Clinical Practice ReviewEditorial 1

Hand hygiene compliance 1

Vitamin and mineral supplements taken @ the Women’s 2

Right Patient – Right Care 4

ISBAR is here! 5

Pharmacy news 6

the Royal women’s hosPital quAlIty And SAfEty unIt nEWSlEttERissue 7 july, AuguSt,

SEPtEmBER 2009

1

hospital acquired infections, hand hygiene and an age-old problem: the renewed focus on improving

hand hygiene in recent years has

seen overall compliance rise from

20% at RWH two years ago (you

may remember the Herald Sun

headline at the time and RWH topping

the “Worst Offenders” list) to 75%

in the latest audit.

• TheWorldHealthOrganizations’

target is 55% and Victorian

hospitals are aiming for 60%.

While women’s hospitals have been

relatively spared from the multi-

resistant organisms (mRO) that are

commonplace in general hospitals,

RWH has observed an increase

in mRO burden.

• Meticuloushandhygiene

practices are essential to reduce

the spread of these mROs

as well as other pathogens.

Doctors versus nurses!multiple studies on hand hygiene

compliance across various institutions

confirm that doctors perform poorly

when compared with nurses. this is

despite the fact that nurses have more

opportunities for patient contact than

doctors. many theories for this have

been proposed but we will let you use

your imagination!

• Nurseshaveimprovedtheirhand

hygiene compliance at RWH

• Doctorshavefailedtomake

significant gains above 60%.

• Doctorshavetheopportunity

to spread more nosocomial

pathogens as they potentially

move between more patients

than do other staff.

• Poorcomplianceamongst

medical staff is reducing the

overall performance of RWH

when we benchmark with

other hospitals.

hand hygiene compliance

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5

gestational trophoblastic disease

(gtd) covers a spectrum of tumors

ranging from premalignant

(hydatidiform mole) to malignant

(invasive mole or choriocarcinoma).

Complete and partial hydatidiform

moles are the two most common

types of pre-malignant gtd and

both can progress to invasive moles.

In a complete mole, an ovum devoid

of maternal nuclear dnA is fertilised

by 2 sperm or a single sperm –

it duplicates its chromosomes

to give a diploid complement

of male dnA. In a partial mole

the two sperms fertilise an ovum

with maternal nuclear dnA forming

a triploid conceptus (figure 1).

these proliferate to form abnormal

trophoblasts. the uterus enlarges

rapidly despite the absence of a fetus

and the placenta contains many cysts

to give a typical molar appearance.

maternal blood vessel formation

increases and facilitates metastatic

spread of the disease. Human

chorionic gonadotrophin (hCg)

is synthesised in the molar tissues

and therefore can be used

as a tumour marker to monitor

disease progression or response.

Invasive moles, choriocarcinomas

and placental site trophoblasts

are malignant tumours and are

collectively known as gestational

trophoblastic tumours1.

gtds are classified as low risk,

high risk and ultrahigh risk and

their medical management differs

based on the risk and resistance

to chemotherapy.

low risk patients are managed

with the methotrexate (mtX) and

calcium folinate regimen. Actinomycin

may be used as an alternative

if methotrexate is not tolerated.

High risk patients are managed

with the EmACO regimen, which

consists of Etoposide, methotrexate

and Actinomycin, given on alternate

weeks with Cyclophosphamide

and vincristine(Oncovin®).

ultra-high risk patients are

treated with the EmAPE regimen

which includes Etoposide,

high dose methotrexate and

Actinomycin, given on alternate

weeks with CisPlatin and

Etoposide with or without

intrathecal methotrexate.

All patients diagnosed with

molar pregnancy are recorded

in the Hydatidiform mole Registry.

Between 2002 and 2008,

a total of 649 patients were

diagnosed with molar pregnancy.

Only forty-eight (7%) patients

had persistent elevated hCg

and received medical treatment

(figure 2). thirty eight of those

patients received low risk

treatment – seven of them

developed resistance to methotrexate

and were switched on to the high

risk treatment regimen. In total ten

patients received high risk treatment

and only one patient received the

ultrahigh risk regimen.

