ISBAR is here!

What is ISBAR?
ISBAR is a structured communication tool that improves the quality of information exchange when discussing patients. The tool was
Carol Vance

Request / Recommendation
State what you want and ask questions. What you say for situation may be a concise summary of what you say for assessment and request. This repetition is helpful as it emphasises the key purpose of the referral.

continued from back page... Adverse reactions to chemotherapy (ADR) were common however few resulted in the delay of treatment. Only two patients required treatment cessation (Figure 3,4).

Pharmacy news
Treatment options for Gestational Trophoblastic Disease
Gestational trophoblastic disease (GTD) covers a spectrum of tumors ranging from premalignant (hydatidiform mole) to malignant (invasive mole or choriocarcinoma).
Huda Ismail

Clinical Practice Review

THE rOYAL WOMENS HOSpITAL QUaLiTY aND saFeTY UNiT NewsLeTTer ISSUE 7 JULY, aUGUsT, sepTeMber 2009
Editorial Hand hygiene compliance Vitamin and mineral supplements taken @ the Womens Right Patient Right Care ISBAR is here! Pharmacy news 1 1 2 4 5 6

initially developed in the Navy to improve communication and has since been adapted for medical use. Inefficient communication can compromise patient care and using a standard approach to communication decreases the chance of forgetting relevant information and helps to decrease assumptions by making the reason for the call obvious at the outset. I Identification S Situation B Background

1 2 3

Uses for ISBAR

Inpatient or outpatient Urgent or non-urgent communications Conversations with other staff, either in person or over the phone - Particularly useful in nurse doctor communication - Also helpful in doctor-doctor and nurse-nurse communication Discussions with allied health professionals Conversations with peers As a prompt for writing letters to other care providers Escalating a concern Lanyard cards are available as a reminder about ISBAR, as well as notepads (which are found on the Gynaecology wards) which may help to organise your thoughts before beginning your communication. We encourage you to give ISBAR a try and start using it as a tool to improve all your clinical conversations.
Carol Vance Principle Registrar Quality and Safety Fellow Claire Fitzgerald Project Manager Agree project

Claire Fitzgerald

1 Nil ADR. 28 (74%) 2 ADR result in hospital admission. 3 (8%) 3 ADR result in treatment cessation. 2 (5%) 4 ADR managed with medications. 5 (13%)

These proliferate to form abnormal trophoblasts. The uterus enlarges rapidly despite the absence of a fetus and the placenta contains many cysts to give a typical molar appearance. Maternal blood vessel formation increases and facilitates metastatic spread of the disease. Human chorionic gonadotrophin (hCG) is synthesised in the molar tissues and therefore can be used as a tumour marker to monitor disease progression or response. Invasive moles, choriocarcinomas and placental site trophoblasts are malignant tumours and are collectively known as gestational trophoblastic tumours1. GTDs are classified as low risk,

Ultra-high risk patients are treated with the EMAPE regimen which includes Etoposide, high dose Methotrexate and Actinomycin, given on alternate weeks with CisPlatin and Etoposide with or without intrathecal methotrexate. All patients diagnosed with molar pregnancy are recorded in the Hydatidiform Mole Registry. Between 2002 and 2008, a total of 649 patients were diagnosed with molar pregnancy. Only forty-eight (7%) patients had persistent elevated hCG and received medical treatment (Figure 2). Thirty eight of those patients received low risk treatment seven of them developed resistance to Methotrexate and were switched on to the high risk treatment regimen. In total ten patients received high risk treatment and only one patient received the ultrahigh risk regimen.
1 Low risk managed with MTX. 31 (66%) 2 Low risk resistent to MTX. 7 (1%) 3 Transferred to other hospital. 4 (8%) 4 Currently receiving treatment. 1 (2%) 5 Ultra-high risk. 1 (2%) 6 High risk treatment required. 1 (2%)

Fig 3. Tolerance to MTX treatment

Complete and partial hydatidiform moles are the two most common types of pre-malignant GTD and both can progress to invasive moles. In a complete mole, an ovum devoid of maternal nuclear DNA is fertilised by 2 sperm or a single sperm it duplicates its chromosomes

Hand hygiene compliance

Hospital acquired infections, hand hygiene and an age-old problem:
The renewed focus on improving hand hygiene in recent years has seen overall compliance rise from 20% at RWH two years ago (you may remember the Herald Sun headline at the time and RWH topping the Worst Offenders list) to 75% in the latest audit. The World Health Organizations target is 55% and Victorian hospitals are aiming for 60%. While womens hospitals have been relatively spared from the multiresistant organisms (MRO) that are commonplace in general hospitals, RWH has observed an increase in MRO burden. Meticulous hand hygiene practices are essential to reduce the spread of these MROs as well as other pathogens.
D09-135 design@thewomens October 2009

Doctors versus Nurses!

