SAMScotland National Training Day/Conference

INTRODUCTION The NHS is increasingly looking overseas for qualified doctors to help fill workforce gaps while maintaining the quality of training for all. The latest estimate is that this group of healthcare professional’s accounts for over a third of the medical workforce and therefore represents a hugely important cohort of clinicians. These doctors arrive in the UK with a diversity of background experience and training, and many will not be familiar with the routine day-to-day practice within the NHS. METHODS Identification of the issues experienced by IMG’s-This was done through the feedback received from the cohort of doctors that joined us in January 2022 The principal issues identified were 1. Lack of a proper induction in the beginning 2. The lack of a social support/ecosystem outside of work 3. Understanding the different cultural norms and practices 4. Practical issues-Accommodation, commute, bank account, registering with the GP etc. 5. Helping Supervisors/Trainers recognise the different needs/background of an IMG trainee Intervention Implemented 1. Initiation of an Induction programme 2. Individual Induction meetings 3. Guided tours of the hospital/setting 4. Informal Social gatherings to help build a network around them 5. Presentation by Senior consultants 6. Handbook’s curated for both the trainees and their educational supervisors to help guide them RESULTS Feedback forms were collected, after the interventions above were carried out, and a marked improvement in feedback and experience by the trainees/fellows were noted CONCLUSION

Settling into another healthcare system and country can be an incredibly hard process, and given the limited time, even small interventions as the ones noted above showed a marked improvement in experience and day to day work within the trust by the IMG’S We at Ayrshire and Arran aim to make the process of settling in easier, it's a different country and a different system, and having that little bit of extra help at the beginning can go miles, and that’s what we hope to give and more-We hope to continue the project further and the additional implementations made for trainees who started in August 2022 were 1. A formal soft landing program with shadowing designed for 6 weeks. 2. Support in On calls-when possible-a delayed start on calls and initial additional support from within the team when starting out 3. An individually named mentor/buddy-this would be curated as far as practically possible to be someone within the specialty team

A second cycle of feedback for interventions implemented above has also been collected and assesed

Sufiya Ahmed

University Hospital Crosshouse

DVT and PE referrals account for 38.1% of patients seen in Same Day Emergency Care (SDEC) at the Western General Hospital (WGH). NHS Lothian use Vidas d-dimer, from venous samples . Median turnaround times for a Vidas d-dimer is 1:36:45 leading to long wait times . Positive d-dimer patients are booked in for Ultrasound doppler or CTPA, in most cases the following day with anticoagulation cover. Reducing turnaround time could improve access to same day scanning which is limited to “in hours” Radiology service.

LumiraDx d-dimer point of care (POC) test, carried out on their hand-held device using capillary blood, provides results in 6 minutes.

The POC d-dimer test was carried out on 187 patients, referred for DVT and PE, who attended SDEC over 19 days in October. Venous samples were also sent for these patients for Vidas d-dimer.

LumiraDx d-dimer compares favourably with Vidas d-dimer, the gold standard. In our study, LumiraDx d-dimer test showed a close correlation with Vidas d-dimer (r=0.72, p<0.001). Vidas has a disease sensitivity of 100% (95% CI 74.1% - 100%) and a NPV of 100% (95% CI 98.3% - 100%)1. 87.7% of the total POC results were in concordance with Vidas values. In over 96% of cases a negative POC correctly predicted negative Vidas.

There were a small number of discrepant results. 20 POC results (19.8%) were positive for 101 negative Vidas d-dimers, while 3 (3.5%) were false negative against 86 positive Vidas d-dimers.

To conclude, these results indicate that LumiraDx POC d-dimer compares well with Vidas, helps reduce turnaround time and in turn time in department of these patients, and therefore may be considered for risk stratification of patients referred for thromboembolic disease.

