uhbristol clinical audit progress report april 2010 progress... · april 2010 (project activity...

UHBristol Clinical Audit Progress Report

Projects listed in report for first time:

Total number of projects listed in report:

Project Status codes: 1 - Planning

2 - Data collection

3 - Data analysis

4 - Preparing presentation

5 - Discussing action plan

6 - Finalising report

7 - Completed

8 - Abandoned (after started)

9 - Deferred

Other codes: Re - Re-audit

S - incorporates a patient survey

Us - involves some other method of consumer involvement

MD - multidisciplinary rating*

MS - involves more than one specialty

Int - interface project

N - NICE or NSF audit

P - proposal form signed-off before project started

10 - Ongoing monitoring project

11 - Current status unknown

376

April 2010

(Project activity between 01/01/2010 and 31/03/2010)

86

* 1 = Fully multidisciplinary (all appropriate specialties and professions involved) 2 = Partially multidisciplinary (not all appropriate areas/staff involved) 3 = Unidisciplinary - failure to involve relevant staff/areas 4 = Unidisciplinary - no impact on work of other staff/areas

12 - Project transferred to Service Review database

MSMD NPROJECT TITLE AUDIT LEAD

S Int

PROJECT STATUS OTHER CODES

Re Us PApr 09 Sept 09 Jan 10 Apr 10Project ID

DIAGNOSTIC AND THERAPY

AUDIOLOGY (ADULT)Re-audit of Real Ear Measurements2498

4Parminder Munde

4

1Total Number of Audits for Audiology (Adult):

LABORATORY MEDICINE

CLINICAL BIOCHEMISTRYAudit of analytical aspects of coeliac screening against NICE Clinical Guideline 86

24391

Tim Thorpe21

HISTOPATHOLOGYHistopathological Reporting of Borderline Ovarian Tumour

18254

Joya Pawade6495

Date Report Printed: 22/04/2010 of 33UHBristol Clinical Audit Return


S Int




LABORATORY MEDICINE

HISTOPATHOLOGYHistological reporting of lung specimen2194

1Joya Pawade

222

Frozen section audit at the Bristol Royal Infirmary for the period 1st January 2009 to 30th June 2009 (re-audit)

24354

Mo Khan52

INFECTION CONTROLInfection Control Ward/Department audit733

3Michelle Lindsay

10101010

Are all Trust employees complying with the Infection Control Hand Hygiene Policy?

9921

Stephanie Carroll

Carly Hall 10101010

Methicillin-resistant Staphylococcus aureus care pathway

19031

Karen Fletcher7632

Prospective audit of linen handling and management at ward level 2010

25021

Karen Fletcher2

Prospective audit of hand washing facilities and alcohol hand gel locations in clinical areas 2010

25073

Michelle Lindsay2

LABORATORY HAEMATOLOGYAntenatal Haemoglobinopathy request entry1813

4Sharif Goolam-Hossen

Alex Macphie 7654

Correct completion of the blood transfusion prescription chart

25083

Soo Cooke2

MICROBIOLOGYLaboratory diagnosis and management of candidaemia in the University Hospitals Bristol NHS Foundation Trust

22574

Vijay Richard762

Audit of appropriate use of the Gentamicin assay service

23351

Rachel Chaplow74

Audit of Urine Testing Algorithm Use at HPA Regional Microbiology Laboratory, Bristol

23971

Karthiga Sithamparanathan74



S Int




LABORATORY MEDICINE

MICROBIOLOGYAudit of bacteriology reports for community 20092438

4Barbara Kirkpatrick

72

15Total Number of Audits for Laboratory Medicine:

MEDICAL PHYSICS & BIOENGINEERINGTreatment of greater than 70% symptomatic internal carotid artery stenosis

19901

Maria Morgan2222

VASCULAR STUDIESDiagnosis and Treatment of Pseudoaneursym914

1Teresa Robinson

6655

Pre cardiac surgery carotid artery duplex and management of patients with significant carotid disease.

16851

Eleanor Walker7666

3Total Number of Audits for Medical Physics & Bioengineering:

NUTRITION & DIETETICSCook/chill: Meeting national nutritional standards for hospital catering

23521

Toni Williams22

Dietetic Record Card Audit 201025704

Julie Barker2

2Total Number of Audits for Nutrition & Dietetics:

PHARMACYAudit of prescribing and administration of medicines policies

20122

Alastair Gray7555

Medicines Reconciliation Process on Admission in the Medical Division at University Hospitals Bristol NHS Foundation Trust

21111

Miriam Michael5564

Medicines Reconciliation Process on Discharge (Medical Division)

21121

Sophie Blow5664

Intravenous to oral antibiotic therapy switch - re-audit of practise in medical division

22271

Daniela Ferro445



S Int




PHARMACYAn audit of ward pharmacist daily antibiotic reviews

24244

Charlotte Pointing22

An audit of missed doses of critical medication in Medical and Surgical Divisions

24561

Carla Cheetham42

Re-audit of Antibiotic Prescribing Guidelines for Adult Cardiac Surgery

25751

Jacqueline Criper2

An audit of oral anticoagulant prescribing for adult inpatients at UH Bristol

25801

Rhiannon Walker

Sally-Ann Hall 2

8Total Number of Audits for Pharmacy:

PHYSIOTHERAPYRe-Audit of Physiotherapy Case Notes 20082082

4Linda Clarke

5443

A re-audit of physiotherapy standards for the management of an acute Exacerbation of Chronic Obstructive Pulmonary Disease

23024

Lucy Craig111

Re-audit of the discharge process for patients on the elderly rehabilitation wards at Bristol General Hospital

25651

Lin Leong2

3Total Number of Audits for Physiotherapy:

RADIOLOGY

CROSS-SECTIONAL IMAGINGAn Audit into the Cardiac Magnetic Resonance Imaging Perfusion Service

