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Abstract
This project aimed to address the issue of patients experiencing prolonged fasting periods before undergoing abdominal ultrasound scans in a busy surgical service at our hospital. A review of in-patient data revealed that 78% of patients were not following the recommended 6 hours fast before the scan. This led to poor patient experiences, prolonged diagnosis and management, and increased costs due to rescheduling of scans. To address this problem, a series of plan-do-study-act (PDSA) cycles were implemented to test different interventions aimed at improving staff awareness and compliance with fasting guidelines. The first PDSA cycle involved displaying a poster with fasting instructions in the doctors and nursing offices. This was followed by increasing awareness of guidelines during meetings and presenting the findings at a teaching session. Each PDSA cycle was followed by data collection to assess the impact of the intervention. The project resulted in an improvement in patient experiences, with 88% of patients being appropriately fasted by the end of the project. The study highlights the importance of using PDSA cycles to test and refine interventions and the positive impact of simple interventions on patient outcomes and clinical workflow.
- Surgery
- Clinical Audit
- Patient-centred care
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
There are robust guidelines that exist for patients requiring abdominal ultrasound scans. The Society and College of Radiographers and British Medical Ultrasound Society state patients should be fasted 6 hours before their scan to optimise their ultrasound scan. This study was important to conduct as some patients were subjected to prolonged fasting times.
WHAT THIS STUDY ADDS
This study highlights that these guidelines exist for radiological scans and that simple interventions can have a large impact on patient experience, outcome and clinical workflow.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Our study demonstrates that PDSA cycles are robust and useful in addressing common problems within hospitals and is something all departments should consider when improving patient care.
Problem
Among inpatients who are admitted under the general surgery team, patients can sometimes present with acute abdominal symptoms. This, therefore, provides an indication for these cohorts of patients to undergo radiological imaging. Ultrasounds can be a useful imaging modality that can allow surgeons to diagnose acute abdominal pathologies.1–3 In order for patients to have a successful ultrasound scan, it is essential they do not eat 6 hours before the scan.4 However, in our hospital, we have found that some patients had breached this instruction, leading to some patients not eating for over 6 hours. To understand the problem further, a review of general surgery in-patients at our hospital was conducted, which revealed that 78% of in-patients were not being fasted as instructed by the radiology department. Of note, 33% of patients were not fasted for at least 6 hours because there were no fasting instructions documented in their notes.
Our general surgery services are located primarily at our hospital in undisclosed location, which serves a diverse population. It compromised of an upper and lower gastrointestinal team which sees as variety of acute surgical presentations. It is a busy surgical service with a high turnover of patients. We recognise that understaffing and the volume of patients can impact the problem. This project aims to ensure that patients are fasted appropriately within the recommended standards to improve their experience and ensure that the ultrasound scans are successful.
Background
It is recommended that patients who require abdominal ultrasound scans do not eat for 6 hours. This ensures that the gallbladder remains filled with fluid and reduces the amount of air in the gastrointestinal tract.5 It also allows for better visualisation of the biliary tract and gallbladder.6 7 It is important that patients are not fasted for time periods above this as it can worsen patients’ experiences in hospital, increase risks of complications in certain groups of patients (eg, patients with diabetes) and can prolong the period to formulate a diagnosis and initiate management plan.7 Furthermore, the quality of the scan may be inadequate and may result in the patient needing the scan to be rescheduled, which is not cost-effective.
The current trust policy at our hospital states that patients requiring ultrasound scans of the abdomen should not eat for 6 hours and only to be allowed to drink small volumes of clear fluids up until 2 hours before the scan. Following this recommendation can increase patient experience, and patient outcomes through quicker diagnoses.8
Baseline measurement
The baseline measurement occurred during a single working week (5 days) across all in patient surgical wards at our hospital. After each working day, the shared jobs list was reviewed to identify patients who had abdominal ultrasound scans that day. We ensured that patients who were not eating and drinking due to illness and/or were vomiting were excluded from the data collection. By the end of the week, we had identified nine patients of which only two patients (22%) were fasted according to trust guidelines.
Qualitative feedback was obtained from the ward nurses and doctors. A survey was sent out via email to staff members which asked whether staff were aware of fasting preparation instructions for abdominal ultrasound scans and if they were not, they were asked to provide a reason why they were not aware. The two most common reasons staff were not aware was because they were either unaware of the instructions prior to the scan or because there were no documented instructions on the patients notes to follow. This allowed us to discover a potential reason to why patients had prolonged fasts and allowed us to think about what intervention we could implement.
In order to address the project aim of reducing excessive fasting, we planned to continue to record data collection on further weeks to increase the reliability of the project and allow for us to see if our intervention is effective.