Multiple studies on hand hygiene compliance across various institutions confirm that doctors perform poorly when compared with nurses. This is despite the fact that nurses have more opportunities for patient contact than doctors. Many theories for this have been proposed but we will let you use your imagination! Nurses have improved their hand hygiene compliance at RWH Doctors have failed to make significant gains above 60%. Doctors have the opportunity to spread more nosocomial pathogens as they potentially move between more patients than do other staff. Poor compliance amongst medical staff is reducing the overall performance of RWH when we benchmark with other hospitals.

EDITORIAL
The backbone of good (best) clinical practice remains patient centred care that is effective and safe. This edition has articles that address the last two of these. Most clinicians consider identifying their patient as a given. So routine that there can be a lapse in concentration. Readers will be astonished to hear that in recent years there have been 105 incidents reported at the Womens where there has been such a lapse. As Ruth Bergman points out in her article on page 4 the true incidence of misidentifying patients is not known. Another patient safety article concerns the age old issue of washing our hands to reduce nosocomial infection. Andrew Daley reports that the gap between doctors and nurses in handwashing compliance has widened again. In August 2008 it was nurses 73%, doctors 67% whereas in August 2009 it was 79% versus 51%! With regards to effective care, Huda Ismail reviews the management of trophoblastic disease in the Pharmacy section, and Jenny Taylor reviews the use of vitamin supplements in our pregnant patients. Her audit shows that pregnant women with poor diets who could benefit most from multivitamin supplements were the least likely to use them. Sobering stuff. Finally, many around the hospital will now be aware of the ISBAR tool for effective communication. Carol Vances and Claire Fitzgeralds article is a concise reminder of the methodology. Please let us know what you think, both of our content this year and thoughts for future articles.
Leslie Reti, editor Leslie.reti@thewomens.org.au

A Assessment R Request or Recommendation

5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0
Nil ADR ADR managed ADR result with medication in dose change or treatment delay ADR result in hospital admission

to give a diploid complement of male DNA. In a partial mole the two sperms fertilise an ovum with maternal nuclear DNA forming a triploid conceptus (Figure 1).
Normal conception A single sperm with 23 chromosomes fertilises an  egg with 23 chromosomes Partial Mole Two sperm fertilise an egg. This results in a triploid conceptus with 69 chromosomes. Monospermic Complete Mole This results in a conceptus with 46 chromosomes but all of them are derived from the father.

Identify
Identify yourself, the person you are speaking to, the patient, your location.

Fig 4. ADR experienced from EMACO treatment

ADR were similar in both main regimen as shown in Figure 5 Chemotherapy is an effective treatment for GTD. Resistance to methotrexate has been low and is effectively managed with other chemotherapy agents.
EMACO group MTX group

high risk and ultrahigh risk and their medical management differs based on the risk and resistance to chemotherapy. Low risk patients are managed with the methotrexate (MTX) and calcium folinate regimen. Actinomycin may be used as an alternative if methotrexate is not tolerated. High risk patients are managed

Situation
Spoil the story. Stating the purpose of the call at the start of the conversation helps the receiver focus their attention appropriately when listening to the story. If urgent, make this clear from the start.

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Background
Tell the story. Provide relevant information only and remember, less is more, particularly if the receiver already knows the patient.

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The maternal chromosomes double up

and

The paternal chromosomes double up

43 5

Dispermic Complete Mole

Fertilisation by two sperm

Fig 5. Common ADR experienced by MTX and EMACO

The maternal chromosomes are lost

This results in a conceptus with 46 chromosomes but again all of them are derived from the father.

with the EMACO regimen, which consists of Etoposide, Methotrexate and Actinomycin, given on alternate weeks with Cyclophosphamide and vincristine(Oncovin).

Assessment
State what you think is going on. Give your interpretation of the situation. Include your degree of certainty - stating the obvious is helpful. Dont leave the receiver to guess what you are thinking tell them.

Huda Ismail Senior Pharmacist, Oncology and ADR coordinator

Fig 1. Genetic Origin of Hydatiform Mole

Fig 2. GTD patients who received treatment

continued next page

References
1. Gestational Trophoblastic disease, SOGC Clinical Practice Guidelines, No. 114, May 2002

For any further enquiries regarding Pharmacy news please contact rwh.pharmacy@thewomens.org.au

Please let the associate editors have your Please let the associate editor have your views on the views on the contents of this newsletter, or contents of this newsletter, or any other matters involving any other matters involving clinical practice clinical practice which may be of interest to our readers. which may be of interest to our readers. 5

Susan Braybrook, telephone (03) 8345 2025 or email susan.braybrook@thewomens.org.au For further information http://www.thewomens.org.au For intranet users http://intranet.thewomens.org.au/qualityandsafety