Please let the associate editors have your views on the contents of this newsletter, or any other matters involving clinical practice which may be of interest to our readers.

huda ismail

treatment options for gestational trophoblastic disease

Susan Braybrook, telephone (03) 8345 2025 or email susan.braybrook@thewomens.org.aufor further information http://www.thewomens.org.au for intranet users http://intranet.thewomens.org.au/qualityandsafety

Please let the associate editor have your views on the contents of this newsletter, or any other matters involving clinical practice which may be of interest to our readers.

for any further enquiries regarding Pharmacy news please contact rwh.pharmacy@thewomens.org.au

ISBAR is here!

Carol Vance

Claire Fitzgerald

what is isBaR?ISBAR is a structured communication

tool that improves the quality

of information exchange when

discussing patients. the tool was

initially developed in the navy

to improve communication and

has since been adapted for medical

use. Inefficient communication

can compromise patient care

and using a standard approach

to communication decreases the

chance of forgetting relevant

information and helps to decrease

assumptions by making the reason

for the call obvious at the outset.

i identification

s situation

B Background

a assessment

R Request or

Recommendation

identify Identify yourself, the person

you are speaking to, the patient,

your location.

situation‘Spoil’ the story. Stating the

purpose of the call at the start

of the conversation helps the receiver

focus their attention appropriately

when listening to the story. If urgent,

make this clear from the start.

Background tell the story. Provide relevant

information only and remember,

less is more, particularly if the

receiver already knows the patient.

assessmentState what you think is going

on. give your interpretation

of the situation. Include your degree

of certainty - stating the obvious

is helpful. don’t leave the receiver

to guess what you are thinking

– tell them.

Request / RecommendationState what you want and

ask questions.

What you say for ‘situation’

may be a concise summary

of what you say for ‘assessment’

and ‘request’. this repetition

is helpful as it emphasises the

key purpose of the referral.

uses for isBaR• Inpatientoroutpatient

• Urgentornon-urgent

communications

• Conversationswithother

staff, either in person

or over the phone

- Particularly useful

in nurse – doctor

communication

- Also helpful in

doctor-doctor and

nurse-nurse

communication

• Discussionswithallied

health professionals

• Conversationswithpeers

• Asapromptfor

writing letters to other

care providers

• Escalatingaconcern

lanyard cards are available

as a reminder about ISBAR,

as well as notepads (which

are found on the gynaecology

wards) which may help

to organise your thoughts

before beginning your

communication. We encourage

you to give ISBAR a try and start

using it as a tool to improve

all your clinical conversations.

Carol Vance Principle Registrar quality and Safety fellow

Claire Fitzgerald Project manager Agree project

eDitoRial

The backbone of good (best) clinical practice remains patient centred care that is effective and safe. This edition has articles that address the last two of these. Most clinicians consider identifying their patient as a given. So routine that there can be a lapse in concentration. Readers will be astonished to hear that in recent years there have been 105 incidents reported at the Women’s where there has been such a lapse. As Ruth Bergman points out in her article on page 4 the true incidence of misidentifying patients is not known. Another patient safety article concerns the age old issue of washing our hands to reduce nosocomial infection. Andrew Daley reports that the gap between doctors and nurses in handwashing compliance has widened again. In August 2008 it was nurses 73%, doctors 67% whereas in August 2009 it was 79% versus 51%! With regards to effective care, Huda Ismail reviews the management of trophoblastic disease in the Pharmacy section, and Jenny Taylor reviews the use of vitamin supplements in our pregnant patients. Her audit shows that pregnant women with poor diets who could benefit most from multivitamin supplements were the least likely to use them. Sobering stuff. Finally, many around the hospital will now be aware of the ISBAR tool for effective communication. Carol Vance’s and Claire Fitzgerald’s article is a concise reminder of the methodology.

Please let us know what you think, both of our content this year and thoughts for future articles.

leslie Reti, editor leslie.reti@thewomens.org.au continued next page

HeraldSun 25.5.08

continued from back page...

Pharmacy news

A single sperm with 23 chromosomes fertilises an egg with 23 chromosomes

Normal conception

Two sperm fertilise an egg. This results in a triploid conceptus with 69 chromosomes.

