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Local Audit Actions

Retrospective Audit of Joint The audit was presented at the Alder Hey Dermatology Department meeting in
Paediatric Dermatology March 2018.
Gynaecology clinic over a two
Action/Recommendation:
year period from December
2015 - December 2017. • To continue this Joint Dermatology Gynaecology service going forward.
• To continue auditing the service going forward.

• Audit to be presented at the Merseyside & Cheshire Vulval Society meeting in
September 2018.
• Re-audit in 12 months.

Evaluation of staff awareness The audit was presented at the Alder Hey Listening into Action (LiA) meeting in July
of breastfeeding support 2017.
needed to give to parents.
Action/Recommendation:
• Improve staff knowledge with the development of a training programme. Plans
being discussed around external training, and on E- learning module.
• Policy updated with clear guidelines on storage, administration of breast milk.
Awaiting ratification after decision made on implementation of waterless warmers.

• Policy to be cascaded for staff to be aware of how to handle, prepare, store,
administer and document breast milk.

• Staff to be made aware of process for feeding mothers and to offer information
leaflet on admission.
• Re-audit in 12 months.

Surgical excision of cardiac The audit was presented at the Alder Hey Cardiology, Cardiothoracic, and Cardiac
tumours: 20 year experience anaesthetic team meeting in July 2017.
at a single institution.
Action/Recommendation:
• No changes were required as it was an internal audit to monitor the cardiac
tumour surgical excision.
• No Re-audit was required as cardiac tumours are very rare.

Audit of Cardiac Arrests on The audit was presented to PICU consultants/trainees/nursing/cardiology at the
PICU (Paediatric Intensive weekly meeting in November 2017.
Care Unit).
Action/Recommendation:
• Regular review of cardiac arrests. Aim to improve rates of documentation and
standard of documentation in line with Utstein suggested criteria.

• Production of PCAR form (Paediatric Cardiac Arrest Review) to be presented to
consultant group.
• Re-audit in 12 months.

Alder Hey Children’s NHS Foundation Trust 90 Annual Report & Accounts 2017/18