Completing the Cycle: Re-Audit of Rotherham Specific Inpatient Physical Health Management and Documentation Following a 2021 Trust-Wide Audit

Abstract

Aims

Rotherham Doncaster and South Humber (RDaSH) NHS Trust completed a Trust-wide audit in August 2021 to look at aspects of physical health management in their inpatient units. Good results were achieved in relation to new admissions having completed initial medical examination within 24 hours and consideration being given as to whether the patient had the capacity to make the decision to agree or refuse such an examination. However, inadequate results were achieved in relation to anything more than an examination of appearance, pulse or blood pressure being conducted with a chaperone, and the patient being given the opportunity to state their preferences in relation to the sex of the chaperone. This audit completed the audit cycle by re-auditing the above criteria in Rotherham inpatient units in order to assess ongoing progress against targets following recommendations.

Methods

A dip sample of five patients per ward (two Acute Adult, one Rehabilitation, one PICU and two Older Adult wards) was used. Patients who were admitted between 1st July and 30th September 2022 were picked randomly and their electronic records were studied.

Results

Nearly 90% of patients received a physical examination by a doctor within 24 hours of admission. But, whilst these patients undertook an examination that was more than just general observation, blood pressure or pulse, in only 14% of these was it documented that they had a chaperone present. In addition, not a single person was offered the choice to choose the gender of their chaperone.

Just one third of patients had their capacity to agree or decline examination documented. Perhaps unsurprisingly, the Older Adult wards performed better against this criteria.

Conclusion

Rotherham inpatient wards continue to perform well in terms of conducting timely initial physical health examinations. However, we identified there is a clear lack of documentation around documenting whether someone has capacity to consent to their physical examination or not and what gender someone would prefer to chaperone them. Unfortunately, this is a continuing issue.

We have identified an opportunity at the RDaSH Junior Doctor's induction, where the clerking is explained, to intervene and educate around what the Trust expects as standard.

We plan to implement this change and re-audit the above criteria again to see if we can make an improvement.