24881

Elisa McAlindon4

Audit of patient radiation dose in Computed Tomography

25561

Ian Negus4

The rate of pulmonary embolism detection and D-dimer usage

25571

Gavin Clague4

Cardiac MRI affecting decision making in haemoglobinopathies

25631

Nathan Manghat7



S Int




RADIOLOGY

GENERAL RADIOLOGYContinuous assessment of the Radiographer Reporting Team against Royal College of Radiologists standards

20631

Simon Brown5332

Abdominal X-ray evaluation in the Trust21241

Fleur Kilburn-Toppin

Huw Roach 7442

Dosage for Barium Enema21411

Adrian Pollentine7542

Appropriate referral for adult abdominal X-rays in the Emergency Department

22471

Rebecca Duerden754

Audit of Paediatric Chest X-rays Image Quality23551

Donna Dimond42

Documentation of anti-spasmodic drugs adminstered during Barium enema procedures

23634

Vijaya Ajjarapu74

Reporting Standards of the Skeletal Survey in cases of suspected Non Accidental Injury

23981

Steven Morgan75

Re-audit of the documentation of antispasmodic drugs administered during barium enema procedures 2010

25534

Alan Cordey4

Audit Neonatal Chest X-rays Image Quality25731

Donna Dimond4

Audit of Pancreatic Biopsy Success Rates25741

Edward Walton4

Re-auditing of the use of gonad protection2582 Katy Phelps6

MAMMOGRAPHYAvon Breast Screening Unit – Connecting to local communities 2009

25351

Suma Chakrabarthi7

ULTRASOUNDRe-audit of Pain diaries after Ultrasound Guided Injection

20674

Charles Wakeley5554



S Int




RADIOLOGY

ULTRASOUNDNormal abdominal ultrasound examinations performed and reports generated by Advanced Practitioner Sonographers

22481

Tina Stoyles332

18Total Number of Audits for Radiology:

Total Number of Audits for Diagnostic and Therapy: 50

MEDICINE

EMERGENCY DEPARTMENT (ADULT)Illicit Drug Users in Accident and Emergency2220

1Sally Lewis

422

Audit of Emergency Department Patients Requiring Large Volume Blood Transfusion

23491

Helen Mansfield73

The Management of Sepsis in the ED23702

Ahmed Sabra72

Audit of the New Alcohol Nurse Service at the Accident and Emergency Department of the BRI

23764

Lucy Harrison22

Audit of Atrial Fibrillation Management in Accident & Emergency

23964

Hyunkee Kim72

Emergency Department Cellulitis Audit24004

Trina Leskiw73

Hypertonic Saline for Severe Head Injury24011

Anna Shekhdar22

Retrospective Audit of Management of Renal Colic

24021

Hannah Brown22

Seniority of Patient Review on the ED Observation Unit

24364

Lucy Prewett71

Management of Falls in the Elderly in BRI ED24694

Meinir Wyn Hughes71



S Int



MEDICINE

EMERGENCY DEPARTMENT (ADULT)"Did Not Wait" in the Emergency Department2503

4Ray Houston

2

ED Audit into Efficiency of Mental Matrix Completion

25064

Kate Metcalfe2

An Audit of the Appropriate Use of Imaging in Assessment of Knee Injuries in ED, BRI.

25334

Alison Hutchings4

Audit of AKi Care in the ED Against the NCEPOD Recommendations

25493

Emma Redfern7

14Total Number of Audits for Emergency Department (Adult):

MEDICAL SPECIALTIESUse of the Bristol Observation Chart - Division of Medicine - Re-audit Cycle 4

23441

Trevor Brookes75

Use of the Bristol Observation Chart - Division of Medicine - re-audit [NICE CG50] 2010

24931

Helen Julian5

CARE OF THE ELDERLYThe National Clinical Audit of Falls & Bone Health in Older People

18891

Rachel Bradley7556

Reversal of Oral Anticoagulation Therapy in Patients Presenting with Intercranial Haemorrhage

22151

Christian Kelly-Morland832

Audit of the Weekend House Officer Written Handovers

24374

Yealin Chung73

Re-audit of Thromboprophylaxis in Adult Medical Patients

24421

Marwan Obeid21

CONTRACEPTIVE & SEXUAL HEALTH SERVICES (CASH)Audit of Record Keeping of Issue of Progestogen-only Emergency Contraception Under Patient Group Direction (PGD) 1

22581

Ann Steele-Nicholson732

Audit of Record Keeping of Progestogen-only Oral Contraceptive Pill Under Patient Group Direction (PGD) 2B

23051

Elaine Smith731



S Int



MEDICINE

MEDICAL SPECIALTIES

CONTRACEPTIVE & SEXUAL HEALTH SERVICES (CASH)MSM Sauna Outreach Audit2569 Ian Lloyd

2

DERMATOLOGYReaudit Dermatology MDM2056

1Mohamed Alrawi

1111611

Audit of the Standards of Service for Patients Treated with Oral/Bath PUVA Phototherapy

22191

Mohamed Alrawi4111

Use of Dermoscopy in Assessing Pigmented lesions

22994

Katharine Nightingale443

An audit of female patients due to be prescribed and treated with isotretinoin for acne vulgaris.

23091

Emma Howard8113

Surgical Attire of Staff and Patients During Skin Surgery in the Bristol Dermatology Centre

23473

Helen Whitley32

Wound Infection Audit Following Skin Surgery in the Bristol Dermatology Centre

23482

Helen Whitley33

Audit of the Prescription of Sub-Cutaneous Biologics (Adalimumab and Etanercept) for the Treatment of Moderate to Severe Psoriasis.

23501

Tracey Wheeler75

Audit of Blood Screening Prior to Self-Administered Biologics Therapy for Psoriasis

24401

Tracey Wheeler71

Retrospective Audit on Basal Cell Carcinoma (BCC) Follow Up

25341

Dr David de Berker1

DIABETES & ENDOCRINOLOGYRegional audit of Diabetic Pregnancies821

1Dr Kurien John

8101010

Department of Health High Impact Intervention 2b, peripheral line care; a re-audit

23231

Dr Suzanne Phillips531

Prevalence and Management of Benign Hypercalcaemia and Primary hyperparathyroidism

24971

Dr Rajeev Raghavan22



S Int



MEDICINE

MEDICAL SPECIALTIES

GASTROENTEROLOGY & HEPATOLOGYVitamin supplementation in patients with alcohol abuse

21011

Richard Parker11633

Audit of documentation of DNAR decisions at the BRI – are we meeting guidelines?

