uhbristol clinical audit progress report november 2009 progress report... · 2016. 4. 4. · 2221...

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

358

November 2009

(Project activity between 01/09/09 and 31/10/09)

62

* 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 PJan 09 Apr 09 Sept 09 Nov 09Project ID

DIAGNOSTIC AND THERAPY

LABORATORY MEDICINE

HISTOPATHOLOGYhistological reporting of ovarian cancer against Royal College minimum dataset

17771

Joya Pawade

Nahida Banu 7533

Histopathological Reporting of Borderline Ovarian Tumour

18254

Joya Pawade4955

Histological reporting of lung specimen21941

Joya Pawade22

INFECTION CONTROLInfection Control Ward/Department audit733

3Michelle Lindsay

10101010

Date Report Printed: 04/11/2009 of 31UHBristol Clinical Audit Return


S Int




LABORATORY MEDICINE

INFECTION CONTROLAre 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 Fletcher6322

LABORATORY HAEMATOLOGYAntenatal Haemoglobinopathy request entry1813

4Sharif Goolam-Hossen

Alex Macphie 5544

National comparative audit of blood collection process

22551

Soo Cooke33

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

22574

Vijay Richard22

Audit of appropriate use of the Gentamicin assay service

23351

Rachel Chaplow2

10Total 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

6554

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

16851

Eleanor Walker6665

3Total Number of Audits for Medical Physics & Bioengineering:

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

23521

Toni Williams2

1Total Number of Audits for Nutrition & Dietetics:



S Int




PHARMACYAudit of Antibiotic Prescribing Guidelines for Adult Cardiac Surgery

19201

Jacqueline Criper

Ruth Coxhead 7433

Audit of prescribing and administration of medicines policies

20122

Alastair Gray5555

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

21111

Miriam Michael5641

Medicines Reconciliation Process on Discharge (Medical Division)

21121

Sophie Blow6642

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

22271

Daniela Ferro55

5Total Number of Audits for Pharmacy:

PHYSIOTHERAPYRe-Audit of Physiotherapy Case Notes 20082082

4Linda Clark

4433

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

23024

Lucy Craig11

A re-audit of the physiotherapy management of the general medical patient

23084

Charlotte Hurry62

3Total Number of Audits for Physiotherapy:

RADIOLOGY

CROSS-SECTIONAL IMAGINGAudit of cardiac computerized tomogram2123

1Adrain Pollentine

7533

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

20631

Simon Brown3322

Information on plain X-ray request forms from the Emergency Department at the Bristol Royal Infirmary

20651

Charles Wakeley7655



S Int




RADIOLOGY

GENERAL RADIOLOGYAbdominal X-ray evaluation in the Trust2124

1Fleur Kilburn-Toppin

Huw Roach 4422

Dosage for Barium Enema21411

Adrian Pollentine4422

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

22471

Rebecca Duerden44

Audit of Paediatric Chest X-rays Image Quality23551

Donna Dimond2

Documentation of anti-spasmodic drugs adminstered during Barium enema procedures

23634

Vijaya Ajjarapu4

ULTRASOUNDRe-audit of Pain diaries after Ultrasound Guided Injection

20674

Charles Wakeley5544

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

22481

Tina Stoyles22

10Total Number of Audits for Radiology:

Total Number of Audits for Diagnostic and Therapy: 32

MEDICINE

EMERGENCY DEPARTMENT (ADULT)Re-audit of ED Blood Transfusion Requests2130

4Maeve Hegarty

7666

Illicit Drug Users in Accident and Emergency22201

Sally Lewis12

National Audit of Moderate and Severe Asthma23304

Helen Mansfield21

Fractured Neck of Femur - National Audit23312

Rebecca Thorpe21



S Int



MEDICINE

EMERGENCY DEPARTMENT (ADULT)Audit of Emergency Department Patients Requiring Large Volume Blood Transfusion

23491

Helen Mansfield2

The management of Sepsis in the ED23702

Ahmed Sabra2

Audit of the new Alcohol nurse service at the Accident and Emergency department of the BRI

23764

Lucy Harrison1

Audit of atrial fibrillation management in Accident & Emergency

23964

Hyunkee Kim1

8Total Number of Audits for Emergency Department (Adult):

