All patients with diabetes should have annual UACR tests. Why is that so hard?

The urine albumin creatinine ratio (UACR) detects abnormal levels of protein in the urine and should be performed annually to detect kidney disease in patients with diabetes mellitus. UK national audits show that 25% of patients do not have annual tests and our data suggested that some patients had more than one test per year. Data from 20 patients showed that 55% had more than one UACR test per year, with a total of 19 unnecessary tests at an estimated cost of £20,000 per year. However 20% had not had a UACR in the previous year, so unreliable testing was potentially causing harm as well as waste. Process mapping showed that having a UACR test depended on whether the patient brought a urine sample to the clinic. Most (72%) patients were unaware that the urine sample was used to detect kidney damage. We encountered barriers when finding a process to automate measures of reliability of UACR testing using computer protocol, and therefore created a patient information leaflet. The first version of the leaflet was too technical and several changes were suggested by patients. After reading the revised leaflet 99% of patients understood the reason for UACR testing and 64% felt more motivated to bring in urine samples. The phlebotomist disseminated the patient information leaflet with a median of 90% reliability for six consecutive clinics. The patient information leaflet has the potential to improve patient involvement in their care and to increase the number of patients who bring urine samples to the clinic. However, this could increase the number of unnecessary tests unless the process of test ordering is changed to ensure that UACR is only measured annually

Secondary care interface:optimising communication between teams within secondary care to improve the rehabilitation journey for older people

Effective communication between members of the multidisciplinary team is imperative for patient safety. Within the Medicine for the Elderly wards at Royal Victoria Hospital (RVH) in Dundee, we identified an inefficient process of information-sharing between the orthopaedics outpatient department (OPD) at the main teaching hospital and our hospital’s rehabilitation teams, and sought to improve this by introducing several changes to the work system. Our aim was for all patients who attended the OPD clinic to have a plan communicated to the RVH team within 24 hours.Before our intervention, clinic letters containing important instructions for ongoing rehabilitation were dictated by the OPD team, transcribed and uploaded to an electronic system before the RVH team could access them. We analysed clinic attendances over a 4-week period and found that it took 15 days on average for letters to be shared with the RVH teams. We worked with both teams to develop a clinical communication tool and new processes, aiming to expedite the sharing of key information. Patients attended the OPD with this form, the clinician completed it at the time of their appointment and the form returned with the patient to RVH on the same day.We completed multiple Plan–Do–Study–Act cycles; before our project was curtailed by the COVID-19 pandemic. During our study period, seven patients attended the OPD with a form, with all seven returning to RVH with a completed treatment plan documented by the OPD clinician. This allowed rehabilitation teams to have access to clinic instructions generated by orthopaedic surgeons almost immediately after a patient attended the clinic, essentially eliminating the delay in information-sharing.The introduction of a simple communication tool and processes to ensure reliable transfer of information can expedite information-sharing between secondary care teams and can potentially reduce delays in rehabilitation

'Where is the ECG machine?':a quality improvement project using WhatsApp to improve the efficiency in locating shared medical devices in an inpatient unit

Access to medical devices are vital to deliver safe patient care. In the context of constrained resources, however, clinical areas often have insufficient basic equipment, which tend to be shared among multiple clinical teams. This can result in delayed patient management and reduced institutional productivity. In our experience, in 2019, while working at Carseview Centre, an inpatient mental health unit in Dundee (National Health Service Tayside), there was only one functioning ECG machine shared between the five wards. Using the work WhatsApp chat, we aimed to facilitate better sharing of the one machine. Plan, do, study, act (PDSA) 1 intervention introduced the project protocol, which encouraged doctors to post a photo of the device after use, captioned with its location. PDSA 2 involved printing a physical copy of the memorandum and attaching it to the machine to prompt further compliance. In PDSA 3, concise photo-posting guidelines were established and adherence was encouraged to mitigate concerns for potential confidential-data leaks. A dynamic outcome measure, the overall effectiveness metric (OEM), was conceived to prospectively monitor the effectiveness of our interventions. An OEM ≥1 indicates engagement and thereby improvement, whereby <1 indicates no change compared with baseline. The intervention in PDSA 1 was a success with an OEM of 3.5. Although no actual data leaks occurred, a potential for concern was raised by a senior doctor. This limited engagement with the protocol during PDSA 2 and 3, causing the OEM to decline to <1 towards the end of the project. Sixty percent reported that the protocol saved them time in locating the machine. Individual factors, mainly frustration with the current situation, was a primary driver for the initial engagement among doctors. Although other factors such as senior doctor buy-in, may play a greater role in directing longevity of a technology-based quality improvement solution

Recent changes in summer distribution and numbers of migratory caribou on the southern Hudson Bay coast

The status of migratory woodland caribou inhabiting the coastal region in southern Hudson Bay is dynamic. The Pen Islands Herd within that region was defined in the 1990s, but opportunistic observations between 1999 and 2007 suggested that its status had significantly changed since the late 1980s and early 1990s. We undertook systematic surveys from the Hayes River, MB, to the Lakitusaki River, ON, in 2008 and 2009 to determine current distribution and minimum numbers of woodland caribou on the southern Hudson Bay coast from the Hayes River, Manitoba, to the Lakitusaki River, Ontario. We documented a significant change in summer distribution during the historical peak aggregation period (7-15 July) compared to the 1990s. In 2008 and 2009, respectively, we tallied 3529 and 3304 animals; however, fewer than 180 caribou were observed each year in the Pen Islands Herd&rsquo;s former summer range where over 10 798 caribou were observed during a systematic survey in 1994. Over 80% of caribou were in the Cape Henrietta Maria area of Ontario. Calf proportions in herds varied from 8% of animals in the west to 20% in the east. Our 2008 and 2009 systematic surveys were focused on the immediate coast, but one exploratory flight inland suggested that more caribou may be inland than had been observed in the 1980s-1990s. The causes of change in the numbers and distribution in the coastal Hudson Bay Lowlands and the association of current caribou with the formerly large Pen Islands Herd may be difficult to determine because of gaps in monitoring, but satellite telemetry, genetic sampling, remote sensing, habitat analysis, and aboriginal knowledge are all being used to pursue answers

Interprofessional, student-led intervention to improve insulin prescribing to patients in an Acute Surgical Receiving Unit

Our aim was to test the feasibility of interprofessional, workplace-based learning about improvement through a 4-week placement for one medical and two pharmacy final year students in an Acute Surgical Receiving Unit (ASRU). The target was insulin because this is a common, high-risk medicine in this ASRU and the intervention was medicines reconciliation. Baseline data were collected from 10 patients and used to construct a cause and effect diagram and a process map through feedback and discussions with staff. Hypoglycaemia occurred in four patients but hyperglycaemia occurred in eight patients, of whom six were placed on intravenous insulin infusion (IVII). We estimated that £2454 could be saved by preventing one patient from going on IVII. The students designed and tested a sticker to improve medicines reconciliation for insulin patients. An online form was created to capture clinician feedback on the layout and usability of the sticker. The intervention was associated with improvements in the reliability of medicines reconciliation. The students’ work contributed to a larger project to reduce the risk of hypoglycaemia in the ASRU. This proved beneficial in enabling the students to engage with the clinical team. Nonetheless, it was challenging for students from two Universities to get a shared understanding of improvement methods and work effectively with the clinical team. The students said that they learnt more about quality improvement in a working healthcare environment than they would ever learn in a classroom and they valued the opportunity to work with students from other healthcare backgrounds in practice. Despite the additional staff time required to support students from two Universities, both have supported continuation of this work