Leicester Royal Infirmary
This initiative improved the documentation of safety net advice given by junior doctors in an Emergency Department via a very simple presentation given at their induction. Although a busy period for staff; orientation programmes provide a valuable opportunity to promote awareness of clinical guidelines.
Please note that this example was submitted to demonstrate implementation of CG47. This guideline was updated and replaced in May 2013 by CG160. The practice in this example remains consistent with the updated guidance.
Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?
Aims and objectives
To improve awareness of a key aspect of a NICE Guideline during an induction programme.
Reasons for implementing your project
The NICE Feverish illness in children guideline contains a visually appealing traffic light system of key signs and symptoms to guide appropriate management. It also provides clear guidelines on providing effective "safety net" advice for those children felt to be appropriate to discharge. In 2009 an audit of 293 case notes of children under five presenting to the emergency department with fever showed variation in the quality of junior doctors record keeping in respect of managing risk in a child with fever (using the traffic light system as a gold standard). It was also noted the documented rate of providing safety net advice fell from 70.9% to 55.9% between doctors in July and August respectively. This was despite a thorough induction programme for all new starting doctors in August.
The Department of Health have previously commissioned the RCPCH to produce a pilot study entitled "To understand and improve the experience of parents and carers who need advice when a child has a fever (high temperature)". This work found 81% of parents recalled receiving safety netting advice (i.e. told what to do if their child got worse / there was a change / didn't get better). However parents who did not receive safety netting advice were more likely to seek another contact than those who did (52% vs. 35%; p=0.01). This demonstrates the importance of the provision of safety net advice in reducing unnecessary re-attendance with its resultant costs of both parent and staff time.
How did you implement the project
The Emergency Department (ED) Junior Doctor Induction programme previously not only included mandatory administrative tasks but also lectures on managing risk and dealing with patients in the different areas of the Emergency Department (ED). In order to raise awareness of the importance of safety net advice a "safety culture" theme was included. A key slide set was introduced into the Paediatric Lecture regarding safety net advice demonstrating key principles and the background to its importance. This lasted no more than five additional minutes to the programme. No other changes were made to staffing levels or availability of information nor were clinical staff actively made aware of the change of emphasis in the induction programme.
There were no associated costs apart from the time of the lead investigator. There were minimal implementation barriers although the time available to induct junior doctors is scarce so a clearly defined strategy must be in place. Lead staff must be engaged with the project and there should be departmental agreement on the standard of safety net advice required.
A case note review of the clinical record of all children presenting with feverish illness in July and August 2010 was repeated by the same individual as the 2009 audit.
293 notes were analysed in the 2009 cohort with a reduction in documented safety net advice from 70.5% (July) to 55.9% (August) following the start of the new medical year. This difference was only marginally non-significant on Fisher's Exact Test (p=0.051).
457 notes were analysed in the 2010 cohort (Swine Flu in 2009 led to a large number of children being deflected to urgent care). Safety net advice increased from 76% (July) to 89.5% (August) which was significant at p=0.019. Newly commencing Junior Doctors were 100% compliant with safety net advice documentation in their notes.
Admission rates increased by approximately 10% from July to August in both 2009 and 2010. The frequency of documentation of traffic light symptoms and signs showed a trend to improvement between July and August in the 2010 cohort versus the 2009 group but would not have produced clinically relevant outcomes.
Key learning points
A simple intervention at Induction has had a marked effect on safety net advice provision.
Although not all doctors in the August 2009 cohort were still present in the July 2010 group it was pleasing to seen an increase in frequency of advice given by presumably indirect or "on-the-job" effects.
Admission rates increase in the August Cohort which, although having cost implications, is optimal for patient safety given recent evidence presented in the BMJ regarding the August changeover.
Groups wishing to develop or implement this work should consider looking at other guidelines where safety net advice is relevant (For example CG 56: Head Injury). It is also important to be able to ascertain whether documented safety net advice correlates with verbal advice given and what the quality of that advice is. The role of patient information leaflets also needs further exploration.
NIHR Doctoral Research Fellow
Leicester Royal Infirmary
Is the example industry-sponsored in any way?