MEDICAL SPECIALTIESUse of the Bristol Observation Chart - Division of Medicine - re-audit [NICE CG50]

2344 Trevor Brookes5

CARE OF THE ELDERLYAssessment and management of patients with acute stroke

18704

Sarah Gillett81166

The National Clinical Audit of Falls & Bone Health in Older People

18891

Rachel Bradley5566

National Sentinel Audit of Stroke (Round 6)18994

Sarah Caine5566

Reversal of Oral Anticoagulation Therapy in Patients Presenting with Intercranial Haemorrhage

22151

Christian Kelly-Morland22

Management of patients with Parkinson's Disease22933

Gerald Tobin54

National Audit of Dementia – care in general hospitals

23941

Jane Buswell1

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-Nicholson22



S Int



MEDICINE

MEDICAL SPECIALTIES

CONTRACEPTIVE & SEXUAL HEALTH SERVICES (CASH)Audit of record keeping of Progestogen-only oral contraceptive pill under Patient Group Direction (PGD) 2B

23051

Elaine Smith21

DERMATOLOGYAudit of waiting time in dermatology outpatient clinic at the Bristol Dermatology Centre

20424

Kate Evans

David de Berker 7666

Reaudit Dermatology MDM20561

Mohamed Alrawi66116

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

22191

Mohamed Alrawi21

Is the general practitioner being notified of a patients diagnosis of skin cancer by the next day?

22462

Gemma Gregory76

Use of Dermoscopy in Assessing Pigmented lesions

22994

Katharine Nightingale43

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

23091

Emma Howard43

Surgical attire of staff and patients during skin surgery in the Bristol Dermatology Centre

23473

Helen Whitley2

Wound infection audit following skin surgery in the Bristol Dermatology Centre

23482

Helen Whitley2

Audit of the prescription of sub-cutaneous biologics (Adalimumab and Etanercept) for the treatment of moderate to severe Psoriasis.

23501

Tracey Wheeler2

DIABETES & ENDOCRINOLOGYRegional audit of Diabetic Pregnancies821

1Dr Kurien John

10101010

South West Regional Audit of Diabetic Lower Limb Amputations

8241

Dr Kurien John10101010

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

23231

Dr Suzanne Phillips21



S Int



MEDICINE

MEDICAL SPECIALTIES

DIABETES & ENDOCRINOLOGYNational diabetes inpatient audit2337

1Suzanne Phillips

3

GASTROENTEROLOGY & HEPATOLOGYUK Inflammatory Bowel Disease (IBD)1901

4Peter Collins

Helen Johnston 11666

Vitamin supplementation in patients with alcohol abuse

21011

Richard Parker4332

A retrospective audit of late complications of ERCP (endoscopic retrograde cholagiopancreatography) at UHB Foundation Trust

22501

Dr John Smithson73

GENERAL MEDICINEAudit of oxygen prescription for medical patients in Bristol Royal Infirmary

20544

Thomas Teare56116

Thromboprophylaxis in acute admissions to the MAU

22492

Tom Miller75

GENITOURINARY MEDICINEAudit on management of vulvovaginal candidiasis in women attending the Bristol Sexual Health Centre

21324

Kendon Macdonald5611

RESPIRATORYAnnual Review of Cystic Fibrosis - Does This Contribute to the Effective Management of Patients?

1161

Nabil Jarad

Iara Maria Sequeiros Camarinha 10101010

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

18721

Kathryn Bateman661111

National Chronic Obstructive Pulmonary Disease (COPD) Audit

19004

James Catterall11666

Diagnosis and management of lung cancer20434

Hazel Woodland3322

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

21131

Hannah Smith6622



S Int



MEDICINE

MEDICAL SPECIALTIES

RESPIRATORYDo cystic fibrosis patients have chest X-rays, liver ultrasound and DEXA scans annually?

21164

Iara Maria Sequeiros Camarinha6444

Re-audit of TB and HIV testing22212

Sarah Mungall74

British thoracic society (BTS) Adult Asthma Audit 2009

23751

Amelia Dunscombe1

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

20401

Melissa Domaille6666

Adalimumab, etanercept and infliximab for the treatment of rheumatoid arthritis

23461

Dr Alex Keough2

An audit of the treatment of recent onset rheumatoid arthritis in adults.

