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BSIRQI Site Assessment Proforma
Using this form:
The questionnaire is designed to allow Interventional Radiology departments to assess their services over four domains; defining scope of services, providing good quality care, patient focus and service improvement. Services that already fulfil the key domains will be eligible for inclusion as an exemplar site. Some services will need to work towards achieving the key domains and these departments are invited to submit for inclusion as a pilot site.
Please click on the grey section after the question and a checkbox, dropdown or textbox will be available for entry. Save the form with a filename that indicates your site.
This questionnaire should be submitted by email to [email protected]. We aim to acknowledge receipt of all submitted forms within 3 working days.
Further information about quality improvement is available at www.bsir-qi.org
Definitions:
Local lead for this BSIRQI site: a clinician that takes responsibility for the quality of Interventional Radiology services. This does not need to be the local clinical lead or clinical director.
Formal rota: a rota that is distributed in advance with a named radiologist and contact details for each on-call period. If you have a formal rota but it does not cover 100% of time, then this is defined as an adhoc rota.
Adhoc rota: any system that permits contact with a list of radiologists who are not on-call but may be available to undertake intervention.
Formal network pathway: a documented patient pathway between two separate hospitals that has been agreed and signed off by both parties.
1Jan 2015
BSIRQI Site Assessment Proforma
Name of person completing this form: Dr Kate Waters, Consultant Interventional Radiologist Date of Completion: 18/02/2015
Contact email: [email protected] Application discussed with Team? Yes
Name of local lead for this BSIRQI site: Dr K Waters / Dr M Glasby (Vascular Radiologist, Head of Service, Leicester Royal Infirmary)
Contact email: [email protected], [email protected]
About Your Unit
Name of Unit: Department of Interventional Radiology, University Hospitals Leicester NHS Trust
Number of Radiologists overall: 53 Number of Interventional Radiologists: 14 (6 Vascular / 8 GI/GU)
What referral services does your unit cover?
Referral service Referral service Referral service
Acute Medical Yes Acute Surgical Yes Urology services Yes
Major Trauma Yes Gastrointestinal Bleeding Yes Renal Services Yes
2Jan 2015
Renal dialysis Yes Obstetric services Yes Gynaecology services Yes
Oncology Services Yes Transplant Yes HPB Yes
Gastrointestinal Intervention Yes
Domain: Defining Scope of Services
What services does your IR unit provide in hours?
Procedure Provided in this unit Formal referral pathway to neighbouring centre
No provision and no formal pathway
Nephrostomy Yes
Biliary drainage / stenting Yes
Oesophageal / colonic stenting Yes
Endovascular Intervention (angioplasty/stent lysis) Yes
Embolization- haemorrhage Yes
TIPSS Yes
EVAR Yes
TEVAR Yes
FEVAR – complex endovascular repair Yes
3Jan 2015
Uterine Fibroid Embolization Yes
Interventional Oncology Yes
Renal access intervention Yes
Vascular access Yes
Venous intervention Yes
IVC filter insertion Yes
What services does your IR unit provide 24/7?
Where there is an adhoc rota, please provide a percentage of the time this can be covered by a rota.
Procedure Formal Rota Adhoc Rota % of Time Covered
Not Available
Nephrostomy Yes
Endovascular Intervention Yes
Embolization Yes
TIPSS No* No
4Jan 2015
E- TEVAR Yes
E-EVAR Yes
IVC filter insertion Yes
Biliary Drainage Yes
*Pts are optimised out of hours for in hours TIPSS to be performed.
If you do not provide IR services 24/7, do you have formal written agreements and protocols with a neighbouring centre?
Procedure Formal written Network Recipient Centre
Nephrostomy N/A
Endovascular Intervention N/A
Embolization N/A
TIPSS No
E-TEVAR N/A
E-EVAR N/A
IVC filter insertion N/A
Biliary Drainage N/A
5Jan 2015
Domain: Providing Good Quality Care
Which of the following does your service participate in?
Weekly Monthly Every 2 months Other
Departmental Discrepancy Meeting Yes
IR Team Meeting Yes
Morbidity and Mortality Meeting Yes
Do you have clinical MDTs in the areas that your services cover?
