Documentation of lumbar punctures - Neurology DIU

Dr Michal RolinskiDr Hannah Rowe

Supervised by Dr M Turner

Learning To Make a Difference

ORH NHS Trust

BackgroundBackground• 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

Learning To Make a Difference

ORH NHS Trust

Project AimsProject Aims

• 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

Learning To Make a Difference

ORH NHS Trust

Action PlanningAction Planning

Act Plan

Study Do

What are we trying toaccomplish?

•Increase in LP documentation meeting required standard•Increase in samples sent with paired serum glucose to 100%

How will we know that achange 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 makethat will result inimprovement?

•Formal education session

•Information leaflet

Learning To Make a Difference

ORH NHS Trust

Learning To Make a Difference

Lumbar puncture processLumbar puncture process

ORH NHS Trust

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

Lumbar puncture indicators

IndicationContraindicationsConsent documentedPosition in which the LP was performedUse of aseptic techniqueType of anaesthetic usedDose of anaesthetic used Site of spinal needle insertionSize of spinal needle usedNumber of attempts at needle insertionOpening pressureAny peri-procedure complication?Post-procedure advice givenLP results documented

Fig1

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MethodsMethods

ORH NHS Trust

14 January, 2011

Month 0 Month 1 Month 2 Month 3

QIP timelineQIP timeline

• 26 patient notes reviewed

• LP’s performed by 7 SHO’s ( 2 FY2’s, 3 CT1’s, 2 CT2’s)

• No formal LP training undertaken prior to QIP

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Data collectionData collection

ORH NHS Trust

What difference has been made?What difference has been made?

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ORH NHS Trust

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 documentationLP documentation

ORH NHS Trust

Fig 3

•Majority of indices improved after interventions

•Position LP performed p=0.0032•Site needle inserted p=0.0114

•Documentation indication (57%) and LP results (43%) remained poor

•After both interventions 100% documentation of 9/14 indices• Fig4

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LP documentationLP documentation

ORH NHS Trust

Indicators Before interventions After both interventions p valueIndication 22% 57% 0.3024Contraindications 33% 86% 0.0601Consent documented 89% 86% 1.0000Position in which the LP was performed

22% 100% 0.0032

Use of aseptic technique 78% 100% 0.4750Type of anaesthetic used 78% 100% 0.4750Dose 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

• Paired serum glucose samples sent increased to 100%

• p=0.0885 fig5

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Paired serum glucosePaired serum glucose

ORH NHS Trust

Fig 5

• Interventions led to a significant improvement in the documentation of LP’s 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 LP’s performed in the afternoon)

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DiscussionDiscussion

ORH NHS Trust

Next StepsNext Steps LP leaflet currently going through departmental approval process

Aim to provide LP education session and information leaflet as part of induction process to all SHO’s 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!

Learning To Make a Difference

ORH NHS Trust

ReferencesReferences

Learning To Make a Difference

ORH NHS Trust

1) 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