1. Body, R et al. EMBOL-1 Study - Clinical performance evaluation of the LumiraDx D-Dimer point of care Test for the exclusion of venous thromboembolism in symptomatic patients. LumiraDx UK Ltd. [Internet]. May 2022. Available from: https://www.lumiradx.com/assets/pdfs/white-papers/s-com-art-02900-r1_white-paper-d-dimer-exclusion-claim_web-(4).pdf?v=1

Aneesha Anand

Western General Hospital, NHS Lothian

AKI is common in acute illness, occurring in more than 15% of emergency admissions. The NCEPOD report (2009) noted serious concerns with management of AKI in UK hospitals, with less than 50% of patients receiving good care. Our aim was to create a framework to be used at the point of admission to assess, investigate, and manage AKI.

We created an AKI bundle using recommendations from KDIGO and NICE, promoting a systematic approach to AKI. Each data cycle was collected within the medical admissions unit, over a 7-day period. Stage 1: Baseline data collection in MAU Stage 2: Introduction of AKI bundle and education via departmental teaching Stage 3: Re-audit, strategy development of bundle, involving nursing staff in implementation, and further education at hospital induction Stage 4: Re-audit with current findings Data was collected anonymously and retrospectively, via NHS Lothian clinical record system (TRAK).

60 patients were reviewed over the course of the project. - Correct identification of AKI increased by 25% - Medication review, consideration for renal imaging, and assessment of fluid status increased by 17%, 19% and 17% respectively. - Obtaining urine dip increased by 34% - Prescription of IV fluids reduced by 21%. - Blood test monitoring, sending a vasculitis screen and referral to renal were unchanged.

Introduction of the framework has successfully improved assessment, investigation and management of patients presenting with AKI. Of note is improvement in fluid assessment, appropriate IV fluid prescribing and obtaining urine dip which are key culprits in the mismanagement of AKI. Our future aim is to embed the AKI bundle into TRAK, for ease of access and implementation.

Victoria Leng

NHS Lothian

Introduction: Delirium is a neuropsychiatric condition which is independently associated with poorer outcomes, and is prevalent in those aged over 75. Early recognition and standardised pathways are key to delivering good delirium care. Despite this, there are no formal screening and standardised pathways in RIE ED. Baseline data suggested around 4% are being screened for delirium.

Aim: To increase screening for delirium from a baseline figure of 4% to 75% for patients aged over 75 years of age attending RIE ED, and also to ensure initial investigations were initiated in any patients who were found to be delirious on screening by the end of April 2022.

Method: With help from the project supervisor, a project driver diagram was produced. In combination with baseline data and pre-intervention surveys, the change ideas were formed. These were then tested through the Model for Improvement approach.

Results: In summary, a total of 25% of patients sampled had a 4AT completed.

Conclusion: Although the results fell short of the goal by a distance, it represented a significant improvement compared to the baseline. The improvement was proven to be sustained throughout a period of 62 days, across 2 PDSA cycles. Further analysis revealed significant variations in daily results. Strategies to decrease variations include further education and increasing accessibility to delirium care (e.g. standardised pathways). It is hypothesised that these strategies will be able to instil a stronger departmental culture which focuses more on delirium care and hence will form the basis of future PDSA cycles.

Brian Ng

University of Edinburgh; NHS Lothian

Ambulatory care pathways are important in the management of Acute Medical Patients, and provide an alternative to hospital admission – with the aim of improving patient experience, avoiding risks of inpatient-associated harms, and reducing pressure on inpatient and front door services. SDEC occupies a key role in NHS strategic policy, underpinned by tacit inference that the service provides patient safety.1 Is SDEC safe? Are any specific conditions less suitable for SDEC? We aimed to address these questions focussing initially on mortality of patients reviewed in SDEC at the Western General Hospital in Edinburgh (NHS Lothian), using data extracted from electronic patient records.

