Reducing unlabelled Arterial Blood Gas results Dr Kelvin Yau CT2 Medicine (Respiratory) Wexham Park Hospital

Project Aim(s) Increasing number of ABG results which are not labelled with oxygen flow rate/air. This makes it difficult for clinician to interpret a patient’s acid base status The aim of this project is to reduce the percentage of ABG results are not labelled with oxygen/air. Secondary aim is to ensure ABG results are written in patient’s notes as the printouts fade with time Wexham Park Hospital

Action Planning What are we trying to accomplish? I am trying to reduce the percentage of ABG results which are not labelled with oxygen flow rate within 3 month period How will we know that a change is an improvement? By a reduction in the number of ABG which are not labelled with oxygen flow rate What changes can we make that will result in improvement? Placing a reminder next to ABG machine in A&E and Ward 9 (Respiratory) to remind users to label their ABG results with oxygen flow rate and write the result in the notes Wexham Park Hospital

Process mapping Wexham Park Hospital Patient in A&E/W9 Doctor takes ABG sample ABG machine runs test ABG machine prints result Management based on result ABG result needs to be labelled with oxygen flow rate/air and written in the notes

Plan ABG results printouts are stuck into patient’s medical notes without information on whether the patient was on air or oxygen. Difficult to interpret the acid base status of the patient on admission. ABG result printouts are loosely stuck in the notes with tendency to fall out and fade with time. 2 ABG machines in the hospital, One in A&E and one in Ward 9 respiratory. Do I looked at 50 ABG results in AMU and recorded the number of unlabelled ABG and number of results written in the notes and where the ABG was done. PDSA Wexham Park Hospital

Study The initial sample of 50 ABG showed 37 samples from A&E, 13 from Ward 9: 38% (19/50) ABG results were not labelled 37.8% (14/37) of the results from A&E machine were unlabelled 38.5% (5/13) of the results from Ward 9 machine were unlabelled In terms of writing in the notes 22% (11/50) were written 18.9% (7/37) A&E results were written 30.8% (4/13) results from Ward 9 were written in the notes. Act Large number of ABG results which are not labelled or written in the notes. The next stage is to implement change to reduce the percentage of unlabelled ABG results and increase the percentage of results written in the notes. PDSA Wexham Park Hospital

Plan Place a reminder next to the ABG machines in A&E and Ward 9 to remind users to label their results with O2 flow rate and write their ABG results in the notes Do Discussed with Outreach diagnostics who services ABG machine in order to request permission to stick a reminder on the ABG machine. They are agree for me to put a reminder near the machines but not on it as it affects cleaning of the machine. Designed a reminder and stuck it on the table next to the machines. I have laminated it in order for it to be easily cleaned if spillage happened. Discussed with the doctors in A&E and they are aware of my QIP PDSA (2) Wexham Park Hospital

Study There is a small increase in percentage of unlabelled ABG results No improvement in the number of results written in the notes. This maybe because it is too early for any change to be detected. Act Continue to measure weekly in order to detect any improvement. If there is no improvement then review the situation and plan the next cycle PDSA (2) Wexham Park Hospital

Plan After 5 weeks of testing there was a small reduction in the number of unlabelled ABG results but no improvement in the number of ABG results written in patient’s notes. Most of the deficit originated from A&E. Decided to review the situation by discussing with A&E staff. Do Noticed that the reminder was covered up by folders next to the A&E machine. I also found that some A&E doctors do not have barcode access to the ABG machine so they ask the nurses to run the test but the nurses did not label the results. I repositioned the reminder and discussed with A&E staff about importance of labelling ABG with oxygen flow rate. PDSA (3) Wexham Park Hospital

Study This raises the issue that doctors should have their own barcodes in order to use the blood gas machine and not borrow another person’s barcode. This is in accordance with hospital policy from Outreach diagnostics. Due to time constraints in A&E it seems difficult to get medical staff to write the results in. Act To inform Outreach diagnostics that each user must have their own barcode. To continue measuring the primary outcomes PDSA (3) Wexham Park Hospital

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What difference has been made? Reduced the number of unlabelled ABG results by about 10% Increased awareness in A&E of the importance of labelling ABG results Did not make a difference in increasing the number of results written in notes Wexham Park Hospital

Learning points ABG results should be labelled with oxygen flow rate/air and written in the notes Identified a fundamental problem which affects patient care Approach this project with input from different departments Regularly reviewing the implemented change through the PDSA cycles Perhaps a reminder is not enough to encourage users to label their result printouts. It is difficult to encourage in A&E doctors to write the results in the notes, due to time constraints Wexham Park Hospital

Next step Increase sample size by including other medical wards and surgical wards Further testing cycles and widespread education regarding the importance of labelling ABG results with flow rates and writing them in the notes Liaise with Outreach diagnostics to see if the software within the ABG machine can be changed so that an oxygen flow rate must be entered before result is printed out Wexham Park Hospital

Team Members Supervisor – Dr Jayne Norcliffe Dr Kelvin Yau (CT2 Medicine) Wexham Park Hospital