Partial Mole

This results in a conceptus with 46 chromosomes but all of them are derived from the father.

Monospermic Complete Mole

The paternal chromosomes double up

The maternal chromosomes double up

and

This results in a conceptus with 46 chromosomes but again all of them are derived from the father.

Fertilisation by two sperm

Dispermic Complete Mole

The maternal chromosomes are lost

Fig 1. Genetic origin of hydatiform mole

Adverse reactions to chemotherapy

(AdR) were common however

few resulted in the delay

of treatment. Only two patients

required treatment cessation

(figure 3,4).

AdR were similar in both main regimen

as shown in figure 5 Chemotherapy

is an effective treatment for gtd.

Resistance to methotrexate has been

low and is effectively managed with

other chemotherapy agents.

huda ismail Senior Pharmacist, Oncology and AdR coordinator

References1. gestational trophoblastic disease,

SOgC Clinical Practice guidelines,

no. 114, may 2002

continued next page

Fig 2. GtD patients who received treatment

1234

5

6

1 Low risk managed with MTX. 31 (66%)

2 Low risk resistent to MTX. 7 (1%)

3 Transferred to other hospital. 4 (8%)

4 Currently receiving treatment. 1 (2%)

5 Ultra-high risk. 1 (2%)

6 High risk treatment required. 1 (2%)

Fig 5. Common aDR experienced by mtX and emaCo

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EMACO group MTX group

Fig 3. tolerance to mtX treatment

Fig 4. aDR experienced from emaCo treatment

5.04.54.03.53.02.52.01.51.00.50.0

1 Nil ADR. 28 (74%)

2 ADR result in hospital admission. 3 (8%)

3 ADR result in treatment cessation. 2 (5%)

4 ADR managed with medications. 5 (13%)

Nil ADR ADR managed with medication

ADR result in dose change or treatment delay

ADR result in hospital admission

2

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Ruth Bergman

continued from front page... continued from page 2...

An audit of suitability of vitamin

and mineral supplements taken

by pregnant women.

Vitamin and mineral use is common

in pregnant women but are women

taking supplements that correlate

with their nutritional deficiencies?

the aim of this audit was

to check how supplement use

related to woman’s individual

needs as well as to nutrients

that are at risk in pregnant

women in general such as iron,

folic acid and iodine.

218 pregnant outpatients

routinely seen by dieticians

at RWH had assessment of

• usualdietaryintake

• nutritionalsupplementuse–

both self prescribed and

prescribed by health professionals

• biochemistrythatcouldindicate

nutritional deficiency such

as iron deficiency indicators,

Vitamin B12 and folate levels,

using Clara or laboratory results

filed in patients records.

this was not a random sample

as the women had been referred

to dieticians for reasons such

as weight control or diabetes

or were screened because they were

attending higher risk antenatal clinics

such as multiple Pregnancy, WAds

or young Women’s Clinic.

from 2005 the quality and Safety

unit at the Women’s has received

105 reports of patient safety

incidents associated with the wrong

identification of a woman or baby.1

So far we have been lucky as none

have resulted in a major outcome,

but the potential is there. the true

incidence and probability of wrongly

identifying a patient is unknown but

it is of enough concern for the

Australian Commission on Safety

and quality to highlight it as a national

‘stand-out opportunity to improve

patient safety’2.

At the Women’s, the occurrence

of mislabelled specimens, duplicate

medical records, unlabelled

medicines charts, incorrect In Patient

management (IPm) registration details

coupled with the wrong person’s Id

stickers in a medical record, indicate

the need for a hospital wide focus on

correct positive patient identification.

Case studies

• Awomaninthebirthcentrehad

a post partum haemorrhage.

In preparation for theatre, one

person collected a cross match

blood specimen and wrote

up a request form, whilst another

labelled the specimen with Id

stickers from the wrong medical

record. the wrong blood type

was detected by pathology.

• Awoman’snamewascalled;

she came in to the outpatient

procedure room accompanied by

her husband who explained he will

interpret for her. the procedure

was explained and a cystoscopy

performed. A short while later

another woman came to the desk

complaining she had been waiting

a long time for a cystoscopy.