24992

Amelia Holme2

Peginterferon Alfa and Ribavirin for the Treatment of Mild Chronic Hepatitis C

25464

James Lagan2

GENERAL MEDICINEThe Management of the Septic Patient in the First Twenty-Four Hours; Current Practice

24034

Christian Kelly-Morland72

Audit of Completion of Learning Difficulties Risk Assessment

24961

Katie Hopgood22

Audit of Prescribing in Inpatient Medicine25471

Dr Katharine Hill2

GENITOURINARY MEDICINEAudit on Management of Vulvovaginal Candidiasis in Women Attending the Bristol Sexual Health Centre

21324

Kendon Macdonald7561

Pelvic Inflammatory Disease audit24214

Karla Blee31

NEUROLOGYClinical Audit of Idiopathic Intracranial Hypertension (IIH) in UHBristol

25044

Angela Lee7

RESPIRATORYRe-audit of CPAP usage and allocation CPAP in patients issued with long term CPAP

18721

Kathryn Bateman811611

Diagnosis and management of lung cancer20434

Hazel Woodland4432

The management of Spinal Cord Compression – are we meeting the guidelines?

21131

Hannah Smith11662



S Int



MEDICINE

MEDICAL SPECIALTIES

RESPIRATORYDo Cystic Fibrosis Patients have Chest X-rays, Liver Ultrasound and DEXA Scans Annually?

21164

Iara Maria Sequeiros Camarinha7644

Re-audit of the BTS Guidelines for investigation of PE

24161

Samrat Bose32

Audit of Continuous Positive Airway Pressure for the Treatment of Obstructive Sleep Apnoea/Hypopnoea Syndrome

24204

Adrian Kendrick32

An Audit of Drug Allergies of Patients with Cystic Fibrosis (CF)

24951

Katy Cockburn

Victoria Hembrow 72

An Audit of Current NIV Practice within the Trust25101

Katy Buchan2

Audit of initial assessment and management of acute heart failure.

25111

Abbey Leahy2

RHEUMATOLOGYAudit of care of Ankylosing Spondylitis patients at the Bristol Royal Infirmary.

20401

Melissa Domaille11666

Adalimumab, Etanercept and Infliximab for the Treatment of Rheumatoid Arthritis

23461

Dr Alex Keough22

An Audit of the Treatment of Recent Onset Rheumatoid Arthritis in adults.

23511

Robert Marshall

Helen Nightingale 21

42Total Number of Audits for Medical Specialties:

Total Number of Audits for Medicine: 56

NON-DIVISION SPECIFIC

TRUST-WIDESaving Lives – a programme to reduce healthcare associated infections

15101

Carly Hall10101010

Catering Ward Rounds – Managing the patient journey through nutritional care

21691

Toni Williams6442



S Int



NON-DIVISION SPECIFIC

TRUST-WIDEThe Prevention of Hospital Acquired Thrombosis [CQUIN target]

23691

Sue Fyfe-Williams22

Delegation of consent audit23822

Nicola Henderson75

Open communication following incidents and complaints

23901

Nicola Henderson7

5Total Number of Audits for Trust-wide:

Total Number of Audits for Non-division specific: 5

SPECIALISED SERVICES

CARDIAC SERVICES

CARDIOLOGYRe-audit of the use of anti-thrombotic and anti-platelet agents as adjuvant therapy during and after percutaneous coronary intervention

17174

John Edmond8101010

Closure of atrial septal defects in patients with pulmonary hypertension

17334

Stephanie Curtis933

Standardisation of Filter settings on 12 lead ECGs2196 Anthony French553

Are patients having an angiogram or PCI at the BRI adequately consented?

22672

Hazel Woodland556

Re-audit of patient satisfcatioin at the one stop23771

Alana Durack32

To determine whether the Ejection Fraction in impaired LV systolic function is being recorded

23782

Angus Nightingale21

To ensure Patients with endocarditis who are IV drug users receive the same treatment as non-IV drug users

2379 Angus Nightingale22

GUCH pre-operative assessment Clinic2431 Wendy Visser32



S Int




CARDIAC SERVICES

CARDIOLOGYCatheter Ablation pre-assessment patient questionnaire

243221

9Total Number of Audits for Cardiac Services:

HOMEOPATHYThe use of a patient generated outcome measure to monitor outcome and completion of package of care and facilitate goal setting in routine practice

9254

Elizabeth Thompson3333

Homeopathy in Management of Childhood Eczema

16254

Dr Willa Muir3322

Audit of Iscador Use Adherence to Guidelines20164

Elizabeth Thompson8533

3Total Number of Audits for Homeopathy:

ONCOLOGY & CLINICAL HAEMATOLOGYCompleteness of chemotherapy summary charts1749

1Louise Medley

6666

Communionication and support received by breast cancer patients - NICE Improving outcomes Guidance

18801

Alison Cameron6643

Blood Transfusions BHOC - Information Collected19811

Paula Wilson6664

Capecitabine, Oxaliplatin, 5FU in adjuvant treatment of stage III (Dukes C) colon cancer - NICE TAG 100

21091

Jessica MasonJessica Mason 6552

NCEPOD - Chemotherapy patient care21661

Clare Barlow

Susanna Alexander 6661

Antibiotic policy - stop/review dates on ward 6122231

Paula Wilson522

DXA Scans - Bone Health - Breast Cancer patients on aromatase inhibitors

22371

Susanna Alexander

Anna Sanders 652

Are patients with relapsed or refactory follicular lymphoma being prescribed rituximab in accordance with NICE guidelines TAG 137