23511

Robert Marshall

Helen Nightingale 1

39Total Number of Audits for Medical Specialties:

Total Number of Audits for Medicine: 47

NON-DIVISION SPECIFIC

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

15101

Carly Hall10101010

Infection Control Clinical Care Audit16201

Carly Hall7555

An audit of 24 hour observation charts18201

Sandra Harriss10101010

Admission and Discharge process18953

Anne Berry661111

2008 Bedside Transfusion Re-audit20951

Soo Cooke5662



S Int



NON-DIVISION SPECIFIC

TRUST-WIDETrustwide Audit of Compliance with Anaesthetic Machine Checking

21261

Kate Thomson6532

Catering Ward Rounds – Managing the patient journey through nutritional care

21691

Toni Williams442

Detecting discrimination against complainants23064

Anne Reader73

National Health Promotion in Hospitals (NHPH) Audit

23412

Phill Hall6

The Prevention of Hospital Acquired Thrombosis [CQUIN target]

23691

Sue Fyfe-Williams2

Delegation of consent audit23822

Nicola Henderson5

Open communication following incidents, complaints and claims

23901

Nicola Henderson5

12Total Number of Audits for Trust-wide:

Total Number of Audits for Non-division specific: 12

SPECIALISED SERVICES

CARDIAC SERVICES

CARDIAC ANAESTHESIACardiac Intensive Care Unit standards of care1782

1Ian Ryder

7111111

CARDIAC SURGERY (ADULT)Central Cardiac Audit Database/Society of Cardiothoracic Surgeons National Adult Cardiac Surgery Audit Database

5491

Alan Bryan10101010

UK Heart Valve Registry5504

Alan Bryan8101010



S Int




CARDIAC SERVICES

CARDIOLOGYCentral Cardiac Audit Database/British Heart Foundation Cardiac Rehabiiltation Database

2071

Fiona Barnard101010

Central Cardiac Audit Database/Myocardial Infarction National Audit Project (MINAP)

2231

Jenny Tagney10101010

Central Cardiac Audit Database/British Heart Foundation Heart Failure Database

3661

Toni Dorrington10101010

Central Cardiac Audit Database/British Cardiovascular Interventionist Society National Angioplasty Database

8094

Andreas Baumbach10101010

Central Cardiac Audit Database/Heart Rhythm UK Cardiac Rhythm Management

15781

Tim Cripps10101010

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

17174

John Edmond10101010

Closure of atrial septal defects in patients with pulmonary hypertension

17334

Stephanie Curtis3333

Are appropriate referrals made for 24hour holter monitoring

2088 Marie Meader6622

Standardisation of Filter settings on 12 lead ECGs2196 Anthony French73

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

22672

Hazel Woodland76

Re-audit of patient satisfcatioin at the one stop23771

Alana Durack1

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

23782

Angus Nightingale1

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

2379 Angus Nightingale2

16Total Number of Audits for Cardiac Services:



S Int




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 Muir3222

Audit of Iscador Use Adherence to Guidelines20164

Elizabeth Thompson6539

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 Cameron5433

Blood Transfusions BHOC - Information Collected19811

Paula Wilson6644

Pregnancy -Consent for radiotherapy - re-audit20201

Karen Bannerman

Sue Humphries 6564

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

21091

Jessica MasonJessica Mason 5522

Out of Hours Telephone Calls to Ward 6121361

Tara Shine7421

NCEPOD - Chemotherapy patient care21661

Clare Barlow

Susanna Alexander 661

Temozolomide for newly diagnosed High Grade Glioma NICE TAG 121

21671

E Gray762

Antibiotic policy - stop/review dates on ward 6122231

Paula Wilson22

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

22371

Susanna Alexander

Anna Sanders 42



S Int




ONCOLOGY & CLINICAL HAEMATOLOGYAre patients with relapsed or refactory follicular lymphoma being prescribed rituximab in accordance with NICE guidelines TAG 137?