HeraldSun 25.5.08

continued next page 1

continued from front page...

continued from page 2... This was a snapshot of what the of many pregnant women. 33% of the women surveyed were getting supplemental iodine either from multivitamins or iodized salt 77% of the women took folic acid supplements at some stage during the pregnancy (alone or in multivitamin or iron preparations), however only 29% started it before conception. Most of the remaining 48% commenced after they knew they were pregnant and thought this was appropriate. 43% had indicators of iron deficiency sometime during the pregnancy to date. At the time of the audit only 46% of iron deficient women were taking iron supplements in doses large enough to be likely to correct deficiency i.e. 60mg or more per day. 69% of the women had test results available for vitamin D. 48% of this sample were deficient when first tested, with 69% of deficient women on supplements of 1000 IU or more. Iron, iodine, calcium and folic acid were common dietary deficiencies. Women with biochemistry indicating iron or Vitamin B12 deficiency were twice as likely to have inadequate diets (by dietary recall) and were also less likely to be taking multivitamins. In contrast women with adequate diets were twice as likely to use multivitamin supplements as those with inadequate diets.

RWH

Nov 2007 Mar 2008 Aug 2008 Nov 2008 Mar 2009 Aug 2009 44% 48% 67% 73% 73% 61% 77% 80% 50% 73% 78% 51% 75% 79% 21%

women were doing at the time they were seen. They may have been at any stage in the pregnancy but second trimester was the most common time.

Right Patient Right Care

From 2005 the Quality and Safety unit at The Womens has received 105 reports of patient safety incidents associated with the wrong identification of a woman or baby.1 So far we have been lucky as none have resulted in a major outcome, but the potential is there. The true incidence and probability of wrongly identifying a patient is unknown but it is of enough concern for the Australian Commission on Safety and Quality to highlight it as a national stand-out opportunity to improve patient safety2. At the Womens, the occurrence of mislabelled specimens, duplicate medical records, unlabelled medicines charts, incorrect In Patient Management (IPM) registration details coupled with the wrong persons ID stickers in a medical record, indicate the need for a hospital wide focus on correct positive patient identification. Case studies A woman in the birth centre had a post partum haemorrhage. In preparation for theatre, one person collected a cross match blood specimen and wrote up a request form, whilst another labelled the specimen with ID stickers from the wrong medical record. The wrong blood type was detected by pathology. A womans name was called; she came in to the outpatient procedure room accompanied by her husband who explained he will interpret for her. The procedure was explained and a cystoscopy performed. A short while later another woman came to the desk complaining she had been waiting Steps for positive identification Positive identification involves asking the woman in front of you to state her first name, surname and date of birth. This information is checked against the patient identification wristband(s). In the outpatient areas, and in situations where there is no wristband, (e.g. Pauline Gandel Womens Imaging Centre, pathology or women phoning for test results), remember to check this information against documented patient identification details such as the medical record, request form or databases such as CLARA and IPM. A simple process; not dissimilar to the questions a bank asks prior to providing any information over the telephone. Steps for right person, right care, right site and side In the outpatient and inpatient setting the verification of the correct person, procedure and site includes clerical staff registering and making a booking in IPM, admitting staff, clinicians and the person in charge of the procedure asking the woman to state her first name, surname, date of birth and type of procedure (if relevant, what site and side is involved). a long time for a cystoscopy. Staff realised a procedure was performed on the wrong person. A woman arrived in theatre. During the team time-out checking process the operating room team were alerted of a potential problem as her medical record contained details of births and procedures that were not hers. With the assistance of the woman it was realised that two medical records were merged, hers and her sisterin-law who share the same surname and date of birth, but one was Meghan and the other Megan.

Overall compliance 20% Nurses Doctors 19% 24%

pregnant women with poor diets who could benefit most from multivitamin supplements were the least likely to use them
In conclusion pregnant women with poor diets who could benefit most from multivitamin supplements were the least likely to use them. multivitamin supplement users may still miss out on at risk nutrients. There is no single supplement that contains iron (in significant amounts) as well as folic acid and iodine. most women were unaware that folic acid needs to be started before pregnancy many iron- or Vitamin D deficient women were not taking supplements. Whether this was due to non-prescription or non compliance was not assessed.
Jenny Taylor Department of Nutrition and Dietetics, The Royal Womens Hospital jenny.taylor@thewomens.org.au

Results
Supplement use was common with 55% of the women taking multivitamin preparations. Elevit was the most popular, used by 47% of those taking a multivitamin supplement, followed by Blackmores Pregnancy and Breastfeeding Gold at 33%. The remaining 20% were taking a variety of at least 9 other brands.

What can you do?

