. Therefore the following actions were identified to improve patient care:
• New local guideline on the identification and management of hip displacement in
children with CP to be produced and agreed
• Local guideline to be discussed and agreed at a regional level to gain south-west
consensus
• Once agreed, clinical guideline to be placed on the Trust intranet to make more
accessible to clinicians
• Further radiology audit to be undertaken around the specific aspect of gonadal
protection in paediatric patients
• The Gross Motor Function Classification System (GMFCS) to be introduced and used on
a routine basis by physiotherapy and paediatrics
Management of Tongue-
Tied Neonates (Re-audit)
Aim: to ensure the
appropriate referral pathway
and management of
tongue-tied patients is being
followed.
Post-natal Mumps,
Measles & Rubella (MMR)
Vaccination (Re-audit)
Aim: to ensure improvements
to the effectiveness of
processes for screening
of women for rubella
susceptibility and subsequent
offer of MMR vaccination
had been achieved.
• Clinical examinations and documentation to be standardised.
This re-audit demonstrated that the appropriate referral pathway is being followed.
Referrals and procedures for this condition had increased by 30%. Follow-up of these
patients at 3 months was poor. Therefore the following actions were agreed to continue to
improve patient care:
• Further education of clinical staff to ensure they are aware that referrals should be only
for patients with feeding problems to reduce unnecessary referrals
• Greater liaison with breastfeeding peer supporters to increase 3 month follow ups.
This re-audit demonstrated a 30% improvement in the offer of post-natal MMR vaccination
since 2010 to 95% compliance. There was 80% compliance with the initial recording of
rubella susceptibility for pregnant women. Therefore the following changes in process were
agreed to improve the robustness of the system:
• Labour Ward midwives to check antenatal hospital and hand-held notes and transcribe
appropriate information on rubella susceptibility and need for MMR to Management
Plan section of postnatal hand-held notes
• Screening Coordinators to follow-up all susceptible women after delivery to find
evidence that MMR has been offered/given. If no record is found the Screening
Coordinators will inform the relevant GP.