Yes
Has your service conducted an audit of the above meetings in the last year?
Departmental Discrepancy No Multidisciplinary team Yes Morbidity and Mortality Yes
Each unit should produce an example of an audit /audit cycle in one of these areas with evidence of achievement: Specify the nature and outcome of the audit
Morbidity and Mortality data audit. April 2014.
6Jan 2015
Audit of patients who had died within 30 days of an interventional radiology procedure performed within University Hospitals Leicester over preceding 6 months. All unexpected deaths/outliers interrogated. Audit findings: Management of displaced RIGS inconsistent. Miscoding for some procedural events which skews audit data. Outcomes: RIGS complications: need to improve liaison with nutrition team within the trust. This has happened and we now have dedicated pathway for management of RIG complications with nutrition team taking initial referral and attempting reinsertions or exchanges, and any problems that cannot be sorted by them subsequently referred to the IR department and three dedicated IR radiologists. Radiographers educated re need for correct CRIS codes to accurately reflect IR work.
Which of the following registries has your service contributed to in the last 6 months?
Registry Registry Registry
BIAS Iliac Angioplasty Yes Biliary Yes NVD: AAA/EVAR Yes
International Spinal Plasty No International Colorectal Yes
Exemplar sites must have completed an audit on their contribution to the BIAS registry in the last 12 months.
Audit on BIAS registry contribution: 108 iliac procedures performed in 2014. 103 iliac procedures entered onto BIAS registry: 95.4% submission of cases.
Domain: Patient Focus
7Jan 2015
Does your service provide written patient information for IR procedures? 100%
Do your in-patients receive written information? Yes Do your out-patients receive written information? Yes
What is the source for written information: In house
Has your service conducted an audit of patient information in the last year? Yes
Please specify the nature and outcomes of this audit:
In patient - Patient Information Leaflet (PIL) Audit. In patients attending the IR dept at Leicester General Hospital were audited using a questionnaire to determine whether they had received a Patient Information Leaflet (PIL) about their procedure prior to attending the IR department. The audit highlighted disappointingly low prior-delivery of PILs to in patients for both vascular and Non vascular procedures. Audit Outcomes: Audit findings prompted a review of practice, with education of both intervention staff and ward teams regarding need for PILs and process of delivery. Copies of all PILs have been sent to the relevant wards with specific instructions for reordering these forms if the wards run out. IR staff asked that when confirming appt time for an in patient’s procedure that the ward staff are also asked to give the patients a PIL and document in the patient’s notes that this has been done.
We are within 3 months since change instigated and are due to re-audit within the next month, but preliminary anecdotal evidence shows that patients have improved access to PILs.
Does your service provide a pre Intervention Clinic? Yes
If yes frequency: Weekly, for both pre-procedure assessment and follow up of pts after procedure performed.
8Jan 2015
Does your service use the NPSA/WHO Safe Surgery (IR) checklist or similar? Yes, the WHO Safe Surgery IR checklist.
Has your service audited the use of the NPSA Safe Surgery check list in the last year? Yes.
Domain: Service ImprovementWe are keen that exemplar sites provide examples of service improvement in Interventional Radiology that we can share on the website and with other units. Your example should provide a solution that improved the local Interventional Radiology service. The example might, for example, describe how you have better utilised stock or solved a staffing issue etc.
Please submit at least one example of service improvement using the following headings:
Service Improvement Example 1:
Reducing in-patient and outpatient waiting times for vascular access procedures
What was the problem?UHL did not have a robust vascular access service that could cope with the increased demand for complex vascular access so there was a long waiting list (up to 8 weeks) for both in-patient and out-patient vascular access procedures.
What changes did you make?A team of specialist nurses were trained under direct supervision by one of the IR consultants to provide basic vascular access techniques to in patients at Leicester Royal Infirmary. This service started with one specialist nurse who has subsequently expanded the team which now employs 2 full time specialist nurses, 1 part time specialist nurses, 1 RDA and a radiographer. What were the key steps in making the changes happen?Using skill mix to train specialist nurses to perform vascular access services. Funding was initially obtained for a year ’s nursing secondment, which subsequently became substantive. This team is now an independently practicing arm of our IR department, covering the Leicester Royal Infirmary and Glenfield hospitals, and currently in the process of further expansion to provide a routine Vascular Access service to the third of the three UHL hospitals.