22591

Sucheta Mane

Anna Morris 54

Compliance with skin radiotherapy protocol in BHOC

22601

Alison Cameron62

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

22641

Anna Sanders21

High dose rate brachytherapy in prostate cancer- NICE IPG 174

22651

Ahmed Aziz44

Istopes/thyroid - Patient preparation prior to Radioiodine Ablation

2320341

CLINICAL HAEMATOLOGYIDENTIFICATION OF POTENTIAL/OBLIGATE Haemophilia carriers

20841

Inas El-Najjar7643

Assessment and Prescribing of Thromboprophylaxis - VTE Phrophylaxis - Inpatients AHU

21633

Kathy Hodby443

Sickle Cell (Acute) Management21713

Sajid Pervaiz532

Management of CML - NICE TAG 70 Imatinib22031

EiEi Htwe53

Neulasta presciptions on Avon Haematology Unit22661

Charlotte Oliver54

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

23571

Paul Flinders2

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

23581

Jo Botton2

PALLIATIVE MEDICINEPreferred Place of Death2224

1Samuel King

72



S Int




ONCOLOGY & CLINICAL HAEMATOLOGY

23Total Number of Audits for Oncology & Clinical Haematology:

Total Number of Audits for Specialised Services: 42

SURGERY AND HEAD AND NECK

ADULT EAR, NOSE AND THROAT (ENT)Re-audit on antibiotic prescribing2298

2R Usher

66

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

23261

Lizzie Ingall42

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

1744 Rebekah Stone1111

OBSTETRICS AND MIDWIFERYNHS Litigation Authority (NHSLA) Documentation Audit - 2009

21821

C Pugh442

4Total Number of Audits for Adult Ear, Nose and Throat (ENT):

ANAESTHESIADelays to theatre of patients with fractured neck of femur

17062

Jill Homewood6666

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 Heywood6665

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

19681

Rebecca Aspinall5544

Daycase Haemorrhoidectomies and Varicose Viens - An Audit

215615554

Prevelance and Management of Peri-operative Iron deficieny Anaemia

21881

James Sidney32



S Int




ANAESTHESIAA re-audit of Same Day Cancellations2222 Laura O'Sullivan

53

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

22411

Gregory Brown51

Audit of safety briefing and debriefing and the WHO surgical safety checklist in Hey Groves Theatres

22681

Sarah Ingamells52

An audit of refused admissions and delayed discharge in Heygroves Recovery

22711

Tamsin Glasgow42

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

22093

Nilesh Chauhan52

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

22734

Steve Lindley42

Epidural and PCA Analgesia and Patient Information Sheets

23433

Sethina Adjarewa42

OBS & GYNAE ANAESTHESIAAudit of Epidural Anaesthesia for Gynaecological Operations

5381

Mike Kinsella12111111

Epidural Analgesia - Following up post procedure (re audit 1488)

16054

Claire Dowse6111111

Audit of accidental dural puncture (ADP)17044

Mark Scrutton10101010

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

17431

Robert Jackson991111

Post Caesarean Section Analgesia Audit17701

Simon Webster8111111

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

19664

Mark Scrutton6633



S Int




ANAESTHESIA

OBS & GYNAE ANAESTHESIANPSA safety alert 21 – Safe administration of epidural medicines.

19671

Mark Scrutton6422

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

22124

Mark Scrutton64

Re-audit of management of Placenta Praevia and Caesarean Section

22161

Nick Wharton32

Re-audit of post Caeserean Section analgesia22171

Nick Wharton32

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

21381

Marcos Kostalas2222

Lifestyle advice in preoperative assessment21481

Mathew Thomas

Clare Evans 4422

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

23071

Clare Evans21

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

23181

Claire Dowse52

27Total 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 Morain3

Salivary gland imaging audit23714

Jennifer Haworth2

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

19551

Esther Perera

Teresa Levy 4333

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

22011

Ceri Hughes

Chris Bell 63



S Int




DENTAL & MAXILLOFACIAL SURGERY

ORAL & MAXILLOFACIAL SURGERYHead and Neck Cancer GP and patient communication - re-audit (1473) [NICE guideline CSGHN, 2004]

23101

Hannah Pepper43

ORAL MEDICINEMedical and neurosurgical intervention in managing trigeminal neuralgia

20711

Sarah Ellison

Amina Abdel-Karim 6522

Antibiotic prophylaxis for patients at risk of developing infective endocarditis [NICE CG64]