We assessed hazard ratios for mortality using the Cox proportional-hazards model, adjusting for age, sex, presenting condition, and SIMD.2 We tested the models' assumptions using standard methods to ensure robustness. Analysis included 4176 patients seen in a 250-day period between November 2020 and July 2021, and examined mortality between index presentation and the 9th of November 2022, a median follow up time of 18 months. There were 219 deaths (5.2%) throughout the study period. Patients had a median age of 56 years at index presentation, and 58% were female. The Modal SIMD was decile 10 (most deprived). Top 8 presenting conditions were Other, DVT, PE, low risk chest pain, headache, shortness of breath, cellulitis, and renal colic in that order. "Other" is a heterogeneous cohort that often just represents inaccurate booking. Patients seen for dyspnoea showed significantly increased mortality (aHR1.89 CI 95% 1.01-3.55, p=0.047), vs "Other" as the reference group. Hazard ratios for other conditions did not reach significance thresholds.

We aim to take this study forwards, reviewing our patients with dyspnoea to better understand the increased mortality rate seen, and analysing how this compares with outcomes in other urgent care settings. We will integrate insights into our care standards.

1. NHS. The NHS long term plan. 2019. https://www.longtermplan.nhs.uk

2. Cox, D. R. 1972. Regression models and life tables. Journal of the Royal Statistical Society, Series B, 34:187-220.

Amar Nanda <amar.nanda@nhslothian.scot.nhs.uk>

Western General Hospital, Edinburgh. NHS Lothian

A 56-year-old lady initially in presented acutely unwell via the medical take with tachycardia and hypertension. She underwent imaging and an adrenal mass was incidentally found. She then underwent laparoscopic adrenalectomy .Plasma metanephrines were elevated pre-op and histology revealed phaeochromocytoma (PCC) with a PASS score of 0/20 with SDHB immunostaining + indicating a very low risk of metastasis. She remained asymptomatic until 9 years later when she presented with palpitations and worsening hypertension. Plasma metanephrines were 3-4 times above reference range. Following diagnosis of bony metastasis from anatomical imaging and no avidity of the metastases with MIBG, Gallium Dotatate and FDG PET scans were arranged.

Despite being widely reported in the literature as having the lowest sensitivity out of the three imaging modalities. FDG-PET showed the most metastatic deposits: nodal, splenic and extensive bone metastases (C2, right humeral head, body of sternum inferiorly, T11-2, L4). MIBG and Gallium scan were less sensitive, with the Gallium Dotatate showing the least metastatic deposits. She was commenced 2-years later on denosumab and doxazosin for alpha-blockade. She continues to undergo on-going surveillance including annual metanephrines.

This case highlights clinicians should consider phaemochromocytoma in the list of differentials in younger individuals presenting with uncontrolled hypertension on the acute medical take. It also emphasises the relative inaccuracy of PASS score in predicting malignant behaviour in phaeochromocytoma. This patient presented with metastatic disease 9-years after initial surgery. It is also interesting to note the less sensitive performance of Gallium Dotatate when compared to other functional imaging modalities in identifying metastatic sites which is often the case in Cluster 2 PCC. The current recommendation is for 10-year surveillance in PCC post-resection. However, rarely, metastatic disease can occur afterwards. This case illustrates the need for more accurate scoring systems and other sensitive tumour markers for surveillance.

