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Local Audit Actions

Retrospective audit looking The audit was presented at the Alder Hey Department of Surgery in December
at timing from clinician review 2017.
to arrival in anaesthetic
Action/Recommendation:
room in daycase, specifically
comparing first patient on list • A pre 9 a.m. start for the first patient on the list should be possible if clinician
to subsequent patients review can be done in an expeditious manner.
• Reduced pre-operative wait times have been maintained in the new daycase
unit. These details will be fed back to the daycase departmental managers for
circulation.
• Re-audit in June 2018, following all medical student placements we will be able
to re-audit daycase start times from September to June allowing us to look at
seasonal variation.

Audit of aortopexy and The audit was presented to the Alder Hey ENT (Ear, Nose & Throat) Department
vascular ring surgery in consultant and disseminated to the cardiothoracic consultants in January 2018.
paediatric patients at Alder
Action/Recommendation:
Hey
• No significant issues arose from the audit. Results hold up well when viewed
alongside those in published literature.
• No changes were required as consolidated existing practice.

• Re-audit in 5 years (infrequently performed procedure).
Audit of genetic testing in The audit was presented at the Alder Hey monthly Cardiology and Cardiac surgery
neonatal CHD. meeting in January 2018.
(Coronary heart disease)
Action/Recommendation:
• Keep the same protocol for genetic testing, reinforce the guidelines.

• Do not order microarray if not indicated by the protocol.
• The consultants will be informed of the audit results and reminded to follow the
protocol. No other action needed.
• Re-audit in 12 months.

Post PEG insertion care - The audit was presented to the Alder Hey Gastroenterology Department weekly
completeness of the PEG meeting in March 2018.
(Percutaneous endoscopic
Action/Recommendation:
gastrostomy) pathway form.
• Digitisation of PEG pathway. Simplifying form as part of digitising process in GDE
(Global Digital Excellence).
• Specialist nurses to update risk register in regards to low levels of sign off for
parents/guardians of PEGs.
• Stoma nurse will continue to stress importance of parental sign off.
• Discharging clinicians to ensure sign off is complete before discharge

• To Re-audit digitised pathway once available (GDE will automatically do this so it
will be an ongoing prospective audit.

Alder Hey Children’s NHS Foundation Trust 95 Annual Report & Accounts 2017/18