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Using quality improvement in response to a significant event

It's important to learn from significant events and implement changes that lead to future improvements

01 October 2020, at 7:10am
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Imagine this clinical scenario: during the weekend emergency clinic, a male neutered domestic short-haired cat, with a history of cystitis, is admitted. The owner has noticed him straining to urinate for the past few days. The cat presents as lethargic with bloody, gritty urine around his prepuce. Clinical exam shows a turgid, over-extended bladder and a diagnosis of a blocked urethra is made. A cystocentesis is performed to decompress the bladder, as well as a minimum database and a urinalysis. The patient is started on analgesia and fluid therapy with a plan to anaes­thetise and place a urinary catheter to clear the obstruction once the patient is more stable. During the procedure, the patient suffers from cardiac arrest and, despite the team’s best efforts, cannot be revived.

What happens next?

A significant event audit (SEA) is completed. An SEA is a ret­rospective audit and a quality improvement (QI) technique, which follows one case in detail to decrease the likelihood of repeating outcomes that went badly and increase the likelihood of repeating outcomes that went well. SEAs are carried out by bringing the team and the relevant case notes together to discuss the event. The event must be discussed without any blame, allowing team members to provide honest and constructive feedback on how they contributed to the care process.

During the SEA, it was identified that the patient was showing spiked T waves on ECG, indicating polarisation abnormalities caused by hyperkalaemia. However, the team were not confident in interpreting the ECG trace, so had not identified this in time. The team were quite new to emer­gency and critical care, with a few members being newly qualified. The need for training was discussed, in particular specific training in general anaesthetic monitoring and ECG.

To get a clearer picture of the procedures that needed to be put in place, a retrospective audit was completed on gen­eral anaesthetic monitoring sheets. The information required on each sheet included a GA chart completed and loaded on to the practice management system (PMS), the multiparam­eter monitor (MPM) used, the surgical safety checklist used, drugs and dosage recorded, monitoring of vital signs and record of ECG trace and notes on quality of GA and recovery.

Each sheet was marked out of three, zero being “missing information”, one “basic information”, two “contains rele­vant details” and three “excellent level of detail”. The audit showed that GA sheets were only used on 29 percent of sedations and 63 percent of anaesthetics, with no mention of ECG when they were used. Most of the forms were scor­ing one, with basic levels of information.

What changes were implemented?

Nurse clubs were set up to engage the team and supply training. The first involved the use of the multiparameter machine and understanding of the ECG. Training was also given one-to-one for individuals that required it. After the nurses received the training, they then delivered the training to other members of the team, to further develop their understanding. The team members who had wanted more support were observed during a GA when possible. The team set up a folder within the prep area that contained articles and tips on anaesthetic monitoring and emergency and critical care topics, so the whole team had access to the information if required.

A repeat audit was completed after the training had been delivered to all team members. The audit showed that the MPM was used on 100 percent of anaesthetics, and 70 percent of sedations, with surgical safety checklists being completed for all. 75 percent of the sheets were filled with an excellent level of detail, and observations made on ECG traces and identification of complex ECG traces. Importantly, there have been no patient mortalities or significant events related to general anaesthetic or sedation since the training was implemented, which is a great success for the whole team. As quality improvement is a continuous process, the team will continue to audit and reflect on their performance.

In summary

SEAs are a useful way to investigate a significant event, as they allow an honest and constructive account on the quality of care provided, focusing on how to learn from the event to implement changes that lead to future improve­ments. They can guide further development of guide­lines, protocols or checklists and may result in additional clinical audits that measure whether the changes have been adopted (process audits) and whether they led to an improvement (by auditing outcomes).

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