Materials. Tools, equipment and apparatus for infusion, punctures, suction.
Documentation of lumbar punctures - Neurology DIU Dr Michal Rolinski Dr Hannah Rowe Supervised by Dr...
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Transcript of Documentation of lumbar punctures - Neurology DIU Dr Michal Rolinski Dr Hannah Rowe Supervised by Dr...
Documentation of lumbar punctures - Neurology DIU
Dr Michal RolinskiDr Hannah Rowe
Supervised by Dr M Turner
Learning To Make a Difference
ORH NHS Trust
BackgroundBackground• 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
Project AimsProject 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
Action PlanningAction Planning
Act Plan
Study Do
What are we trying toaccomplish?
•Increase in LP documentation meeting required standard•Increase in samples sent with paired serum glucose to 100%
How will we know that achange 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 makethat will result inimprovement?
•Formal education session
•Information leaflet
Learning To Make a Difference
ORH NHS Trust
Learning To Make a Difference
Lumbar puncture processLumbar puncture process
ORH NHS Trust
• 14 important indicators in LP documentation identified pre data collection (box 1)
Lumbar puncture indicators
IndicationContraindicationsConsent documentedPosition in which the LP was performedUse of aseptic techniqueType of anaesthetic usedDose of anaesthetic used Site of spinal needle insertionSize of spinal needle usedNumber of attempts at needle insertionOpening pressureAny peri-procedure complication?Post-procedure advice givenLP results documented
Fig1
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MethodsMethods
ORH NHS Trust
14 January, 2011
Month 0 Month 1 Month 2 Month 3
QIP timelineQIP timeline
• 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
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Data collectionData collection
ORH NHS Trust
What difference has been made?What difference has been made?
Learning To Make a Difference
ORH NHS Trust
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 documentationLP documentation
ORH NHS Trust
Fig 3
•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
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LP documentationLP documentation
ORH NHS Trust
Indicators Before interventions After both interventions p valueIndication 22% 57% 0.3024Contraindications 33% 86% 0.0601Consent documented 89% 86% 1.0000Position in which the LP was performed
22% 100% 0.0032
Use of aseptic technique 78% 100% 0.4750Type of anaesthetic used 78% 100% 0.4750Dose 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
• Paired serum glucose samples sent increased to 100%
• p=0.0885 fig5
Learning To Make a Difference
Paired serum glucosePaired serum glucose
ORH NHS Trust
Fig 5
• 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
DiscussionDiscussion
ORH NHS Trust
Next StepsNext 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
ReferencesReferences
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