Arina Madan

Guy's and St Thomas' NHS Foundation Trust, London

Introduction: A 58 year old Afro Caribbean lady with Type 2 diabetes was admitted to the acute medical unit after presenting to the emergency department with severe right shoulder pain, high-grade pyrexia and left eye pain with visual loss. She had attended other emergency departments prior to this and had been prescribed several courses of antibiotics but no blood cultures had been taken. Past medical history includes Type 2 diabetes, ischaemic heart disease and hypertension. Methods: This lady underwent extensive investigative work-up to determine the underlying cause of her pyrexia. This included blood cultures, vitreous taps and PCR, MRI shoulder, CT thorax, abdomen and pelvis, as well as an echocardiogram. Results: The initial impression was septic arthritis due to severe right shoulder pain and pyrexia. However, an MRI shoulder showed degenerative changes and bursitis but no septic arthritis. She was investigated extensively to find a source of infection explaining her pyrexia. However, her blood cultures remained negative and her ECHO and CT TAP were unremarkable and this was initially treated as a case of pyrexia of unknown origin. However, a few days into her admission, the vitreous PCR from the vitreous tap performed by the Opthalmology came back as strongly positive for Streptococcus pneumoniae and Staphylococcus aureus. Subsequently, a diagnosis of left eye endopthalmitis was made. She was treated with several courses of IV antibiotics and intravitreal antibiotics including IV vancomycin, ceftazidime and moxifloxacin eye drops. She unfortunately has lost a significant amount of vision in her left eye with irreversible visual loss. Fortunately, her right eye was spared. Conclusion: This case highlights the importance of taking blood cultures before starting empirical antibiotic treatment. In this case, the vitreous tap was crucial in helping determine the underlying causative organism as it tested positive for Streptoccus pneumoniae and Staphylococcus aureus so targeted antimicrobial treatment could be given to the patient. This case also illustrates the relatively poor prognosis of endopthalmitis caused by Streptococcus pneumoniae.

Arina Madan

Guy's and St Thomas' NHS Foundation Trust, London

Introduction: Since the start of the Covid pandemic, bilateral pneumonitis changes have been frequently encountered in clinical practice and some patients with similar radiological features have been wrongly attributed to this aetiology due to clinical bias. We would like to present two such clinical scenarios where the clinical and radiological features were similar to Covid pneumonitis, but the diagnosis was entirely different and had a treatable cause.

Discussion: Daptomycin induced pneumonitis is a recognised complication of the drug, and patients should be actively monitored for these symptoms after initiation of this antibiotic. Daptomycin is effective against gram-positive bacteria and is being increasingly used in clinical practice recently. The presence of fever, new pulmonary infiltrates, peripheral eosinophilia and eosinophilia on Broncho-alveolar lavage where possible, and improvement of symptoms and resolution of CT changes after stopping Daptomycin and treatment with steroids point towards the diagnosis of Daptomycin induced pneumonitis. Early recognition of symptoms and prompt treatment with steroids after stopping Daptomycin will lead to a positive outcome in most patients.

Alarmeluvalli Sivaramakrishnan

University Hospitals of Coventry and Warwickshire NHS Trust

Introduction and Objectives

The treatment escalation plan (TEP) is a tool which prompts clinicians to define a ceiling of care for patients. The benefits of TEPs include facilitating timely decision making if a patient deteriorates, streamlining referrals to higher levels of care and encourages the inclusion of the patient and their family. This project aims to assess the percentage of patients admitted to HDU/CCU who have a TEP in place and to implement change to the HDU/CCU admission criteria which we hypothesise will increase usage of TEPs.

Methods

Baseline data was collected to identify the percentage of patients in HDU who had TEPs in situ daily. We undertook one PDSA cycle from 3/10/22-14/10/22. During cycle 1 we added a prompt to the HDU/CCU admission form to include the patient’s TEP and then on HDU/CCU the responsible consultants were encouraged to review the TEP form as part of their daily review. We then remeasured the percentage of patients in HDU/CCU who had TEPs.

Results

Baseline data (n= 83) showed that on average 30% of patients on HDU/CCU had a TEP form each day. Only 1 patient had the TEP prior to admission to HDU/CCU. Cycle 1 (n= 89) showed that this number increased to an average of 77% each day after the change was implemented; the number of patients who had a TEP before admission to HDU/CCU was 0.

Conclusions

The results show that the usage of TEP forms in HDU/CCU increased after the patients’ consultants were asked to review these daily. Patients rarely had a TEP in place prior to escalation to HDU, even after prompting the referring clinician to establish a ceiling of care. This shows that there are barriers to TEPs being used prior to patient deterioration and this highlights the need for further PDSA cycles.