21721

Sarah Ellison

Jennifer Haworth 651

Compliance with antibiotic prescribing and monitoring in the Primary Care Unit

21951

Sarah Ellison

Clare Gleeson 66

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

21734

Neil McCusker311

Cephalometric outcomes of orthognathic surgery22614

Hem Shah43

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

22621

Hem Shah42

Treatment pathway for multidisciplinary patients23111

Hem Shah52

National Audit of Mini Screws / Temporary Anchorage Devices (TADs) [NICE IPG 238]

23404

Nigel Harradine2

Lost orthodontic appliances23644

Hem Shah2

PAEDIATRIC DENTISTRYLongevity of Fissure Sealants1750

4Ruth Fairhurst

3332

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

20504

Rachel Fletcher6643



S Int




DENTAL & MAXILLOFACIAL SURGERY

PAEDIATRIC DENTISTRYUsers’ views of the paediatric dental clinic2263

1Lucy Stead

22

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

23361

Rebecca John2

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

22391

Casey Carnall

Rob Jagger 63

Quality of prescriptions given to crown and bridge laboratory

23651

Aliza Jesani2

Success and failure of Dental Implants in BDH23664

Claire Forbes-Haley2

21Total 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 Duncan63

ITU/HDUTherapeutic Hypothermia for Cardiac Arrest on ITU

19911

Matt Thomas5422

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

21463

Alisje Kuur6432

CVP line insertion in ITU and Theatre (NICE TA 49)

21473

Victoria McGill

Anne Whaley 8222

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

21891

Louise Jenkins32

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

23274

Steve Cantellow22

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

23323

Rachel Bennett22



S Int




INTEGRATED CRITICAL CARE SERVICES

ITU/HDUAudit of ITU acquired Hypernatraemia and subsequent treatment within Intensive Care

23591

Jonathan Lightfoot2

Audit on the management of hyperglycaemia in ITU patients

23731

Vaseilios Chortis2

OUTREACH CRITICAL CAREAnaesthesia and intensive care services for the primary angioplasty

22334

Kathryn Jackson51

Emergency Anaesthesia outside the Operating Theatre

23421

Matt Thomas22

11Total Number of Audits for Integrated Critical Care Services:

OPHTHALMOLOGYNurse-led management of patients with lid lumps2334

1Mohan Mundasad

Hannaa Bobat 3

A&E AND PRIMARY CAREPatients presenting with floaters and flashes to Bristol Eye Hospital Emergency Department

22691

Gill Sefton32

Bristol Eye Hospital A&E 4 hour breaches - re-audit

23451

Elisabeth MacDonald2

Eye A&E Follow Up Patients23531

Elisabeth MacDonald2

CORNEA & CATARACTSPatient follow-up after posterior YAG capsulotomy2093

1Panagiotis Georgoudis

7642

Outcomes of cataract surgery in diabetic patients22134

Matthew Wakefield21

Ocular biometry23621

Nat Knox Cartwright2



S Int




OPHTHALMOLOGY

GLAUCOMA & SHARED CAREGlaucoma outpatient follow up appointments at Bristol Eye Hospital (re-audit of 1589)

21771

Sonia Yong441

MEDICAL & SURGICAL RETINAOutcomes following Pars Plana Vitrectomy for retinal detachment - re-audit

22524

Branka Marjanovic63

ORTHOPTICS & OPTOMETRYReferrals to Orthoptic service at school nurse vision screening

23811

Ann Starbuck

Penny Warnes 2

PAEDIATRICS, OCULOPLASTICS & SQUINTIdentifying patients requiring Retinopathy of Prematurity (RoP) screening

20941

Cathy Williams6643

Children's ophthalmology clinics at North Bristol NHS Trust: waiting times and quality of service

21491

Cathy Williams662

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

22044

Adam Ross42

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

22541

Cathy Williams

Kate Perryman 44

External Dacryocystorhinostomy (DCR)23124

Julia Hale32

Adult Squint Surgery Outcomes 2007/200823131

Julia Hale22

Referrals from Paediatric Rheumatology of children diagnosed with Juvenile Idiopathic Arthritis to the Eye Hospital for uveitis screening

23611

Brinda Muthusamy2

17Total Number of Audits for Ophthalmology:

