AH ANNUAL REPORT 2018

2.2.4 Actions arising from Local Clinical Audits
There were a total of 173 local audits registered in the reporting period 1st April 2017 to 31st March 2018. There are
39 (23%) local audits completed. There are 113 (66%) audits that will continue in 2018/19. There are three audits not
yet started and 18 audits have been cancelled (11%).
The reports of the completed local clinical audits were reviewed by the provider in the reporting period April 1st 2017
to March 31st 2018 and examples of the outcomes are listed below.
Local Audit
Patient satisfaction survey for
same day ENT pulse oximetry
service
Audit to assess if appropriate
radiographs are being sent
upon referral to the Oral
and maxillofacial surgery
department for Orthodontic
extraction cases.
Audit of surgical site infections
in patients undergoing
appendicectomy.
Audit of Quality of
Documentation for Paediatric
Surgical Patients.
Actions
The project was discussed and presented at the Alder Hey ENT (Ear, Nose and
Throat) Department Clinical Governance meeting in December 2017.
Action/Recommendation:
• This study was originally only conducted with one consultant’s patients. We have
now rolled out the same day pulse oximetry service to another consultant.
• Re-audit in 12 months.
The audit was presented at the Alder Hey Oral and maxillofacial surgery department
post clinic meeting in June 2017.
Action/Recommendation:
• Ensure we write to all Orthodontic Practices and consultants audited with the
results. Remind them of the importance of enclosing all necessary radiographs.
• Set up a new trust email address which is verified so that orthodontic practices
can directly email across the appropriate images to the department.
• Contact the Alder Hey scanning department to see if it is possible to keep the
radiographs sent with the referrals and provide them to the OMFS department to
sort through so they are not only scanned on but also retained and can be referred
to at the patient appointment.
• Re-audit in 3 months.
The audit data were submitted to the National Getting It Right First Time (GIRFT)
Surgical site infection audit database.
Action/Recommendation:
• Data were submitted to the National database for Getting It Right First Time.
• Data will be reviewed with similar data from other centres before presentation and
change in practice decided.
• Continuous data collection till August 2018.
The audit was presented as departmental teaching in September 2017.
Action/Recommendation:
• Individuals were reminded about the standards required and advised that this
would be re-audited.
• Re-audit in 3 months.
Alder Hey Children’s NHS Foundation Trust 88
Annual Report & Accounts 2017/18