1. Learn the WHO Five moments for hand hygiene and incorporate these into your daily routine. 2. Review Hand Hygiene Australias recommendations for Medical Staff: http://www.hha.org.au/UserFiles/ file/HHAJulyManual 2009(1).pdf Section 5.3 (page 45)
Andrew Daley

Hand hygiene: Your example matters

Colleagues, trainees, and other staff watch what you do: Research has shown that the actions of clinicians influence the behavior of others. Show your colleagues that hand hygiene is an important part of quality care. Your patients and their families watch you too: Your actions send a powerful message. Show your patients that you are serious about their health.
From Centers for Disease Control and Prevention (USA) Dr Andrew Daley Departments of Microbiology & Infectious Diseases and Infection Control

3. Perform the Hand Hygiene competency quiz (takes 5 minutes) at http://intranet.thewomens. org.au/ClinicalEducation Competency Assessment 4. Play the Wi 5 game: http:// www.rch.org.au/washup/prof.cfm? doc_id=12968 5. Model appropriate practices for more junior staff and medical students. 6. Work with senior nursing staff to assist with enforcing HH compliance. 7. Review the WashUp website at www.washup.org.au

Supplement use was common with 55% of the women taking multivitamin preparations
Supplements vary in content of significant nutrients such as iron, vitamin D, omega 3 and vitamin B12. One of the reasons Elevit is popular is because it contains a substantial iron dose, however in contrast to other pregnancy multivitamins, it contains no iodine (at this stage). Iodine is one of the nutrients most needed from a supplement as there is mild deficiency in most parts of Australia. Even bread fortification (commencing September 2009) will not meet the iodine needs

from 2005 the Quality and Safety unit at The Womens has received 105 reports of patient safety incidents associated with the wrong identification of a woman or baby
This information is checked for accuracy against the consent or procedural request form and appropriate diagnostic images (when available). In theatre this process is called Team Time Out where a standard formal process is followed by the whole team; the anaesthetist, surgeon and theatre nurses. The matching of the correct person, procedure, site and side occurs at all stages of outpatient and inpatient contact. That is, when a procedure is booked; at the time of admission; during preparation for a procedure; upon admission to a department where the procedure is to be conducted (e.g. Pauline Gandel Womens Imaging Centre, Day Chemotherapy, Pregnancy Day Care Centre) and again on entry to the procedural room and indeed anytime a woman or baby moves within the hospital or is transferred to another hospital location.
Ruth Bergman Clinical Incident Co-Ordinator

Vitamin and mineral supplements taken @ the Womens

An audit of suitability of vitamin and mineral supplements taken by pregnant women. Vitamin and mineral use is common in pregnant women but are women taking supplements that correlate with their nutritional deficiencies? The aim of this audit was
Jenny Taylor

Comparison of levels of at risk nutrients in a sample of multivitamins suitable for pregnancy

Number of Cost tablets or per day capsules per daily dose Blackmores Pregnancy and Breasfeeding Gold Blackmores I-Folic Cenovis Pregnancy and Breastfeeding Formula Elevit Fabfol Plus Fefol Multipreg Myadec Multivitamins and Minerals 2 1 2 1 1 1 1 2 1 2 1 $0.92 $0.13 $0.53 $0.69 $0.44 $0.58 $0.13 $0.83 $0.45 $0.50 $0.63 Ruth Bergman Nutrient content per daily dose Folic acid Iodine 600g* 220 g* 250 g (WHO) 500 500 500 800 500 500 500 500 500 500 250 250 150 150 200 150 270 250 150 250 10 60 12 12 5 10 5 10 5 500 200 200 440 500 200 200 4 4 4 4 6.3 500 100 3 2.6 340 252 150 340 Iron 27mg* Vitamin D B12 500IU* 2.6g* Omega 3 115-430 mg

usual dietary intake nutritional supplement use both self prescribed and prescribed by health professionals biochemistry that could indicate nutritional deficiency such as iron deficiency indicators, Vitamin B12 and folate levels, using Clara or laboratory results filed in patients records. This was not a random sample as the women had been referred to dieticians for reasons such as weight control or diabetes or were screened because they were attending higher risk antenatal clinics such as Multiple Pregnancy, WADs or Young Womens Clinic.
Natures Way Pregnancy Smart Swisse Pregcel Natal Plus Natures Own Pregnancy Platinum

10

500

300

to check how supplement use related to womans individual needs as well as to nutrients that are at risk in pregnant women in general such as iron, folic acid and iodine. 218 pregnant outpatients routinely seen by dieticians at RWH had assessment of 2

References
1. RISKMAN incident database, report by patient identification classification 2. Australian Commission on Safety and Quality in Health Care 2009 Identification of Adults; Identification of Babies Womens Hospital Procedure located on the Intranet.

*Recommended dietary intake for healthy women. Recommendations may be different if deficiency is present