22591

Sucheta Mane

Anna Morris 754



S Int




ONCOLOGY & CLINICAL HAEMATOLOGYCompliance with skin radiotherapy protocol in BHOC

22601

Alison Cameron762

Re-audit of cardiac function assessment for patients on adjuvant trastuzumab (Herceptin) – NICE TAG 107 - (original proj 1665)

22641

Anna Sanders751

NHSLA 2010-1125791

Nathalie Delaney3

CLINICAL HAEMATOLOGYSickle Cell (Acute) Management2171

3Sajid Pervaiz

7632

Vinca Alkaloids Intrathecal Chemotherapy - Re-audit of compliance with new DOH guidance on and NPSA Rapid Response Report

2531 Kathryn Newton1

Re-audit of Neulasta prescribing25781

Claire Chisholme2

ONCOLOGYErlotinib in the treatment of non-small cell lung cancer - NICE TAG 162

23571

Paul Flinders22

Irinotecan, Oxaliplatin and Raltitrexed for the treatment of advanced Colorectal Cancer (NICE TAG33)

23581

Jo Botton22

16Total Number of Audits for Oncology & Clinical Haematology:

PALLIATIVE MEDICINEManagement of diabetes mellitus in the last 48 hours of life.

25301

Sophy Gretton

Christina Baggott 2

1Total Number of Audits for Palliative Medicine:

Total Number of Audits for Specialised Services: 29

SURGERY AND HEAD AND NECK

ADULT EAR, NOSE AND THROAT (ENT)Nutritional assessment of patients with head and neck cancer and adherence to NICE guidelines

1744 Rebekah Stone1111



S Int




ADULT EAR, NOSE AND THROAT (ENT)Thromboprophylaxis in adult ENT inpatients2571

2M.Manickavasagom

4

NHS Litigation Authority (NHSLA) Documentation Audit - 2010

25722

C Langton-Hewer2

ENT (ADULT)NHS Litigation Authority (NHSLA) Documentation Audit - 2009

21821

C Pugh7642

Outpatient management of patients with rhinosinusitis and polyps prior to endoscopic sinus surgery

23261

Lizzie Ingall752

5Total Number of Audits for Adult Ear, Nose and Throat (ENT):

ANAESTHESIADelays to theatre of patients with fractured neck of femur

17062

Jill Homewood966

Ongoing Monitoring of Patients Undergoing General Anaestheia for Caesarean Section

1792 Nick Wharton10101010

The use of monitoring devices to assess the neuromuscular function of patients

18371

Claire Heywood6666

An audit into the mean arterial pressure (MAP) ranges on ward patients post-bowel resection

19681

Rebecca Aspinall6654

Daycase Haemorrhoidectomies and Varicose Viens - An Audit

215616555

Prevelance and Management of Peri-operative Iron deficieny Anaemia

21881

James Sidney532

A re-audit of Same Day Cancellations2222 Laura O'Sullivan563

An audit to assess the timing of discharge of patients following day surgery and measuring patient satisfaction

22411

Gregory Brown561

An audit of refused admissions and delayed discharge in Heygroves Recovery

22711

Tamsin Glasgow652



S Int




ANAESTHESIAAudit of Aortic Stenosis and Fractured Neck of Femur

2527 Ari Sampath2

Audit of Neuro-Axial Blockade Documentation25294

Ari Sampath2

ACUTE PAIN SERVICEAudit of anaesthetic technique and postoperative analgesia in patients undergoing lower limb amputation

22093

Nilesh Chauhan662

Audit of use of the Pain Observation form for pain assessment at UHBristol

22734

Steve Lindley652

OBS & GYNAE ANAESTHESIAAudit of accidental dural puncture (ADP)1704

4Mark Scrutton

10101010

Timely anaesthetic review of patients with cardiac problems presenting to the delivery suite

17431

Robert Jackson99911

An audit of seniority of anaesthetist managing morbidly obese (BMI>40) obstetric anaesthetics

19664

Mark Scrutton6663

NPSA safety alert 21 – Safe administration of epidural medicines.

19671

Mark Scrutton7642

CNST Standard 1: 5. Organisation of staffing levels: Anaesthetists

22124

Mark Scrutton764

Re-audit of management of Placenta Praevia and Caesarean Section

22161

Nick Wharton432

Re-audit of post Caeserean Section analgesia22171

Nick Wharton432

Audit of Blood Pressure control at elective Caesarean Section

24231

Neil Muchatata32

PRE-OPERATIVE ASSESSMENTThe use of coagulation testing in pre-operative assessment (NICE CG3)

21381

Marcos Kostalas111122



S Int




ANAESTHESIA

PRE-OPERATIVE ASSESSMENTLifestyle advice in preoperative assessment2148

1Mathew Thomas

Clare Evans 5542

A comparative retrospective audit of F1 and nursing staff performance in assessing elective surgical patients in POAC

23071

Clare Evans431

Audit of Patient Body Mass Index (BMI), ASA Grade and Smoking Status in Pre-op Assessment Clinic

23181

Claire Dowse552

25Total Number of Audits for Anaesthesia:

DENTAL & MAXILLOFACIAL SURGERYReferral to treatment time for North Bristol Trust patients treated under General Anaesthetic at Bristol Dental Hospital

23331

Donn O Morain55

Salivary gland imaging audit23714

Jennifer Haworth32

Adequacy of the radiograph request forms sent to the dental radiology department

25371

Rebecca Davies2

NHS Litigation Authority (NHSLA) Documentation Audit - 2010 - Dental

25773

Jon Penny2

ORAL & MAXILLOFACIAL SURGERYNeck Lump Clinic and FNA results in the Oral and Maxillo Facial Surgery Department

19551

Esther Perera

Teresa Levy 6633

Condition of surgical margins in resections for cancer of the oral cavity and oropharynx

22011

Ceri Hughes

Chris Bell 663

Head and Neck Cancer GP and patient communication - re-audit (1473) [NICE guideline CSGHN, 2004]