Charlotte Watson

Inverclyde Royal Hospital

Nicole Haggarty

Western General Hospital, NHS Lothian

Lumbar puncture is a frequently used procedure in Acute Medicine for both diagnostics and therapeutics. Conventionally it is performed by using anatomical landmarks and without radiological optimisation. Patients who have difficulty in undergoing lumbar puncture often have multiple attempts by multiple practitioners using conventional methodology prior to escalation to specialties who have skillsets involving radiological optimisation. Evidence shows that patients undergoing Ultrasound Guided Lumbar Puncture (UG-LP) have higher success rates and have better patient experiences. We sought to assess the usage of spinal ultrasound in a subset of inpatients whom had multiple unsuccessful lumbar puncture attempts using conventional methodology.

Primarily, we wished to compare the total number of attempts required between conventional lumbar puncture and UG-LP in patients where conventional attempts had been unsuccessful. Secondarily, we wished to assess patient experience. This was a prospective study. The inclusion criteria was that the patient had had at least 2 unsuccessful lumbar puncture attempts using conventional methodology and had had attempts from at least 2 different clinicians. These patients who had not had a successful lumbar puncture with conventional methodology were then all referred to a clinician with spinal ultrasound experience for an attempt of an UG-LP. 11 inpatients met this criteria in a 6 month window in the Acute Receiving Unit. Data of the number of attempts using conventional methodology and number of clinicians was collected. Patients then underwent UG-LP. Data of the number of subsequent attempts with ultrasound guidance and number of clinicians was collected. Patients were asked to provide an opinion regarding whether they had a more comfortable experience between the conventional method and UG-LP.

The mean number of unsuccessful lumbar puncture attempts using conventional methodology, prior to escalation to a clinician with spinal ultrasound experience, was 3.73±0.79. The mean number of UG-LP attempts subsequently required in these patients, in whom conventional methodology was unsuccessful, was 1.18±0.40. 100% of patients had less discomfort undergoing UG-LP compared with attempts that were undertaken using conventional methods.

In Acute Medicine ultrasound is frequently used for point of care assessments and interventions. Lumbar puncture is one of the most common procedures in Acute Internal Medicine however spinal ultrasound is not a common skillset, nor is it a skill taught at Point of Care Ultrasound courses such as FAMUS (Focused Acute Medicine Ultrasound). The inclusion of spinal ultrasound teaching into Acute Medicine training and Point of Care Ultrasound courses would improve outcomes and comfort in patients who have unsuccessfully undergone conventionally performed lumbar punctures.

Abdurahman Tarmal

Inverclyde Royal Hospital

Introduction and Objectives

The Scottish Patient Safety Program states that 95% of patients should have a documented Medicines Reconciliation (MR) process within 24 hours of admission1. A novel intervention was devised that incentivised completing an accurate MR, ensuring withheld medications are prescribed on admission and to clearly document the reason for withholding medications.

Method

The clinical notes and drug charts of 107 patients admitted to Borders General Hospital Medical Admissions Unit (MAU) were reviewed to evaluation MR quality and prescribing practices. During 2 weeks of feedback, the same data was collected from 129 patients including the admitting practitioner and the post-taking consultant. Individuals received feedback on their individual MR and prescribing practices throughout this period. Feedback was mostly positive and included a whiteboard with “top-10 prescribers” and “med-rec hero” in the MAU doctors’ office. Individual feedback was also given via email, WhastApp and posters. The clinical notes and drug charts of 70 patients admitted through the MAU over a 1-week period were then reviewed to determine the impact of the intervention.

Results

The proportion of patients with a MR increased from 74% to 94%, the proportion of withheld medications appropriately prescribed on the drug chart increased from 67% to 95% and the proportion of medication with a documented reason for withholding increased from 72% to 81%.

Discussion

An accurate MR and clear documentation of withheld medications reduces prescribing errors, allows prompt reintroduction of medications and makes restarting medication safer2,3. Providing positive feedback to prescribers improved the quality of all these measures. Positive feedback to clinicians on their own practices could be adopted to improve other areas of the admission process such as documentation of escalation and resuscitation status, prescribing thromboprophylaxis or antimicrobials, documentation of delirium scores or falls risk, documentation of peripheral cannulation or catheterisation or obtaining a collateral and social history.

