Hospital Support Team Audit: Delays In Advice Being Implemented Melanie Kilner Clinical Nurse Specialist ABMU HB Specialist Palliative Care Team My name is Melanie Kilner I work as a clinical nurse specialist in ABMU HB based at Ty Olwen. Picture of Ty Olwen.

Problem? The Hospital Support Team, had a hunch that not all advice given to the ward teams was always implemented in a timely fashion. An audit was undertaken to assess the number of incidents of medication advice delays and to assess why assess delays were happening.

The Team Hospital Support Team across ABMU HB Nurses= 5 nurses Doctors= 5 doctors

The Plan One ward Set a standard Pilot Pilot We started the process by undertaking a pilot study on the oncology ward in Singleton hospital To test the audit proforma To Set a standard

The Pilot Time period of two weeks 12 audit forms completed 22 medication suggestions 3/22 delays Face to face with doctor most chance of success Change…… Audit proforma Set number instead of time frame. Audit proforma It was tested and changes were made to make it more robust included whether it was a dose alteration? Did the hospital support team doctor prescribe? Included dates seen by pharmacist and date it was dispensed? Date of first administration Methodology of main audit Multi centre approach, involving the four main hospitals in the HB. 25 from each of the main hospitals.

Four Hospitals Singleton Morriston Both covered by the Ty Olwen based hospital support team Neath Port Talbot hospital team POW covered by Y Bwythyn N hospital team

Plan Standard All medication advise recorded Advice given before 2pm should be implemented the same day. All medication advise recorded Significance of timing of advice How the advice was given Any delays

Results

Results 92/100 forms fully completed (92%) 14/92 delays identified (15% of patients) 4 delays from NPT (4/24 17% of patients) 2 delays from Singleton (2/20 10% of patients) 7 delays from Morriston (7/23 30% of patients) 1 delay from POW (1/25 4% of patients) Haven’t got the time to go into each of the delays, but have grouped them into: Three main categories: Prescribing- the doctors Dispensing- pharmacy Administration- nurses.

Administration Four delays Four Delays

Dispensing Six delays Six delays

Prescribing Five delays 5 delays: 2- conscious choice not to implement recommendations 3- not discussed with doctors, advice in health records/discussed with nursing staff. Five delays

Discussion Face to face discussion with the doctor had most success in terms of timely implementation of advice. Too high a delay percentage in Morriston hospital. Concept of severity introduced into discussion Re-audit Morriston Proforma adapted to incorporate, severity of symptom. New standard set. During the audit period Severity- at this point the team discussed how knowing severity impacts on the delay. How much suffering did the delay potentially cause. Hunch was that the delays occurred in the less severe symptoms. Morriston- large very busy, tertiary centre compared to the other three hospital.

Standard No more than 10% of advice should result in a delay. But…. 100% of recommendations should be acted upon where the symptom severity is 3-4/4 Based on the pilot and main audit, the team discussed across ABMU Hb and decided that 10% based on the results as far.

Morriston Re-audit Prospective audit of 25 consecutive referrals as previously 1/25 delay Administrative delay, medicine prescribed orally but unable to swallow.

Not the End.. Morriston re-audit was within standard set Did the team change there approach? Team believe it is important to re-audit this in 2012.