Staff realised a procedure was

performed on the wrong person.

• Awomanarrivedintheatre.During

the team time-out checking

process the operating room team

were alerted of a potential problem

as her medical record contained

details of births and procedures

that were not hers. With the

assistance of the woman it was

realised that two medical records

were merged, hers and her sister-

in-law who share the same

surname and date of birth, but one

was meghan and the other megan.

“from 2005 the Quality and Safety unit at The Women’s has received 105 reports of patient safety incidents associated with the wrong identification

of a woman or baby”

Vitamin and mineral supplements taken @ the Women’s

Jenny taylor

Right Patient – Right Care

What can you do?1. learn the WHO “five moments for

hand hygiene” and incorporate these

into your daily routine.

2. Review Hand Hygiene Australia’s

recommendations for medical Staff:

http://www.hha.org.au/userfiles/

file/HHAjulymanual 2009(1).pdf

Section 5.3 (page 45)

3. Perform the “Hand Hygiene

competencyquiz”(takes5minutes)

at http://intranet.thewomens.

org.au/ClinicalEducation

Competency Assessment

4. Play the “Wi 5” game: http://

www.rch.org.au/washup/prof.cfm?

doc_id=12968

5. model appropriate practices

for more junior staff and

medical students.

6. Work with senior nursing staff to

assist with enforcing HH compliance.

7. Review the Washup website

at www.washup.org.au

hand hygiene: your example matters

Colleagues, trainees, and other

staff watch what you do:

• Researchhasshownthatthe

actions of clinicians influence

the behavior of others.

• Showyourcolleaguesthat

hand hygiene is an important

part of quality care.

your patients and their families

watch you too:

• Youractionssendapowerful

message.

• Showyourpatientsthatyou

are serious about their health.

from Centers for disease Control

and Prevention (uSA)

Dr andrew Daley departments of microbiology & Infectious diseases and Infection Control

this was a snapshot of what the

women were doing at the time they

were seen. they may have been

at any stage in the pregnancy but

second trimester was the most

common time.

Resultssupplement use was common with

55% of the women taking multivitamin

preparations. Elevit was the most

popular, used by 47% of those taking

a multivitamin supplement, followed

by Blackmores Pregnancy and

Breastfeeding gold at 33%. the

remaining 20% were taking a variety

of at least 9 other brands.

“Supplement use was common with 55% of the women taking multivitamin preparations”

Supplements vary in content of

significant nutrients such as iron,

vitamin d, omega 3 and vitamin B12.

One of the reasons Elevit is popular is

because it contains a substantial iron

dose, however in contrast to other

pregnancy multivitamins, it contains

no iodine (at this stage). Iodine is one

of the nutrients most needed from a

supplement as there is mild deficiency

in most parts of Australia. Even bread

fortification (commencing September

2009) will not meet the iodine needs

of many pregnant women. 33%

of the women surveyed were getting

supplemental iodine either from

multivitaminsoriodizedsalt

77% of the women took folic acid

supplements at some stage during

the pregnancy (alone or in multivitamin

or iron preparations), however only

29% started it before conception.

most of the remaining 48%

commenced after they knew

they were pregnant and thought

this was appropriate.

43% had indicators of iron deficiency

sometime during the pregnancy

to date. At the time of the audit only

46% of iron deficient women were

taking iron supplements in doses

large enough to be likely to correct

deficiency i.e. 60mg or more per day.

69% of the women had test results

available for vitamin d. 48% of this

sample were deficient when first

tested, with 69% of deficient women

on supplements of 1000 Iu or more.

Iron, iodine, calcium and folic acid

were common dietary deficiencies.

Women with biochemistry indicating

iron or Vitamin B12 deficiency were

twice as likely to have inadequate

diets (by dietary recall) and were also

less likely to be taking multivitamins.

In contrast women with adequate

diets were twice as likely to use

multivitamin supplements as those

with inadequate diets.

