1. Management of infective endocarditis- a Quality Improvement project
G Nayar , M Albur, J Abramik, J Graby, A Thompson, S Aziz – North Bristol NHS Trust
Background
Infective endocarditis (IE) is a rare but serious medical condition with varied clinical manifestations, that is almost invariably fatal if untreated. There are guidelines outlining how patients with suspected IE should be investigated, but some physicians find them convoluted.
The incidence of infective endocarditis (IE) in patients with Staphylococcus aureus bacteraemia (SAB) is 10-30%. British, European and American guidelines recommend an echocardiogram (ECHO) routinely for all patients with SAB. If the clinical suspicion of IE is high, they recommend that the ECHO should be done within 24 hours of the positive blood culture.
In 2013, we performed an audit, which showed suboptimal performance in 1) investigating patients with suspected IE and 2) obtaining ECHO for patients with SAB. This led to a quality improvement project to improve the investigation and management of such patients.
Timeline of Quality Improvement Interventions
Must not be more than 400 words
Methodology
In 2013, an audit at North Bristol trust showed that only 51% of patients with SAB had ECHO performed. It also showed that in patients with confirmed endocarditis, ECHO had been delayed in 54% of cases and only 64% of patients had three sets of blood cultures taken. Following this, a simple flow chart for the investigation of IE was created, which was easily accessible on the hospital intranet.
In 2016, this Quality Improvement project was restarted and utilising PDSA methodology, we investigated whether the introduced changes had made any impact. Based on our findings, focus group discussions and literature reviews, we implemented further improvements.
Reviewing the impact of previous recommendations
Educational tutorials for junior doctors and consultants
Uploading guidelines onto Intranet
Enable micro SpR to request echocardiograms
Improve ICE requesting system for echo and blood cultures
Nov 2016 – Jan 2017
Apr 2017 – May 2017
June 2017
Planned for November 2017-January 2018
Uploading flowchart for the investigation of IE onto the intranet
Outcome measures and targets
100% of patients with ? IE should have an urgent ECHO
100% cases of patients with ? IE should have three sets of blood cultures
100 of patients with ?IE should be discussed with microbiology
100% of patients with SAB should have an ECHO
Performance in 2013 (blue) and 2016 (red)
in obtaining ECHO in SAB
71%
51%
Further work
Further PDSA cycles are required in order to evaluate the full impact of the interventions.
Further interventions are required to improve time to ECHO for patients with SAB. At present, only consultants can request ECHOs. Soon, microbiology SpRs will be able to request ECHOs.
We are making improvements to the computer requesting system for patients with IE, such as an electronic prompt to take three sets of blood cultures and information on how to make urgent ECHO requests.
We were unable to reach some of the doctors in the hospitals with our tutorials. Including it in the doctors induction to the trust could be trialled.
Conclusion:
Overall, Quality Improvement interventions have led to an improvement in the investigation of patients with SAB and also of those with suspected IE
The improvements have been extremely well received by key stakeholders who are keen to engage with the project to achieve optimal quality of care.