ORTHOPAEDICS (T&O)Audit of Orthopaedic Coding1710

1Charles Chambers

11666



S Int




ORTHOPAEDICS (T&O)Management of suspected scaphoid fractures1832

1Phil McCann

81111

Correct Site Surgery (re audit)19774

Jonathan Eldridge6665

An audit of good practice at key stages of hip fracture care

20343

Shafat Gangov1111114

Hand surgery at Bristol Royal Infirmary21393

Peter Robinson5543

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

21401

Peter Robinson5543

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

22054

Hannah Smith32

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

22074

James Ansell22

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

22103

James Ansell22

Adult Peri-operative Normothermia22401

Rebecca Griggs53

The orthopaedic referrals process - documentation of key decisions

22833

Hannah Smith32

11Total Number of Audits for Orthopaedics (T&O):

SURGERYEffective pain assessment and management post operatively

19691

Emma Neale6654

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

22081

Sheona Burns42

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

223453



S Int




SURGERYImproving the quality of information for patients on admission to STAU

2292 Rachael Walters11

A Re-audit of Gentamicin Prescribing and Monitoring within UHBristol

23541

Joseph Manjaly2

Audit into Blood culture taking procedures in the trust

23603

Rebecca Martin4

BREAST SURGERYRe-audit of Cancer Standards2253

2Angela Nicholson

31

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

18561

Rob Longman6111111

An audit of fluid replacement for patients undergoing colorectal surgery

18571

Rob Longman6111111

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

21901

Peter Steed62

Reduction of Surgical Site Infections in Colorectal Surgery

21911

Peter Vaughn-Shaw52

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

22561

Richard James21

UPPER GI (GASTROINTESTINAL) SURGERYImplementation of decisions from the colorectal MDT

13511

James Wood

Jane Blazeby 6111111

An audit of clinical outcomes in patients with pancreatic adenocarcinoma undergoing Percutaneous Transhepatic Cholangiography

15611

Jane Blazeby6111111

A re-audit of the patient pathway from GP referral to treatment decision and then to start of treatment for patients with upper GI cancer

17351

Jane Blazeby

Jonathan Rees 6111111

An 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 661111



S Int




SURGERY

UPPER GI (GASTROINTESTINAL) SURGERYAn audit of the risks and complications of feeding jejunostomy

19721

Ian Pope8111111

An audit of informed consent for elective Oesophagectomy

19784

Jane Blazeby11111111

Completion of Upper GI preoperative safety checks

21454

Andy Hollowood6622

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

22724

Angus McNair44

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

23141

Jane Blazeby32

Audit of Laparoscopic Surgery in Oesophago-Gastric Malignancy

23291

Paul Barham2

VASCULAR SURGERYAudit of Radiofrequency Ablation of Varicose veins VNUS CLOSURE Fast

19701

Nicola Laurence22112

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

22001

Neil Upadhyay52

24Total Number of Audits for Surgery:

Total Number of Audits for Surgery and Head and Neck: 115

WOMEN'S AND CHILDREN'S

CHILDRENS SERVICES

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

19471

Rdodri David6654

Audit of timescales regarding Deliberate Self harm Assessments

20971

Chrissie Gay6543



S Int




CHILDRENS SERVICES

CAMHS (CHILD ADOLESCENT MENTAL HEALTH)Audit of prescribing practice in child and adolescent mental health service

21341

Louise Molodynski6432

COMMUNITY PAEDIATRICSAudit of service provision for children with special needs - re audit

20491

Ben Marsh7643

GENERAL PEADIATRICSUse of parent held child health record (PHCHR) in outpatient / ward settings

2154432

NICE Guidance on atopic ecezma - CG21851

Lindsay Shaw75

Reducing the harm caused by misplaced nasogastric feeding tubes - National Patient Safety Agency (NPSA) Safety Alert No 5 February 2005

21921

Sandra Cutts64

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

23391

Helen Lee1

Prescription of IV fluids : A reaudit2367 Kate Binns1

NEONATOLOGYInternational, national and regional benchmarking of mortality & morbidity and resource allocation on the newborn intensive care unit