References

1. Healthcare Improvement Scotland, Primary Care - Safer Medicines, 2016. http://www.scottishpatientsafetyprogramme.scot.nhs.uk/ programmes/primary-care/safer-medicines 2. Witherington EMA, Pirzada OM, Avery AJ (2008) Communication gaps and readmissions to hospital for patients over 75 years and older: an observational study. Qual Saf Health Care. 2008; 17: 71–75 3. Forster AJ, Clark HD, Menard A, et al. Adverse events affecting medical patients following discharge from hospital. CMAJ. 2004: 170: 345–9

William Stanley <william.stanley@nhs.scot>

NHS Borders

Abstract Title: Same Day Emergency Care (SDEC) Staff Wellbeing - ‘Joy in Work – Lothian Improving Staff Experience’

Lead Author: Emma Savory Sarah-Jane Breen Adam Rouse

Introduction & Objectives SDEC is a unit based at the front door within the Western General Hospital. The multidisciplinary team consists of Doctors, Advanced Nurse Practitioners, Clinical Fellows, and Health Care Support Workers – 30 individuals with diverse backgrounds and skill sets.

Individuals within the team were nominated to participate in NHS Lothian’s Improving Staff Experience Programme. The programmes vision centres around the IHI Framework for Improving Joy in Work (Perlo et al., 2017). This aims to increase joy, reduce burnout, and reduce turnover, by guiding staff members in a participative process by asking “What matters to you?”.

Aim & Methods When approaching “What matters to you?” we facilitated informal discussions with 18 members of the SDEC team. These questions focused on what mattered to the team members overall, as well as what makes a good or bad day and how they felt a bad day could be improved.

By utilising the Double Diamond Approach (Council, 2021), we formed our aim. A driver diagram was created, proposing multiple change ideas. Staff leaving on time was predicted to improve staff morale and improve work/life balance.

Results & Conclusions Run chart results indicated that percentage of staff leaving on time was inconsistent and did not demonstrate any improvement patterns. SDEC closure and relocation is understood to have negatively impacted potential for improvement.

However, staff feedback of the implemented processes was extremely positive, resulting in a team decision to continue with the evening huddles moving forward. These huddles provided better structure to the unit, with increased patient journey awareness.

Moving forward further changes will be made to the evening huddles regarding paperwork and the introduction of an alarm prompt. To progress the team will work to understand the new system they now face due to relocation and discuss how this affects what matters to them in future.

References: Perlo, J., Balik, B., Swenson, S., Kabcenell, A., Landsman, J. and Feeley, D., 2017. IHI framework for improving joy in work.

Council, D., 2021. What is the framework for innovation? Design Council's evolved Double Diamond. Design Council.

Emma Savory

Western General Hospital, NHS Lothian

A 62-year-old Bangladeshi man with Type 2 Diabetes was admitted acutely dyspnoeic and hypoxic to the admissions unit. He had initially presenting to his GP acutely short of breath and was found to be desaturating on exertion. He had been recently discharged from hospital following contracting COVID-19 and had been unable to resume work as a waiter. The top differential diagnosis when he was initially admitted was pulmonary embolism and CTPA showed widespread ground-glass and fibrotic changes. A diagnosis of COVID pneumonitis and early-stage fibrosis was made. The patient was advised that his symptoms were due to post-Covid fibrosis and he was discharged with safety-netting advice. He then represented more acutely dyspnoeic on 2 separate occasions in the next few weeks and was treated with a prolonged course of steroids and antibiotics, with clinicians still suspecting this was COVID pneumonitis. On the third hospital admission, persistent dyspnoea and desaturation on exertion led to him being tested for Pneumocystis carinii pneumonia which came back as positive. His HIV test was negative but the prolonged course of steroids for COVID-19 likely adversely affected his glycaemic control and made him more immunocompromised. He had a second CTPA and in the context of the positive swab, ground-glass changes were interpreted as superadded infection and not just fibrosis. He was treated with co-trimaxazole and made a good recovery. After being reviewed in chest clinic , it was noted that eosinophils had been persistently high during his inpatient admissions but this had been attributed to COVID-19. An ELISA test for Strongyloides stercoralis was done which was positive and the patient underwent successful treatment with ivermectin. This case demonstrates that even in the context of COVID pneumonitis, persistent symptoms despite treatment should raise suspicion of alternative differential diagnoses’. There is a risk of clinician bias in attributing all respiratory symptoms to COVID-19 sequelae. Clinicians are urged to recognise that patients may become immunocompromised due to prolonged steroid treatment for COVID-19, which puts them at risk of other opportunistic infections, which should not be missed.

