1. Documentation of lumbar punctures - Neurology DIU Dr Michal Rolinski Dr Hannah Rowe Supervised by Dr M Turner Learning To Make a Difference ORH NHS Trust

2. Background First lumbar puncture (LP) performed in 1891 Although common an LP is an invasive procedure Previous audits (1-3) have shown LP documentation to be poor Raised concerns over consent and technical aspects Learning To Make a Difference ORH NHS Trust

3. Project Aims To improve the quality of LP documentation on the Neurology DIU To improve technical aspects of the procedure, specifically the sending of paired serum glucose Learning To Make a Difference ORH NHS Trust

4. Action Planning ActPlan StudyDo What are we trying to accomplish? Increase in LP documentation meeting required standard Increase in samples sent with paired serum glucose to 100% How will we know that a change is an improvement? Good documentation is essential for patient safety. Sending paired serum glucose enables accurate interpretation of results and diagnosis What changes can we make that will result in improvement? Formal education session Information leaflet Learning To Make a Difference ORH NHS Trust

5. Indication for LP Patient consented LP performed Samples sent Documentation of procedure Results chased and acted upon Documentation of results and actions Learning To Make a Difference Lumbar puncture process ORH NHS Trust

6. 14 important indicators in LP documentation identified pre data collection (box 1) Lumbar puncture indicators Indication Contraindications Consent documented Position in which the LP was performed Use of aseptic technique Type of anaesthetic used Dose of anaesthetic used Site of spinal needle insertion Size of spinal needle used Number of attempts at needle insertion Opening pressure Any peri-procedure complication? Post-procedure advice given LP results documented Fig1 Learning To Make a Difference Methods ORH NHS Trust

7. 14 January, 2011 Month 0Month 1Month 2Month 3 QIP timeline

9. 26 patient notes reviewed LP’s performed by 7 SHO’s ( 2 FY2’s, 3 CT1’s, 2 CT2’s) No formal LP training undertaken prior to QIP Learning To Make a Difference Data collection ORH NHS Trust

10. What difference has been made? Learning To Make a Difference ORH NHS Trust

11.  Pre-intervention median indicators documented = 8/14 fig3  Consent documented in 8/9  Less than half had -  indication (22%)  contraindications (33%)  position LP performed (22%)  site of spinal needle insertion (33%)  spinal needle size (44%) fig4 Learning To Make a Difference LP documentation ORH NHS Trust Fig 3

12. Majority of indices improved after interventions Position LP performed p=0.0032 Site needle inserted p=0.0114 Documentation indication (57%) and LP results (43%) remained poor After both interventions 100% documentation of 9/14 indices Fig4 Learning To Make a Difference LP documentation ORH NHS Trust IndicatorsBefore interventionsAfter both interventionsp value Indication 22%57%0.3024 Contraindications 33%86%0.0601 Consent documented 89%86%1.0000 Position in which the LP was performed 22%100%0.0032 Use of aseptic technique 78%100%0.4750 Type of anaesthetic used 78%100%0.4750 Dose of anaesthetic used 67%100%0.2125 Site of spinal needle insertion 33%100%0.0114 Size of spinal needle used 44%86%0.1451 Number of attempts at needle insertion 89%100%1.0000 Opening pressure 89%100%1.0000 Any peri-procedure complication? 55%100%0.0885 Post-procedure advice given 55%100%0.0885 LP results documented 0%43%0.0625 Fig 4

13. Paired serum glucose samples sent increased to 100% p=0.0885 fig5 Learning To Make a Difference Paired serum glucose ORH NHS Trust Fig 5

14. Interventions led to a significant improvement in the documentation of LP’s and doubling of the number of paired serum glucose samples being sent to 100% fig5 Disappointingly, pre-intervention no notes had LP results documented this only increased to 43% fig4 Likely due to DIU closing and notes being sent to secretaries/coding (most LP’s performed in the afternoon) Learning To Make a Difference Discussion ORH NHS Trust

15. Next Steps LP leaflet currently going through departmental approval process Aim to provide LP education session and information leaflet as part of induction process to all SHO’s starting Neurology rotation Create a file on DIU to hold records with outstanding LP results We have learnt that simple interventions can make a difference! Learning To Make a Difference ORH NHS Trust

16. References Learning To Make a Difference ORH NHS Trust 1)Baer Et. Post-dural puncture bacterial meningitis. Anaesthesiology, 2006; 105(2): 381-93 2) Dakka Y, Warra N, Albadareen RJ, Jankowski M, Silver B. Headache rate and cost of care following lumbar puncture at a single tertiary care hospital. Neurology.2011; 77(1): 71-4 3) Vallejo MC, Mandell GL, Sabo DP, Ramanathan S. Postdural puncture headache: a randomised comparison of five spinal needles in obstetric patients. Anesth Analg. 2000; 91(4) 916-20