23101

Hannah Pepper753

Access to primary dental care in patients admitted to hospital with dental infection [including NICE CG019]

25221

John Collin2

Dental Care and Management of Oral Cancer Patients Undergoing Radiotherapy in Bristol

25421

Chris Bell2



S Int




DENTAL & MAXILLOFACIAL SURGERY

ORAL & MAXILLOFACIAL SURGERYApicectomy referrals [re-audit of 1355]2543

4Chris Bell

2

Management of Oral Surgery Patients on Anti-Platelet / Anti-Coagulation Therapies

25444

Tim Collins2

ORAL MEDICINEMedical and neurosurgical intervention in managing trigeminal neuralgia

20711

Sarah Ellison

Amina Abdel-Karim

Holly Cole-Hawkins

6652

Standard of referral letters to Oral Medicine department at BDH

25384

Rachel Fletcher2

ORTHODONTICSOrthodontic treatment and General Dental Practitioner (GDP) attendance [includes standard from NICE CG19]

21734

Neil McCusker7411

A re-audit of orthodontic instrument trays from the decontamination unit: Are they of a satisfactory standard?

22621

Hem Shah642

Lost orthodontic appliances23644

Hem Shah33

Broken brace clinic23991

Hem Shah33

Incidence of infected titanium plates following orthognathic surgery: re-audit.

24081

Hemendranath Shah22

Study Model Quality at the Bristol Dental Hospital24941

Elizabeth Paice2

Referral and management of patients diagnosed with obstructive sleep apnoea [re-audit of 1423]

25401

Hemendranath Shah

Chris Barker 2

PAEDIATRIC DENTISTRYLongevity of Fissure Sealants1750

4Ruth Fairhurst

6333



S Int




DENTAL & MAXILLOFACIAL SURGERY

PAEDIATRIC DENTISTRYAre radiographs being taken when children are assessed for routine extractions under general anaesthesia? - re-audit

20504

Rachel Fletcher7664

Users’ views of the paediatric dental clinic22631

Lucy Stead732

Continuing oral healthcare in children at risk of developing infective endocarditis [NICE CG64]

23361

Rebecca John32

Consent for inhalation sedation for children [re-audit of 1333]

25414

Deborah Franklin2

Extraction of first permanent molars (FPM) of poor prognosis in children.

25451

Sakirat Toyin Balogun2

PRIMARY CARE DENTAL SERVICES (PCDS)Medical History taking within the BANES zone of UH Bristol Primary Care Dental Service

25541

Elizabeth Scott2

Adherence to Conscious Sedation Guidelines within UHB PCDS clinics

25551

Petrina Wood2

RESTORATIVE DENTISTRYQuality of laboratory prescription forms, special trays and wax rims made at the Bristol Dental Hospital

22391

Casey Carnall

Rob Jagger 663

Quality of prescriptions given to crown and bridge laboratory

23651

Aliza Jesani63

Success and failure of Dental Implants in BDH23664

Claire Forbes-Haley43

Dental undergraduate treatment plans25394

Jennifer Morecroft2

32Total Number of Audits for Dental & Maxillofacial Surgery:

INTEGRATED CRITICAL CARE SERVICESAudit of the use of the “Do not attempt resuscitation” (DNAR) form in the Bristol Royal Infirmary.

22063

Fiona Duncan763



S Int




INTEGRATED CRITICAL CARE SERVICES

ITU/HDUTherapeutic Hypothermia for Cardiac Arrest on ITU

19911

Matt Thomas6642

An audit of sepsis management in intensive care patients - Surviving Sepsis Campaign

21463

Alisje Kuur6643

Are Critical Care Nurses filling in a bereavement checklist following the death of a patient?

21891

Louise Jenkins432

Audit of the compliance with the Liverpool Care Pathway (LCP) in Palliative Care on General ITU

23274

Steve Cantellow432

Audit of Renal Investigation performed on ITU patients with Acute Kidney Injury (AKI)

23323

Rachel Bennett432

Audit of ITU acquired Hypernatraemia and subsequent treatment within Intensive Care

23591

Jonathan Lightfoot432

Audit on the management of hyperglycaemia in ITU patients

23731

Vaseilios Chortis32

Delirium Monitoring in ITU and HDU Patients at the BRI

2492 Charlotte Kenyon21

OUTREACH CRITICAL CAREEmergency Anaesthesia outside the Operating Theatre

23421

Matt Thomas332

"Score to Door" time. An audit of ward admissions to HDU/ITU

24041

Elizabeth Pellowe32

11Total Number of Audits for Integrated Critical Care Services:

OPHTHALMOLOGYNHS Litigation Authority (NHSLA) Documentation Audit - 2010 - Eye

25761

Jon Penny2

A&E AND PRIMARY CAREBristol Eye Hospital A&E 4 hour breaches - re-audit

23451

Elisabeth MacDonald54



S Int




OPHTHALMOLOGY

A&E AND PRIMARY CAREEye A&E Follow Up Patients - re-audit2353

1Elisabeth MacDonald

54

CORNEA & CATARACTSOutcomes of cataract surgery in diabetic patients2213

4Matthew Wakefield

221

Ocular biometry23621

Nat Knox Cartwright73

Conversion rate of patients being referred through the new combined clinic for cataract surgery

24131

Kevin Holmes42

2nd eye cataract surgery following evaluation of quality of vision with quality of life questionnaire

24632

Panagiotis Georgoudis3

GLAUCOMA & SHARED CAREBristol Eye Hospital Argon Laser Trabeculoplasty (ALT) using the Pascal laser machine

24814

Bashar Mohammed3

MEDICAL & SURGICAL RETINALucentis Outcomes 2009 [re-audit of project 2002] [NICE TAG 155]

24414

Brad Johnson21

Is our management of diabetic retinopathy in line with national and local guidelines?