Arina Madan

Guy's and St Thomas' NHS Foundation Trust, London

REVIVE Research into the Effects of Virtual reality in the Improvement of Vital signs and Intensive care patient Experience

Patients admitted to the intensive care unit (ICU) are subjected to painful interventions and dynamically changing environments. Prevalence of anxiety and post-traumatic stress disorder is particularly high in this population (1). There is growing evidence that immersive Virtual Reality (VR) can be used as a non-invasive and non-pharmacological adjunct to reduce pain in patients admitted to the intensive care settings (2). Hoffman et al, identified that VR can be an effective adjunctive therapy for pain control in patients admitted for burns and other studies have identified that VR can be used to alleviate pain and anxiety while reducing time to complete procedures in children e.g. peripherally inserted central catheter (3).

This study aims to evaluate the effectiveness of VR use as an adjunct to analgesia in managing pain, vital signs and well being in ICU patients.

18 participants were identified according to strict inclusion criteria. Criteria outlined that patients must be in ICU level 0-1 care, have a Glasgow coma score of 15 and aged over 18 years. Patients were excluded if they had any of the following criteria: experiencing delirium, pre-existing mental health disorders or currently taking patient-controlled analgesia. 14 patients admitted to surgical and medical intensive care units were consented into this cross-sectional study. Each individual selected one of a selection of VR experiences that incorporated breathing techniques with relaxing visuals. A proforma was used to measure primary outcomes including vital signs, anxiety and pain scores before and after the VR scenario. Secondary outcomes looked at whether the patient enjoyed the experience and requested more VR experience.

This study reported reduced anxiety scores in 13 out of 14 patients, 36% of participants reported a reduction in pain scores. Vital signs showed a reduction in pulse rate 30 minutes post-VR compared to before VR experience in 50% of the cohort and 57% had lower respiratory rate post-VR. 86% showed that they would like to have further experience with the VR scenario with patients commenting that they found the experience ‘relaxing’. This pilot study has found promising data that VR could be an effective adjunct to achieve analgesia and anxiolysis. The overall improvement in pain and wellbeing suggests that there is scope for use of VR as an adjunct in medical care, particularly highly traumatic settings such as ICU where this service could aid outcomes. Evidence of improved vital signs provides scope for further study of identifying the effectiveness of VR in health outcomes and hospital stay duration.

Farishta Khan

The Dudley Group NHS Foundation Trust, Russells Hall Hospital

Introduction: Over the last year, patients have been spending more of their hospital journey in CAU, as demands on the service have increased and hospital flow has slowed. This results in the acute medicine team spending more time reviewing these patients daily to ensure progression of care. This has proved challenging to balance with the other demands in CAU. By introducing a standardised proforma, our aim was to improve communication within the team and reduce time spent documenting reviews. Method: We used the PDSA method of quality improvement. We collected baseline data by reviewing the notes of 14 patients on a selected day. We then created a ward round template and ensured emphasis was placed on areas that were often missed in the ward round entries from our baseline data. Members of the CAU team then tested the proforma during their reviews over a two-week period. We then reaudited reviews which had used the proforma and surveyed staff for qualitative feedback. Results: The proforma improved documentation of planned discharge date by 35.7%. In addition, record of antimicrobial indication and duration improved from 57.1% to 92.8%. The template increased documentation of page number of reviewing doctor from 42.9% to 85.7%. It also highlighted days since last consultant review, with 92.8% of doctors documenting this in the proforma. The survey showed that all participants felt the proforma outlined a comprehensive assessment for patients and helped standardise documentation, however many felt it was too lengthy and slowed the reviewing process. Conclusion: Our proforma encouraged improvement in key areas of documentation and was generally well received, although requires alterations to ensure both comprehensive yet timely reviews. We plan to do a further PDSA cycle and condense the proforma to a small reminder card to see if this is effective and more acceptable to staff.

