QUALITY IMPROVEMENT REPORT

Improvement in the management of acutely poisoned patients using an electronic database, prospective audit and targeted educational intervention

S L Greene¹, D M Wood¹, I B Gawarammana², C Warren-Gash³, N Drake⁴, A L Jones⁵, P I Dargan¹

¹ Guy’s and St Thomas’ Poisons Unit, London, UK
² University of Peredeniya, Sri Lanka
³ UCL Centre for Infectious Disease Epidemiology, London, UK
⁴ Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, UK
⁵ University of Newcastle, NSW, Australia

Correspondence to:
Dr D Wood, Guy’s and St Thomas’ Poisons Unit, Avonley Road, London SE14 5ER, UK; david.wood{at}gstt.nhs.uk

Problem: The need to improve the clinical assessment and management of acutely poisoned patients presenting to an NHS hospital emergency department (ED).

Design: Creation of an electronic clinical toxicology database to prospectively collect all aspects of clinical information on poisoned-patient presentations. Systematic analysis of collated information to identify shortfalls in patient assessment and management. Bimonthly audit meetings, and design and implementation of educational interventions to address identified shortfalls. Ongoing audit to demonstrate continued improvement in patient care.

Background and setting: ED in tertiary-level inner-city London teaching hospital. Study conducted by staff from the ED and clinical toxicology service.

Key measures for improvement: Demonstration of overall reduction in the incidence of predefined shortfalls in patient assessment and management during 12-month study period.

Strategies for improvement: Targeted educational lectures and case-based clinical scenarios addressing identified deficiencies in the knowledge required to effectively manage poisoned patients. Weekly case-based anonymised feedback report sent electronically to staff involved in caring for poisoned patients.

Effects of change: Implementation of targeted teaching of ED staff and regular electronic distribution of teaching cases. Between the first and second 6 months of the study, there was a significant increase in the proportion of presentations for which clinical management was graded as "good" (77.6% to 89.4%, p<0.0001) and a significant reduction in the proportion of "major" (9.9% to 5.8%, p = 0.012) and "minor" (12.6% to 4.8%, p<0.0001) shortfalls.

Lessons learnt: Systematic collection of clinical information, using a dedicated electronic database and subsequent review and audit of collated data by interested clinicians, enabled design and implementation of targeted educational interventions to address shortfalls in patient management. This process has led to significant improvements in the clinical care of acutely poisoned patients presenting to the ED.

Keywords: poisoned patient; poisoning; database; toxicity; clinical audit; educational intervention

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