ThTP8.1 Improving Adherence to NCEPOD Guidelines in a District General Hospital

Background

NCEPOD classification defines urgency for appropriate surgical intervention. Use of this classification ensures patient safety, clinical governance, and promotes communication and teamwork. NCEPOD advises classification is allocated at time of the decision to operate; classification should be recorded both in the patient casenotes and on the theatre management system.

Aim

To assess use of NCEPOD classification in a district general hospital and improve adherence to national guidelines.

Methods

Retrospective data review of theatre management system (OPRA) for all emergency cases performed at a district general hospital between 01-14/09/2021. Data reviewed included procedure performed, NCEPOD classification and adherence to selected classification (time of booking ◊ time to theatre). Theatre booking form was amended to include NCEPOD classification and distributed throughout the department. Further data collection 14-28/01/2022 to assess for improvement, and 02-13/05/2022 to assess for sustained change.

Results

Cycle 1

Cycle 2

Cycle 3

Conclusion

Introduction of new theatre booking form has improved adherence to NCEPOD guidelines. There is scope to improve this further. Ongoing efforts include more departmental education and introduction of a WHO surgical sign-out.