Sophie El-Nahas

University Hospital Crosshouse, NHS Ayrshire and Arran

Introduction and Objectives RCPE’s Trainees and Members’ Committee (T&MC) recognised the need to deliver a new form of flexible and remote medical education during the COVID-19 pandemic and the podcast series COVID-19 Conversations was launched by T&MC members in March 2020. In August 2020, this evolved into Clinical Conversations. The main objective of Clinical Conversations is to meet the educational needs and support professional development of internal medicine trainees. Feedback and usage have been evaluated since podcast launch. Methods Clinical Conversations is designed by trainees, for trainees. Episodes are released fortnightly. Each episode consists of a T&MC member(s) interviewing an expert speaker(s) to discuss key learning points for trainees and guideline updates. RCPE staff provide administrative, editing and quality assurance, and publicity support. Figure 1 displays the production process. Podcast statistics are collated monthly from the host platform (SoundCloud) and major distribution platforms, and analysed Results As of 1 December 2022, 74 episodes have been released and there have been >80,000 plays across all platforms There are >1,500 followers on Spotify alone Written feedback from RCPE’s Evening Medical Update attendees is used to inform future episode planning All-time cumulative plays (Figure 2) and monthly plays (Figure 3) are provided for host and main distribution platforms Conclusions As the success of Clinical Conversations continues to grow, the role of podcasts in medical education is clear Our work and listenership demonstrate that trainee-led and -delivered medical education podcasts can provide a reliable and popular source of continuing professional development In October 2022, T&MC launched a new career-focussed podcast, Career Conversations, which will be similarly evaluated

Jonathan Bardgett

Royal College of Physicians of Edinburgh

Background Communities are pivotal to affecting behavioural change as they have a wealth of knowledge on how healthcare providers can best meet their needs, as demonstrated by the vaccine equity uptake efforts. NHS ‘Anchor Institutions’ rooted in local communities are increasingly encouraged to use their resources to benefit their local community.1 As an Anchor institution Imperial College Healthcare NHS Trust (ICHT) is trialling a new approach to build regular Trust presence at Westminster’s local community to provide meaningful engagement, understanding and co-production to improve population health and reduce health inequalities.

Approach ICHT engage the community at a Westminster City Council monthly run market in Church Street, one of the most deprived wards of the borough and have an open discussion on “what matters to you”. ICHT Strategy and Patient Experience and Engagement Team routinely assess and share this feedback with the trust to identify possible solutions to improve services, health outcome and tailor future community engagement activities.

Results/Evaluation The feedback provided different perspectives on key Trust improvement areas for example challenges with trust transportation provision and interpreting service which were not seen through existing trust feedback mechanisms. Insights were also fed back to support the Trust’s equity improvement work to reduce higher outpatient “did not attend” rates in the deprived and ethnic minority patient cohorts. ICHT community presence also promoted job opportunities, health checks, midwife representative, signposting available services and providing pre-requested information.

Conclusions It is important that ICHT develops deep seeded trust and relationships with the population it serves, using opportunities to truly listen to what is important to the local community and improve access and experiences accordingly. This work demonstrates the need for healthcare providers to look beyond existing patient gathered feedback and traditional patient involvement mechanisms and transition out of their comfort zones into the community.

Zahra Arzoky

Imperial College Healthcare Trust