Documentation of lumbar punctures - Neurology DIU

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Documentation of lumbar punctures - Neurology DIU
Learning To Make a Difference

• Dr Michal Rolinski
• Dr Hannah Rowe
• Supervised by Dr M Turner

ORH NHS Trust
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Background
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• First lumbar puncture (LP) performed in 1891
• Although common an LP is an invasive procedure
• Previous audits (1-3) have shown LP documentation
  to be poor
• Raised concerns over consent and technical
  aspects

ORH NHS Trust
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Project Aims
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• To improve the quality of LP documentation on the
  Neurology DIU
• To improve technical aspects of the procedure,
  specifically the sending of paired serum glucose

ORH NHS Trust
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Learning To Make a Difference
Action Planning
What are we trying to accomplish? Increase in LP documentation meeting required standard Increase in samples sent with paired serum glucose to 100
How will we know that a change is an improvement? Good documentation is essential for patient safety. Sending paired serum glucose enables accurate interpretation of results and diagnosis
What changes can we make that will result in improvement? Formal education session Information leaflet
ORH NHS Trust
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Lumbar puncture process
ORH NHS Trust
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Methods

• 14 important indicators in
• LP documentation identified pre data
  collection (box 1)

• Lumbar puncture indicators
• Indication
• Contraindications
• Consent documented
• Position in which the LP was performed
• Use of aseptic technique
• Type of anaesthetic used
• Dose of anaesthetic used
• Site of spinal needle insertion
• Size of spinal needle used
• Number of attempts at needle insertion
• Opening pressure
• Any peri-procedure complication?
• Post-procedure advice given
• LP results documented
• Fig1

ORH NHS Trust
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QIP timeline
Month 0
Month 1
Month 2
Month 3
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(No Transcript)
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Data collection

• 26 patient notes reviewed
• LPs performed by 7 SHOs ( 2 FY2s, 3 CT1s, 2
  CT2s)
• No formal LP training undertaken prior to QIP

ORH NHS Trust
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What difference has been made?
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• Pre-intervention median indicators documented
  8/14 fig3
• Consent documented in 8/9
• Less than half had -
• indication (22)
• contraindications (33)
• position LP performed (22)
• site of spinal needle insertion (33)
• spinal needle size (44) fig4

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LP documentation
Fig 3
ORH NHS Trust
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LP documentation

• Majority of indices improved after interventions
• Position LP performed p0.0032
• Site needle inserted p0.0114
• Documentation indication (57) and LP results
  (43) remained poor
• After both interventions 100 documentation of
  9/14 indices
• 
  Fig4

Indicators Before interventions After both interventions p value
Indication 22 57 0.3024
Contraindications 33 86 0.0601
Consent documented 89 86 1.0000
Position in which the LP was performed 22 100 0.0032
Use of aseptic technique 78 100 0.4750
Type of anaesthetic used 78 100 0.4750
Dose of anaesthetic used 67 100 0.2125
Site of spinal needle insertion 33 100 0.0114
Size of spinal needle used 44 86 0.1451
Number of attempts at needle insertion 89 100 1.0000
Opening pressure 89 100 1.0000
Any peri-procedure complication? 55 100 0.0885
Post-procedure advice given 55 100 0.0885
LP results documented 0 43 0.0625
Fig 4
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Learning To Make a Difference
Paired serum glucose

• Paired serum glucose samples sent increased to
  100
• p0.0885 fig5

Fig 5
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Discussion

• Interventions led to a significant improvement
  in the documentation of LPs and doubling of the
  number of paired serum glucose samples being sent
  to 100 fig5
• Disappointingly, pre-intervention no notes had LP
  results documented this only increased to 43
  fig4
• Likely due to DIU closing and notes being sent to
  secretaries/coding (most LPs performed in the
  afternoon)

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Next Steps
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• LP leaflet currently going through departmental
  approval process
• Aim to provide LP education session and
  information leaflet as part of induction process
  to all SHOs starting Neurology rotation
• Create a file on DIU to hold records with
  outstanding LP results
• We have learnt that simple interventions can make
  a difference!

ORH NHS Trust
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References
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• Baer Et. Post-dural puncture bacterial
  meningitis. Anaesthesiology, 2006 105(2) 381-93
• 2) Dakka Y, Warra N, Albadareen RJ, Jankowski M,
  Silver B. Headache rate and cost of care
  following lumbar puncture at a single tertiary
  care hospital. Neurology.2011 77(1) 71-4
• 3) Vallejo MC, Mandell GL, Sabo DP, Ramanathan S.
  Postdural puncture headache a randomised
  comparison of five spinal needles in obstetric
  patients. Anesth Analg. 2000 91(4) 916-20

ORH NHS Trust