Design
It was evident from our qualitative survey that there was a lack of awareness of trust policy, therefore, resulting in scanning instructions not being followed. The intervention chosen to implement was a poster that would be displayed in the doctors and nursing office, which would highlight the fasting regimen for abdominal ultrasound scans and reinforce appropriate documentation in patient notes to ensure that all members of the multidisciplinary team were aware. An example of the poster made available can be seen in figure 1. By implementing this intervention, preparation instructions are clear for all the team and will result in patients having a successful scan as well as a better experience.
Poster for general surgery staff members highlighting abdominal ultrasound preparation advice.
Strategy
Our first PDSA cycle involved implementing the poster for surgical staff members working in the offices of nurses and doctors. Following staff exposure to this intervention for 2 weeks, data collection was restarted to determine if the posters had an impact on reducing excessive fasting by patients. At the end of each day of the week that the data collection occurred, a cohort of patients were included with the exact same criteria and the notes were scrutinised to determine if patients were being prepared appropriately for their abdominal ultrasound scans.
The second PDSA cycle involved increasing awareness of abdominal ultrasound preparation through existing meetings. During meetings for ward doctors and nurses, we made staff aware of the current guidelines for abdominal ultrasound scans and then recollected data 2 weeks following this intervention.
The final PDSA cycle involved presenting the findings of the previous two PDSA at the general surgical quality improvement half-day teaching session, to further promote awareness for the whole department regarding the preparation instructions, with data being recollected 2 weeks later to measure if an impact has been made.
Results
Following each PDSA cycle, data were recollected to determine if an impact had been made and how we could further improve interventions to maximise impact. Initial baseline measurements revealed that 22% of patients were being prepared for abdominal ultrasound scans appropriately. By the final PDSA cycle, results had shown that seven out of eight patients (88%) were appropriately prepared for their ultrasound scan, with all patients having correct instructions documented into their notes. By the end of the project, we had made an improvement to patient experience in our department, thus leading to reduced waiting time between presentation and diagnosis. We managed to reduce the average fasting time from 10 hours 43 min to 6 hours 18 min. Tables 1 and 2 show the results from both PDSA cycles.
PDSA cycle 1 findings
PDSA cycle 2 findings
Lesson and limitations
Our project highlights that multiple, simple interventions that are executed well can have a positive impact on patient experience and clinical workflow which ultimately benefits patient outcomes. An important lesson learnt was that PDSA cycles allows the team to see how each intervention is influencing the result and allows for appropriate planning of the next PDSA cycle and careful selection of the next intervention if needed. This project also highlights that in order to improve outcomes, we need to address the issue with all members of the multidisciplinary team. One important limitation for this project includes the small size of the project. Each cycle would run over 1 week and cycle 1 used nine patients whereas cycle 2 used eight patients. This may be due to the size of our district general hospital and the strict inclusion criteria that were applied to the patients selected. The reliability of this project could be increased further by conducting more PDSA cycles. A limitation of this project is that although this provides a solution for these in patients, it will only continue to work for as long as the staff members remain aware. Doctors and nurses frequently rotate to different departments and new staff members may not be aware of this current problem within the department. This means in the long term, the problem may reoccur. To resolve this, at the quality improvement half day, it was discussed that this information could be disseminated in induction material to ensure that this provides a long-term solution for the department despite staff members rotating. This will include attaching the poster to induction emails for new nurses and doctors as well as adding a one slide summary to existing slideshows for in person induction material. This will be notified to permanent departmental administrative staff members who will ensure the material remains in inductions, which will be sufficient to ensure sustainability of the intervention in the future.
Conclusion
In summary, our project identified that in patients in our department were experiencing a prolonged fasting period as a result of staff not being aware of preparation guidelines for abdominal ultrasound scans. A series of interventions including posters and talks at department meetings have promoted awareness for highlighting the importance of thorough documentation to ensure that patients are fasted appropriately for their abdominal ultrasound scans. To guarantee that this problem does not reoccur, the material generated from the project will be included in future new staff induction so that patient experience and outcomes are optimised in the department.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Sandwell and West Birmingham Hospitals NHS Trust clinical effectiveness team (reference number: 2163). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We would like to thank the general surgery department at Sandwell and West Birmingham Hospitals NHS Trust for their commitment to improving patient outcomes through this project. We would like to thank the RCSEd for allowing us to present this project at their national 21st QI & Audit Symposium 2023.
Footnotes
Contributors Conception: RSS and RM. Planning and development: RSS and RM. Data analysis: RSS. Initial draft of manuscript: RSS. Manuscript writing, review and approval: RSS and RM. Guarantor: RM.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.