Patient records were audited to determine if height, weight and blood pressure have been monitored and recorded following commencement of medication in line with recommendation 1.8.5 in NICE NG87. The recommendation advises that heart rate and blood pressure should be plotted on a centile chart. Height and weight measurements should be plotted on a growth chart.
This example was originally submitted to demonstrate implementation of NICE guideline CG72. It has since been reviewed and updated. The practice it describes remains consistent with the updated NICE guideline NG87.
Example
Aims and objectives
The audit was carried out to determine compliance of monitoring side effects of medication in the treatment of ADHD/ADD in children and young people as recommended by NICE Clinical Guideline 72 (since updated and replaced by NG87). The audit was deemed necessary to provide a basis on which to carry out future audits and to improve the service.
The key objectives were:
- To review 30 records from each of the 3 sectors. A total of 90 records.
- To determine if patients have had medication reviewed in line with NICE guidance
- To assess if height, weight and blood pressure are recorded at time intervals as set out by NICE guidelines
- To determine of measurements are plotted on centile chart at each visit
Reasons for implementing your project
Prior to the audit it was recognised that reviews were often delayed. Delays occurred because of lack of clinical time, inconsistency in allocation of appointments and demand i.e. where parents with queries phoned in they tended to be allocated an appointment. Two years ago the introduction of scheduler ensured that all children/young people are sent appointments according to when they are due. Prior to this each sector had a different method of managing appointments. By standardising appointments this was eliminated. Height, weight and blood the pressure were mostly recorded but not plotted on an appropriate centile chart.
There are approximately 1,600 children/young people attending our service, and 4 areas in which children are reviewed. Audit prompted discussion as to how clinicians could be allocated to reduce waiting times for review according to demand from each sector.
How did you implement the project
For the purpose of this audit a data collection tool was designed in conjunction with the Multi-professional audit department. Ninety patient records were reviewed from different sectors to help establish a baseline to work from for future reference. Within the South Eastern Trust ADHD clinics are established in 4 areas, Scrabo Children's Centre, the Downe Hospital, Warren Children's Centre and Stewartstown Road Health Centre. This is to provide ease of access for families within the Trust sectors. The service has undergone significant change during the last 2-3 years with the introduction of a single point of entry and partial booking.
Data was collected prospectively. Records of children and young people who were diagnosed and commenced on medication towards the end of 2011-2014 were targeted. This provided a sufficient time period in which to ascertain compliance. Data was collected during December 2014 and January 2015.
Clinicians, managers and administration were already aware of difficulties and there was already a willingness to make changes to benefit the child who is central to the service. There was no opposition to the audit at any stage.
Following a meeting with the lead consultant, senior nurse manager, administration lead and myself to discuss findings from the audit changes were made within a short period of time. Including dissemination of report findings to relevant staff, introduction of blood pressure centile charts, and a copy of the guidelines placed in records. In addition to the figures produced by the audit it was apparent that providing a good service that is NICE guideline compliant requires not only the participation of clinicians but also management and administration.
Key findings
Areas of high compliance (areas achieving 90% compliance and above):
Measure of Quality:
Expected % Achieved %
- Weight was measured at initial review appointment 100% 92%
- Height measured was at every review appointment 100% 90%
- Weight was measured at every review appointment 100% 94%
- Areas identified for improvement (areas achieving less than 90% compliance) included:
Measure of Quality:
- Initial review should be 3 months from starting medication 100% (expected) 59% (achieved)
- Height was measured at initial review appointment 100% (expected) 87% (achieved)
- Height measurement was plotted on centile chart at initial review appointment 100% (expected) 41% (achieved)
- Weight measurement was plotted on centile chart at initial review appointment 100% (expected) 40% (achieved)
- Blood Pressure was measured at initial review appointment 100% (expected) 70% (achieved)
- Blood pressure measurement was plotted on centile chart at initial review appointment 100% (expected) 1% (achieved)
This was the first audit using prospective data and following results an action plan was established:
- To improve efficiency of timely reviews through skill mix
- Shared care guidelines to be placed in shared care folder
- Meeting with GP representatives to progress shared care
- Monitoring guidelines to be placed in medical records along with ICD-10 symptoms
- Provision of blood pressure cuffs to all clinicians
- Blood pressure centile charts to be placed in all medical records
- Re audit to determine higher degree of compliance
Blood pressure centile charts have been ordered and will be placed in medical records. In doing this audit we also became aware of the importance of using rating scales to monitor side effects and these have also been introduced.
All clinicians and administration staff have been contacted regarding changes to service in terms of recording. A copy of guidelines regarding monitoring will be placed in all medical records.
Senior management are already looking at skill mix to ensure timely reviews. The team consultant is to meet with GP representatives to progress shared care arrangements which if successful will reduce pressure on the service.
Key learning points
Auditing NICE CG72 has provided clarity as to how the service can be improved by involving all concerned in running the service. The audit brought about discussion which resulted in some great ideas being generated. The ideas included skill mix, proposals for future audit and using shared folders to disseminate information.