25511

Sajjad Haider3

ORTHOPTICS & OPTOMETRYReferrals to Orthoptic service at school nurse vision screening

23811

Ann Starbuck

Penny Warnes 53

PAEDIATRICS, OCULOPLASTICS & SQUINTChildren's ophthalmology clinics at North Bristol NHS Trust: waiting times and quality of service

21491

Cathy Williams6662

Is simple punctal stenosis appropriately assessed and treatment effective? Re-audit

22044

Adam Ross442

Vision follow-up and results of treatment for children treated for Retinopathy of Prematurity

22541

Cathy Williams

Kate Perryman 764



S Int




OPHTHALMOLOGY

PAEDIATRICS, OCULOPLASTICS & SQUINTExternal Dacryocystorhinostomy (DCR)2312

4Julia Hale

432

Adult Squint Surgery Outcomes 2007/200823131

Julia Hale292

Nurse-led management of patients with lid lumps23341

Mohan Mundasad

Hannaa Bobat 76

17Total Number of Audits for Ophthalmology:

ORTHOPAEDICS (T&O)Hand surgery at Bristol Royal Infirmary2139

3Peter Robinson

111154

Antimicrobial prophylaxis in patients at high risk of MRSA colonisation with insertion of metalwork

21401

Peter Robinson111154

The role of patient information leaflets in consent for Trauma/Orthopaedic Surgery: Do they help patients better understand the risks?

22054

Hannah Smith332

Comparison of the treatment of Weber B ankle fractures with medial ligament instability against current recommendations

22074

James Ansell11112

Audit on the use IV fluids for resuscitating the peri-operative surgical patient

22103

James Ansell3112

Adult Peri-operative Normothermia (NICE CG 65)22401

Rebecca Griggs653

The orthopaedic referrals process - documentation of key decisions

22833

Hannah Smith632

Compliance with NHS South West targets on time to surgery for Acute trauma admissions

24151

Nnamdi Obi31

Management of Severe Open Lower Limb fractures

24261

Nnamdi Obi32

Audit of Ankle Fracture management at the BRI24891

Andrew Barnett31



S Int




ORTHOPAEDICS (T&O)

10Total Number of Audits for Orthopaedics (T&O):

SURGERYAn audit of Pre-operative assessment for Elective Surgical Patients out of hours at the BRI

22081

Sheona Burns652

Use of the Bristol Observation Chart - Division of Surgery - re-audit

223410113

Improving the quality of information for patients on admission to STAU

2292 Rachael Walters1131

A Re-audit of Gentamicin Prescribing and Monitoring within UHBristol

23541

Joseph Manjaly43

Audit into Blood culture taking procedures in the trust

23603

Rebecca Martin65

An audit of Post-operative Fluid Management25251

James Lopez Bernal2

BREAST SURGERYRe-audit of Cancer Standards2253

2Angela Nicholson

331

LOWER GI (GASTROINTESTINAL) SURGERYAn audit of nutrition replacement for patients undergoing colorectal surgery

18561

Rob Longman661111

An audit of fluid replacement for patients undergoing colorectal surgery

18571

Rob Longman661111

Venous Thromboembolism Prophylaxis in Acute Surgical Admissions in the Bristol Royal Infirmary

21901

Peter Steed662

Reduction of Surgical Site Infections in Colorectal Surgery

21911

Peter Vaughn-Shaw662

Nutritional support for pre-operative colorectal patients – A Clinical Audit

22561

Richard James72



S Int




SURGERY

UPPER GI (GASTROINTESTINAL) SURGERYAn audit to evaluate the role of the multi-disciplinary cancer team in recruting patients into a National Randomised Trial, OEO5

18551

Angus McNair

Jane Blazeby 1111611

An audit of informed consent for elective Oesophagectomy

19784

Jane Blazeby991111

An audit of the provision of information to patients with Oesophago-Gastric Cancer

22724

Angus McNair444

An audit of the management of relapsed gastric cancer and reasons for poor recruitment to the COUGAR-02 trial

23141

Jane Blazeby332

Audit of Laparoscopic Surgery in Oesophago-Gastric Malignancy

23291

Paul Barham1010

The Role of Multi Disciplinary Teams in Decision Making for Patients with Recurrent Disease

24071

Thomas Fox32

UROLOGYNICE CG58 - Trans-Rectal UltraSound (TRUS) Prostate Biopsy guidance adherance

2405 Alexandra Boyce32

VASCULAR SURGERYAudit of Radiofrequency Ablation of Varicose veins VNUS CLOSURE Fast

19701

Nicola Laurence22211

Management and Complications of Carotid Endarterectomy (Re-audit Project 1973)

22001

Neil Upadhyay552

Audit of Follow-up of EVAR at the BRI (will include NICE TA167)

25264

Vera Lees2

22Total Number of Audits for Surgery:

Total Number of Audits for Surgery and Head and Neck: 122



S Int



WOMEN'S AND CHILDREN'S

CHILDRENS SERVICESAn audit of consent for genetic testing in paediatric patients

25014

Karen Low2

CAMHS (CHILD ADOLESCENT MENTAL HEALTH)Audit of standards of record keeping in Child and Adolescent Mental Health Services (CAMHS)

19471

Rdodri David8665

GENERAL PEADIATRICSNICE Guidance on atopic ecezma - CG2185

1Lindsay Shaw

55

Audit of empirical antibiotic prescribing in the Bristol Children's Hospital

23391

Helen Lee76

Prescription of IV fluids : A reaudit2367 Kate Binns43

Peripheral venous cannula insertion and compliance with cannula care plans and VIP scores in paediatric inpatients in the Children's Hospital

24111

Hannah Barry66

Re-audit of Prescribing Practice on General Paediatric wards at Bristol Royal Hospital for Children

25121

Jenny Haylor3

An audit of the quality of discharge summaries for general paediatric patients at BRHC

25593

Sarah Johns3

Compliance with Trust Guidelines for MRSA screening of patients transferred from other hospitals

25601

Georgia Woodfield3

NEONATOLOGYAudit to assess the accuracy of the neonatal naso-gastric tube length chart