11424

David Harding10101010

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

16991

Jennifer Kemp2222

National Neonatal Audit Programme19022

David Harding10101010

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

20792

Archana Mishra5422

Frequency and quality of head scans in neonate21832

A Tarabishi332



S Int




CHILDRENS SERVICES

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

23012

S Gupta

Manal El-Bokle 22

Audit of immunisation of long stay babies on NICU23042

Caroline Platt52

Re-audit of NICU care plans – Blood Pressure monitoring

23191

Carol Aldridge76

National Comparative Audit of use of Red cells in Neonates and Children

23802

S Cooke1

PAEDIATRIC ANAESTHESIAAudit of antimicrobial prophylaxis against infective endocarditis in children undergoing interventional procedures

2045 Sarah Sanders6433

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

22951

James A Sydney21

Pre op fasting in elective and emergency patients2297 Mala Greamspet32

When are children better after Tonsillectomy23151

Sarah Parry21

PAEDIATRIC CARDIAC SERVICESPost-Operative Morbidity Following Cardiac Catheterisation

794

Dr R Martin10101010

Post-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

Paediatric cardiac surgery audit (CCAD - Central Cardiac Audit Database)

9471

Dr Andrew Tometzki10101010



S Int




CHILDRENS SERVICES

PAEDIATRIC CARDIAC SERVICESAudit of current practice regarding the use of prophylaxis against infective endocarditis NICE CG64 April 2008

20294

Sid Kaithakkoden5543

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

20871

Jonathan Forsey6662

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

2294 Kalyan Gurusamy22

PAEDIATRIC DIETETICSHealthy Start Vitamin Uptake1957

4Sarah Bergun

6654

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

21521

Simon Binks443

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

21531

Russell Jones632

Management of Gastroenteritis in the Paediatric Emergency Department

22421

Anne Frampton76

Urinary tract infection in children : diagnosis,treatment and long term management. NICE CG 54 (Aug 2007)

22431

Anne Frampton76

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

23681

Samuel Davies1

PAEDIATRIC ENDOCRINOLOGYNational Diabetes Audit (NCASP)1451

4Christine Burren

10101010

Re - audit of Obesity National Institute for Health and Clinical Excellence (NICE) Guidelines: CG43 (December 2006)

19091

Jessica Williams7699

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

1928 Melanie Guilder4333



S Int




CHILDRENS SERVICES

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

19422

Christine Wei5554

Guidance on the use of Human Growth Hormone (Somatropin) in children with growth failure; NICE Technology Assessment No 42, April 2002

22261

Christine Burren76

Audit of annual reviews of children with diabetes submitted to the National Diabetes Audit (NDA)

22911

Gita Mogdil76

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

20081

Saras Hosgurga4333

Referrals from primary care and BCH consultants with query constipation - Were they appropriate?

22511

Rebecca Winterson74

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 Cutts6665

Bronchiolitis in need of CPAP: outcome project (BINCO)

15471

Helen Brewer2222

Audit of medical discharge list sticky labels16871

Sandra Cutts6554

Suction Audit1925922

Audit of Management of Traumatic Brain Injury in PICU

21681

Darwin Pauldhas333

Audit of rib fracture in children22844

New Soe43

Audit of PICU acute lung injury guidelines in relation to use of nitric oxide and surfactants

2356 Jaya Parasuraman2



S Int




CHILDRENS SERVICES

PAEDIATRIC NEPHROLOGYAdvice given to children with isolated scars on DMSA scan

17883

Dr Jonathan Graham6665

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

20061

Anna Kilonback6643

Audit of prescribing drugs on discharge from renal ward

21811

Karim Shebani432

Paediatric renal biopsy audit September 04 - September 07

22254

Ezzat Afifi76

Retrospective audit of anaemia in paedatric patients with CKD stage 5 disease 2003- 7

2285122

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

22871

Hugh McCarthy33

PAEDIATRIC NEUROLOGYFolic acid prescription and advice in female young people with epilepsy.

17681

Dr M Almaghrabi9

Re-audit of Specialist epilepsy referral and neurological investigations

20351

Andrew Lux7692

Investigations, treatment and outcome of childhood stroke

23034

Jimmy Kai fai Sun32

PAEDIATRIC ONCOLOGYPerinatal transmission of HIV: audit of infected infants born in England between 2002 and 2005

15931

Lizzie Hutchison6664

Congenital adrenal hyperplasia - from diagnosis to transfer to adult services. How are we doing?