“pregnant women with

poor diets who could benefit

most from multivitamin

supplements were the least

likely to use them”

In conclusion

• pregnantwomenwithpoordiets

who could benefit most from

multivitamin supplements were

the least likely to use them.

• multivitaminsupplementusers

may still miss out on at risk

nutrients. there is no single

supplement that contains iron

(in significant amounts) as well

as folic acid and iodine.

• mostwomenwereunawarethat

folic acid needs to be started

before pregnancy

• manyiron-orVitaminDdeficient

women were not taking

supplements. Whether this was

due to non-prescription or non

compliance was not assessed.

Jenny taylor department of nutrition and dietetics, the Royal Women’s Hospital jenny.taylor@thewomens.org.au

RWH nov 2007 mar 2008 Aug 2008 nov 2008 mar 2009 Aug 2009

Overall compliance 20% 44% 73% 77% 73% 75%

nurses 19% 48% 73% 80% 78% 79%

Doctors 24% 67% 61% 50% 51% 21%

Comparison of levels of ‘at risk’ nutrients in a sample of multivitamins suitable for pregnancy

number of tablets or capsules per daily dose

Cost per day

nutrient content per daily dose

Folic acid 600µg*

iodine 220 µg* 250 µg (who)

iron 27mg*

Vitamin D 500iu*

B12 2.6µg*

omega 3 115-430 mg

Blackmores Pregnancy and Breasfeeding gold 2 $0.92 500 250 10 500 3 300

Blackmores I-folic 1 $0.13 500 250

Cenovis Pregnancy and Breastfeeding formula 2 $0.53 500 150 10 - 4 340

Elevit 1 $0.69 800 - 60 500 4 -

fabfol Plus 1 $0.44 500 150 12 200 4 -

fefol multipreg 1 $0.58 500 200 12 200 4 252

myadec multivitamins and minerals 1 $0.13 - 150 5 440 6.3 -

natal Plus 2 $0.83 500 270 10 500 500 -

nature’s Own Pregnancy Platinum 1 $0.45 500 250 5 200 100 150

nature’s Way Pregnancy Smart 2 $0.50 500 150 10 - 3 340

Swisse Pregcel 1 $0.63 500 250 5 200 2.6 -

*Recommended dietary intake for healthy women. Recommendations may be different if deficiency is present

steps for positive identification

Positive identification involves asking

the woman in front of you to state her

first name, surname and date of birth.

this information is checked against the

patient identification wristband(s).

In the outpatient areas, and in

situations where there is no wristband,

(e.g. Pauline gandel Women’s Imaging

Centre, pathology or women phoning

for test results), remember to check

this information against documented

patient identification details such

as the medical record, request form

or databases such as ClARA and

IPM.Asimpleprocess;notdissimilar

to the questions a bank asks prior

to providing any information over

the telephone.

steps for right person, right care,

right site and side

In the outpatient and inpatient

setting the verification of the correct

person, procedure and site includes

clerical staff registering and making

a booking in IPm, admitting staff,

clinicians and the person in charge

of the procedure asking the woman

to state her first name, surname,

date of birth and type of procedure

(if relevant, what site and side

is involved).

this information is checked for accuracy

against the consent or procedural

request form and appropriate diagnostic

images (when available). In theatre this

process is called ‘team time Out’ where

a standard formal process is followed

bythewholeteam;theanaesthetist,

surgeon and theatre nurses.

the matching of the correct person,

procedure, site and side occurs

at all stages of outpatient and inpatient

contact. that is, when a procedure

isbooked;atthetimeofadmission;

duringpreparationforaprocedure;

upon admission to a department where

the procedure is to be conducted

(e.g. Pauline gandel Women’s Imaging

Centre, day Chemotherapy, Pregnancy

day Care Centre) and again on entry

to the procedural room and indeed

anytime a woman or baby moves within

the hospital or is transferred to another

hospital location.

Ruth Bergman

Clinical Incident Co-Ordinator

References1. RISKmAn incident database, report

by patient identification classification2. Australian Commission on Safety and quality

inHealthCare2009IdentificationofAdults;Identification of Babies Women’s Hospital Procedure located on the Intranet.

andrew Daley