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Local Audit                  Actions

         Audit of the Burns Unit ward   The audit was discussed with the ward manager and consultant and all Burns Unit
         based clinic.               staff have had a copy of results in December 2017.
                                     Action/Recommendation:
                                     • In addition to the patient information leaflet the parents receive we are producing a
                                       card to give to the parents.
                                     • The card we are producing details what will happen at the clinic appointment -
                                       where the clinic is held, what time to arrive, if they are given medication here, or
                                       if the parents administer their child’s analgesia at home, when the medication
                                       becomes effective, length of time they may expect to spend at the hospital,
                                       contact number of clinic/nurses if they have any questions themselves, or to
                                       rearrange their child’s appointment if they are unable to attend the date and time
                                       they have been given.

                                     • No Re-audit required as we feel the detailed cards/information will explain some of
                                       the reasons why some patients have a longer clinic time allocation.

         Audit of unplanned admission  The audit is a part of the national PAPAYA project The data has been submitted to
         after paediatric day case   the audit in November 2017 and will have to wait for report/feedback from PATRN.
         anaesthesia in UK.          (Paediatric Anaesthesia Trainee Research Network) part of (APA) Association of
         (PAPAYA) Paediatric         Paediatric Anaesthetists of Great Britain and Ireland.
         Unplanned Daycase           PAPAYA aim to complete analysis and write up by Autumn 2018.
         Admissions.
                                     Action/Recommendation:
                                     • Will discuss in the anaesthetic department audit meeting and present to daycase
                                       services/specialties as indicated upon completion.

                                     • Re-audit in 12 months.

         A Re-Audit of completion of   The audit was presented at the Alder Hey CAMHS (Child and Adolescent Mental
         Routine Outcome Measures,   Health Service) Clinical Governance meeting in January 2018.
         with comparison of results
                                     Action/Recommendation:
         for children with ASD (autistic
         spectrum disorder) and      • Consider further study on the comparison of ROMS (Routine Outcome Measures)
         Neuro-typical children (i.e.   completion, for children/Young People with ASD and Neuro-typical children.
         children not on the autistic   • Consideration to create a specific ROMS aimed to meet the needs of children/
         spectrum).
                                       Young People with ASD. E.g. visual prompts, use of electronic devices and take
                                       core symptoms into consideration.

                                     • Dissemination of the results. Staff training on the importance of ROMS and how
                                       and when to administrate them in order to achieve >90% completion rate.
                                     • Recognition for staff who have achieved high ROMS completion rate.

                                     • Re-audit in 6 months.
         Audit of the removal of     The audit was presented at the Alder Hey Orthopaedic department meeting in
         metalwork from lower limb   September 2017. Previously presented at the anaesthetic meeting in March 2017.
                                     Action/Recommendation:
                                     • Daycase pathway in progress for patients not requiring much analgesia post-
                                       operation.
                                     • Daycase pathway written for removal of metalwork from lower limb.
                                     • Re-audit in 6 months.











        Alder Hey Children’s NHS Foundation Trust           91                          Annual Report & Accounts 2017/18
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