9Jan 2015
What improvements have you seen?Out-patient waiting lists for vascular access have been cut down from up to 8 weeks to 24 hrs wait for an OP appointment. In patients routinely have their vascular access procedure within 24 hours of request. There is a dedicated vascular access suite at Leicester Royal Infirmary and Glenfield Hospitals.The service has been audited and found to be a safe and effective service. This has been published (Vascular Access Society Britain and Ireland, Annual Meeting, 2013)
What would you do differently?Improved securement of funding prior to cross site expansion.
Service Improvement Example 2:
Increased Radiology Scrub Nurse Provision: What was the problem?Under utilisation of potential skills of Radiology Department Assistant (RDA) staff members that would free up trained nursing time for other areas of activity.
What changes did you make?
A rolling Radiology scrub competency package was put in place for RDAs to become fully trained scrub assistants. Through this training scheme we now have 3 fully trained RDA scrub assistants and a fourth in training, thus has enabled the IR department to free up time for trained nurses for other activities. This additional scrub nurse provision supports increased day case provision as there are more trained nurses available to support this service.
What were the key steps in making the changes happen?
10Jan 2015
A realisation of potential ability of RDAs. In house training scheme was created for RDAs to become competent in assisting IR procedures, supported by senior nursing and medical members of the team. Interview application process for RDA scrub nurse training. The RDAs are trained by the IR department Sister with in house assessment of competency of core skills.
What improvements have you seen?Extra scrub assistants in-hours means we are able to perform more day case procedures and free up nursing time for other service development. One future aim is to incorporate the trained RDA scrub assistants onto the 24/7 scrub assistant rota.
What would you do differently?Seek out a formal qualification for the RDAs who participate in this scheme.
Service Improvement Example 3:
Nurse led nephrostomy changes
What was the problem?Lack of capacity in the routine nephrostomy change service. Lengthy in-patient waits for patients with blocked nephrostomies. What changes did you make?An experienced radiology nurse has been formally trained by an IR consultant in the change of nephrostomies and dealing with blocked nephrostomies. They are currently being trained to practice under indirect supervision and deal with standard nephrostomy changes and deal with blocked nephrostomies.
What were the key steps in making the changes happen?Identification of need for service change. MDT meeting to discuss possible solutions for the problem.Employment of skills mix to educate and train nurses.Period of training and assessment for radiology nurse under direct supervision of IR consultant.
11Jan 2015
What improvements have you seen?This initiative is in its early phase with Radiology nurse in training currently and able to practice under direct supervision. We envisage that we will be able to have nurse led lists remotely supported by IR consultants, with direct support for challenging cases when required. This will reduce in patient waiting times and hence hopefully we will see an impact of reduction on bed occupancy.
What would you do differently?Have audited bed occupancy for nephrostomy patients prior to commencing this project.
Service Improvement Example 4:
In-patient pre-procedure planning improvement service.
What was the problem?In patients attending for biliary and biopsy IR procedures without adequate pre-procedure information sometimes resulting in procedures being cancelled.Patients attending without appropriate pre-procedure bloods available, and not being NBM when required.
What changes did you make?Radiology nurse and RDAs were trained in appropriate delivery of pre-procedural information directly to patients on the wards, and in the checking/requesting of appropriate blood tests. They routinely visit the biliary / ultrasound guided biopsy patients on the ward prior to the procedure to deliver a PIL and check suitability for procedure.
What were the key steps in making the changes happen?Identification of need for service change. MDT meeting to discuss possible solutions for the problem.Employment of skills mix to train nurses and RDAs in delivery of this new service.
12Jan 2015
Training of other nurses and RDAs to release time for new service provision
What improvements have you seen?Improved in-patient biliary and biopsy service with reduction in postponed/cancelled procedures due to inadequate pt preparation.
What would you do differently?We would have done a pre service implementation patient satisfaction survey to have a bench mark for whether pt experience has improved with the delivery of this service.
Based on your responses to the questions above, please indicate which category you think your service fulfils.
Exemplar Site: already fulfills the main domains above
Further Comments
13Jan 2015