17221

Sharon Yee Sit Yu865

Optimising Paediatric Haematology / Oncology patients for theatres

19141

Judith Armstrong8664

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

22861

Caroline Roberts22



S Int




CHILDRENS SERVICES

PAEDIATRIC ONCOLOGYAudit of Vancomycin prescribing2288

1Rebecca Palmer

33

PAEDIATRIC RADIOLOGYAudit of diagnosis of intestinal malrotation2228 Nicola Matcham

33

Audit of paediatric radiographs2338 David Grier2

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

17851

Dr Hannah Midwinter6643

Asthma in schools17941

Neil Archer6643

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

19411

Louise Chapple4433

An audit of Palivizumab use in paediatrics21001

Kamran.Mahmood4432

Audit of effectiveness of Epipen training in nursery school staff

21031

Fiona Duncan6656

British Paediatric Respiratory Society / British Thoracic Societ Asthma Audit 2008

21061

Deb Marriage6643

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

2244 Jon Courts32

PAEDIATRIC SURGERYNational Institute for Health and Clinical Excellence (NICE) Guidance on Surgical Site infection (CG: 74)

22291

Andrew Robb74

Audit of diagnostic imaging for antenatally diagnosed congenital lung lesions

223222



S Int




CHILDRENS SERVICES

PAEDIATRIC SURGERYLength of stay and complication rate for laparascopic Pyloromyotomy

23723

Kathryn Evans2

Outcomes following laparscopic orchidopexy23744

Kathryn Evans2

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 6664

Audit of referrals to the paediatric orthopaedic department for patients with suspected malignancy

229622

81Total 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

National audit of invasive cervical cancers19452

Robert Anderson10101010

South West Cancer Intelligence Services Uterine Cancer Quality Assurance Audit

21802

Diana Bailey642

NHSLA Litigation Authority (NHSLA) Documentation Audit - Gynaecology

22782

Deb Panes74

Early Pregnancy Clinic23162

Zoey Robinson42

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

Sally Tedstone10101010



S Int




WOMEN'S SERVICES

OBSTETRICS AND MIDWIFERYAudit into the management of women at high risk of preterm labour throught the preterm labour clinic

18392

Kate Collins9

Re-audit of fetal monitoring in labour18762

Belinda Cox5219

Diabetes in pregnancy (NICE CG63)22752

Sonia Barnfield64

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

22761

Joanna Clark104

Midwife - Anaesthetic Practitioner Handovver22791

Nicky Ellis66

Audit of antenatal screening tests (NICE CG62)22801

Wendy Ring42

Outcomes for women meeting NICE criteria, but not UHBristol criteria, for diagnosis of gestational diabetes (NICE CG63)

22811

Esyllt Iago76

Re-audit of the guidelines for pre eclampsia and severe hypertension.

22821

Janet Pollard22

National Screening Committee Audit Haemoglobinopathies, Infectious Diseases, Downs Screening and Newborn Blood spot - (NICE CG 62)

23211010

Use of syntocinon in induction and augmentation of labour (NICE CG55)

23221

C Hillman-Cooper43

Referral when fetal abnormality detected23242

Mark Denbow72

Women who refused transfusion of blood or blood products

23252

Manjula Subramanian42

Missed appointments (NICE CG62)23834

SJ Sheldon4

"Booking appointments" completed by 12 weels and 6 days (NICE CG 62)

23844

SJ Sheldon4



S Int




WOMEN'S SERVICES

OBSTETRICS AND MIDWIFERYAudit of Clinical Risk Assessment (antenatal and in labour)

23851

George Attilakos4

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

23861

Sophie Wood4

Re-audit of use of fibronectin test23871

Eloise Weeks4

Management of pregnant women with high BMI (NICE CG 55, NICE 62)

23881

J Pollard4

Re-audit of maternity records (CNST 3.1.7)23891

Janet Pollard4

Caesarean section monitoring23911

Emma Treloar10

Management of and prophylaxis for venous Thromboembolism in Obstetrics

23921

Janet Pollard4

Monitoring documentation for management of perineal trauma

23931

Janet Pollard4

29Total Number of Audits for Women's Services:

Total Number of Audits for Women's and Children's: 110


uhbristol clinical audit progress report november 2009 progress report... · 2016. 4. 4. · 2221...

Documents