16991

Jennifer Kemp2222

Complliance with CESDI 27/28 recommendations (re-audit)

20792

Archana Mishra7542

Frequency and quality of head scans in neonate21832

A Tarabishi5332

Clinic follow up of pre-term babies less than 30 weeks

23012

S Gupta

Manal El-Bokle 222



S Int




CHILDRENS SERVICES

NEONATOLOGYAudit of immunisation of long stay babies on NICU2304

2Caroline Platt

752

NCEPOD Parenteral Nutrition Study - This is not primarily an audit

2417 Pam Cairns22

Hypothermia in the newborn (CNST 3.5.4)24531

David Harding72

Seizure management in term inborn infants25501

K Luyt2

Use of Folic acid therapy in Direct Coombs Test positive infants

25524

Ela Chakkarapani2

PAEDIATRIC ANAESTHESIAPain and postoperative nausea and vomiting (PONV) in children undergoing squint surgery

22951

James A Sydney431

Pre op fasting in elective and emergency patients2297 Mala Greamspet542

When are children better after Tonsillectomy23151

Sarah Parry431

Non elective procedures in theatre at BRHC ; Are we meeting clinical needs in this group of patients?

24251

Philip Segar22

Audit to assess the effectiveness of the guideline for pre op sickle cell screening of children at the Bristol Dental Hospital

24661

Muthu Thadsad3

Maintenance of normothermia in the perioperative period at Bristol Royal Hospital for Children (BRHC)

25001

Matthew Drake3

Use of Regional Anaesthesia in children25581

Juan Graterol2

PAEDIATRIC CARDIAC SERVICESPost-Operative Morbidity Following Cardiac Catheterisation

794

Dr R Martin10101010



S Int




CHILDRENS SERVICES

PAEDIATRIC CARDIAC SERVICESPost-Operative Morbidity Following Cardiac Surgery

804

Dr G Stuart10101010

Radiofrequency Ablation in Paediatric Arrhythmias814

Dr G Stuart10101010

Review of Peri-operative Infections834

Dr R Martin10101010

Audit of current practice regarding the use of prophylaxis against infective endocarditis NICE CG64 April 2008

20294

Sid Kaithakkoden7554

Audit of Home Anticoagulation with Warfarin in the Paediatric Cardiology Patient Group

20871

Jonathan Forsey9966

Fetal echocardiography during the second trimester for the detection of major congenital heart disease in the Southwest Region

2294 Kalyan Gurusamy542

Risk factors for sudden unexpected death in children following arterial shunt operation (Blalock Taussig Shunts )

24681

Nana Akyaa Yao3

PAEDIATRIC DIETETICSHealthy Start Vitamin Uptake1957

4Sarah Bergun

6665

PAEDIATRIC EAR, NOSE AND THROAT (ENT)Audit of discharge criteria for Tonsillectomies2410

1Lucy James

53

PAEDIATRIC EMERGENCY DEPARTMENTManagement of febrile pre - school children presenting to the Emergency Department (ED)

21521

Simon Binks6543

Management of children under two years with head injuries in whom non accidental injury is suspected

21531

Russell Jones6632

Implementation of (NICE) Guidelines CG47 (May 2007) of Fever in Children under Five years. An audit across Primary and Secondary Care

23681

Samuel Davies43



S Int




CHILDRENS SERVICES

PAEDIATRIC EMERGENCY DEPARTMENTAudit of paediatric asthma management2467

1Eoin Harty

2

PAEDIATRIC ENDOCRINOLOGYNational Diabetes Audit (NCASP)1451

4Christine Burren

10101010

Correlation of clinical procedures to clinical coding applied to Endocrine admissions to the Clinical Investigations unit

1928 Melanie Guilder6633

Audit on the screening of Endocrinopathies and Cognitive Dysfunction in childhood brain tumour survivors

19422

Christine Wei6655

PAEDIATRIC GASTROENTEROLOGYManagement of Paediatric Inflammatory Bowel Diseases in the South West Region

20081

Saras Hosgurga6533

Management of central line (CVL) related infections in children on parenteral nutrition (PN) at Bristol Royal Hospital for Children (BRHC)

25611

Beth Hazeldine

Susan Green 2

PAEDIATRIC INTENSIVE CARE (PICU)Regional Audit of Critical Care Outcomes (Audit of Critically Ill Children)

724

Carol Maskrey10101010

Chest Drain Removal in Post-op Cardiac Paediatric Patients

15271

Sandra Cutts6666

Bronchiolitis in need of CPAP: outcome project (BINCO)

15471

Helen Brewer8822

Audit of medical discharge list sticky labels16871

Sandra Cutts81155

Suction Audit19259992

Audit of Management of Traumatic Brain Injury in PICU

21681

Darwin Pauldhas9433



S Int




CHILDRENS SERVICES

PAEDIATRIC INTENSIVE CARE (PICU)Audit of PICU acute lung injury guidelines in relation to use of nitric oxide and surfactants

2356 Jaya Parasuraman32

Identification and presumptive treatment of H1N1 in severely ill children

24614

Anna Seale4

PICU Discharge delay audit 20102548 Tracey Phillips2

PAEDIATRIC NEPHROLOGYAdvice given to children with isolated scars on DMSA scan

17883

Dr Jonathan Graham6666

Audit of prescription and administration of blood products in paediatric nephrology patients

20061

Anna Kilonback6664

Audit of prescribing drugs on discharge from renal ward

21811

Karim Shebani5532

An audit of the care of patients undergoing renal transplantation at the Bristol Royal Children’s Hospital

22871

Hugh McCarthy543

Compliance with current guidelines of MRSA swabs on the paediatric nephrology ward

24191

Joanne Humphries52

PAEDIATRIC NEUROLOGYInvestigations, treatment and outcome of childhood stroke

23034

Jimmy Kai fai Sun542

PAEDIATRIC ONCOLOGYAudit of pentamidine administration: a retrospective and prospective study of both adult and paediatric patients post stem cell transplant”

22861

Caroline Roberts432

Audit of Vancomycin prescribing22881

Rebecca Palmer543

Aseptic non touch technique audit 2009-1024651

Wendy Saegenschnitter3



S Int




CHILDRENS SERVICES

PAEDIATRIC RADIOLOGYAudit of diagnosis of intestinal malrotation2228 Nicola Matcham

543

PAEDIATRIC RESPIRATOLOGYSerum levels of vitamin D in children with cystic fibrosis (CF)

17851

Dr Hannah Midwinter8664

Asthma in schools17941

Neil Archer864

The use of Ciclosporin in children and young people with difficult to treat asthma

19411

Louise Chapple7643

An audit of Palivizumab use in paediatrics21001

Kamran.Mahmood6643

Anaphylaxis : An audit of management in the Children's Emergency Department

2244 Jon Courts542

Parental satisfaction in a nurse led paediatric clinic

24341

Deb Marriage22

Prednisolone prescription in viral induced wheeze24624

Laura Hinchcliffe3

PAEDIATRIC SURGERYAudit of diagnostic imaging for antenatally diagnosed congenital lung lesions

2232 Khamran Mahmood332

Outcomes following laparscopic orchidopexy23744

Kathryn Evans32

Audit on training and development opportunities for paediatric surgical trainees

24224

Joanne Bareham62

Oral care in paediatric bone marrow transplant patients

24641

Tim Hall3

Audit of paediatric lymphoma waiting times. National Targets

25054

Tim Rogers5



S Int




CHILDRENS SERVICES

PAEDIATRIC TRAUMA & ORTHOPAEDICS (T&O)Audit of management of patients' undergoing external fixation from pre - admission to three months post discharge

18271

Sharron Carrie

Sarah Parry 6666

76Total Number of Audits for Childrens Services:

WOMEN'S SERVICES

GYNAECOLOGYThe collection of regional gynaecological cancer for the purposes of audit and improvement of management

2311

J Murdoch10101010

South West Cancer Intelligence Services Uterine Cancer Quality Assurance Audit

21802

Diana Bailey6642

Early Pregnancy Clinic23162

Zoey Robinson662

Obtaining consent for laparoscopic procedures24574

Shahad Hussein62

Appropriate use of anaethetic for hysteroscopy25232

Claire Chisholm4

Re-audit of assessment and prophylaxis for venous thromboembolism in gynaecology (NICE CG 46)

25661

D Hoy4

Compliance with MDT decision for Gynae Oncology patients

25671

K Edey2

NHS Litigation Authority (NHSLA) Documentation Audit – Gynaecology 2010

25811

J Moxham2

OBSTETRICS AND MIDWIFERYAudit of blood usage on Central Delivery Suite633

1Annie Tizzard

10101010

A series of audits of UNICEF UK Baby Friendly Initiative best practice standards

16384

Joan Beales10101010

Audit into the management of women at high risk of preterm labour throught the preterm labour clinic

18392

Kate Collins9



S Int




WOMEN'S SERVICES

OBSTETRICS AND MIDWIFERYRe-audit of fetal monitoring in labour (CNST 3.2.2 and 3.2.3)

18762

Belinda Cox7221

Diabetes in pregnancy (NICE CG63, CNST 3.3.9)22752

Sonia Barnfield764

Re-audit of the management of Shoulder Dystocia at St Michaels Hospital

22761

Joanna Clark10104

Midwife - Anaesthetic Practitioner Handover22791

Nicky Ellis766

Audit of antenatal screening tests (CNST 3.4.5)22801

Wendy Ring762

Re-audit of the guidelines for pre eclampsia and severe hypertension (CNST 3.3.1)

22821

Janet Pollard722

Use of syntocinon in induction and augmentation of labour (CNST 3.2.5, NICE CG 55, 70)

23221

C Hillman-Cooper723

Booking appointments (CNST 3.4.1)23834

SJ Sheldon72

Missed Appointments (CNST 3.4.2)23844

SJ Sheldon72

Audit of Clinical Risk Assessment (antenatal and in labour - CNST Standards 3.4.3, 3.4.6)

23851

George Attilakos76

Monitoring the Fetus in Labour - Fetal Blood Sampling (FBS)

23861

Sophie Wood72

Re-audit of use of fibronectin test23871

Eloise Weeks64

Management of pregnant women with high BMI (CNST 3.3.10, NICE CG 55)

23881

J Pollard76

Caesarean section monitoring23911

Emma Treloar1010



S Int




WOMEN'S SERVICES

OBSTETRICS AND MIDWIFERYMonitoring documentation for management of perineal trauma (CNST 3.3.5)

23931

Janet Pollard76

Maternity High Dependency Care (CNST 3.2.9)24062

J Pollard76

Maternity Records (CNST 3.1.7)24281

Janet Pollard76

Care of women in Labour (CNST 3.2.1, NICE CG55)

24431

Belinda Cox72

Audit of Recovery (CNST Standard 3.2.7)24481

Clare Hipkin76

Obstetric haemorrhage (CNST 3.3.7)24491

Ann Tizzard1010

Operative Vaginal Delivery (CNST 3.3.3)24504

Bryony Strachan1010

Maternal transfer25141

G Attilakos7

Re-audit of the implementation of Modfied Obstetric Early Warning Score (MEOWS) charts at St Michaels Hospital Delivery Suite (CNST 3.2.8)

25241

E Treloar7

Emergency department admissions for pregnant women (CNST 3.4.10)

25281

G Attilakos7

Maternal transfer (CNST 3.4.8)25321

Lisa Damsell7

Re-audit of management of epilepsy in pregnancy (NICE)

25621

Lidia Kwasnicka2

Provision and discussion of information during ante-natal, inta-partum and postnatal periods (CNST 3.4.4)

25641

SJ Sheldon7

38Total Number of Audits for Women's Services:



S Int




Total Number of Audits for Women's and Children's: 114


uhbristol clinical audit progress report april 2010 progress... · april 2010 (project activity...

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