Knowledge Natter with Eloise Collins

Knowledge Natter – Lou Northway and Eloise Collins

RCVS Knowledge

Welcome to this Knowledge Natter by RCVS Knowledge. Here we have
friendly and informal discussions with our knowledge award champions and those who are empowered by quality improvement in their work. Whether you are a veterinary surgeon, veterinary nurse, receptionist, or member of management, quality improvement will and can positively impact your everyday life. Listen and be inspired.

Lou Northway:

Hello everybody and welcome to this RCVS Knowledge Natter. My name is Lou Northway, I’m clinical lead RVN at RCVS Knowledge. And I have the fantastic and honoured job of interviewing the 2022 Knowledge Award winners. And today I’m speaking with Eloise Collins, formerly of Beech House Veterinary Group. So hello, Eloise. Welcome.

Eloise Collins:

Hi there. Thank you for having me. It’s nice to be talking things QI.

Lou Northway:

It’s always good to talk things QI, isn’t it? I have been so excited about
talking to you today about your project in particular because this is very similar to things that I’ve also looked at in practice over the years. And something which I think will resonate with the majority of listeners. Before we get started with your project, I would love for you to tell me and the audience all about your career so far and how you got to where you are right now.

Eloise Collins:

I went to Harper Adams University. I qualified in 2013. And I then went straight into equine practice, into a equine first opinion and referral hospital where I was there for three years. And then I met my partner who was in the military and that meant an awful lot of moving around. So I did locum work for about four years. And then went to a practice in Surrey for about 18 months luckily during Covid. So I was working all throughout Covid. And then we moved again to Hampshire and that’s when I then went to Beech House and started working there. And in the meantime I also qualified as a physiotherapist just before Covid. And then obviously lockdown put my plans aside. So I then started practicing afterwards. So yeah, I’ve been doing nursing and physio for the last few years.

Lou Northway:

Amazing. So you’ve got so many strings to your bow, haven’t you?

Eloise Collins:

Yeah, yeah, lots of plates spinning.

Lou Northway:

And how did your love for QI come about, when did it all start for you?

Eloise Collins:

So I think going to Harper Adams was really good for me. They don’t teach you QI specifically but they teach you a lot about critical thinking and analysing everything and questioning things and not necessarily doing things because that’s the way they’ve always been done. So that was really good. And then going into the equine practice I found really helpful. And again it wasn’t necessarily called QI but we used to do journal clubs and we’d do M&M meetings monthly and that was really useful. And there was just this cwhole culture of continuous learning and continuous improvement.

And then when I was doing locum work, I would be working in so many different practices and just seeing how different practices do things and what works and what doesn’t. And I then thought, it’d be really nice to be in practice where I can actually implement what I think is, for me anyway, gold standard nursing. What I see as gold standard nursing because I have all these ideas and I feel like I know what works.

And so then I went to go and work in Surrey for a year and a half during Covid. And did a few things there mainly around patient safety. So I made a business, we didn’t have any multiparameter machines or anything like that, so I made a business plan, and I managed to get our practice and our branch practice multiparameter machines. And just doing little things like that.

And then when I went to Beech House, I went there and I went in a
management role, so I went to go in as a head nurse, they wanted me to do physio, so I went in as deputy head nurse. And that allowed me time to do physio. But actually I spent an awful lot of time doing a lot of management stuff, especially when I started doing the QI stuff.
I went into a management role and I thought straight away, there are so many things that I want to change here. I can improve this place so much.

That was really exciting for me. And I didn’t want to go in like a bulldozer and just change everything and be like, you’re doing this wrong, you’re doing this wrong. Because that’s not a good way to get people on board. You don’t want to go in and be like, you’re doing everything wrong. They weren’t at all by the way, just saying. But I could see many areas that I thought I could improve.

And I just thought, I just need to take a few months and just
settle in, get to know everyone and get to know the practice and how it
works. And then I had my notebook with me and I’d just write stuff down, everything that I thought, all the little changes. And I thought I would just position myself as the person that people can go to if they had any problems or anything that they wanted changing.

And I think most importantly, actually doing the things that they were asking me to do or at least showing them that I was trying to do them. Because I think a lot of the time people would maybe make suggestions and then they’re not followed through. And then they’d stop making suggestions because they think, what’s the point? So I really wanted to make sure that I was actually delivering stuff that people wanted.

And that’s how I came into QI. Because talking to everyone individually, it wasn’t like a formal conversation, it was just when I was operating with vets or cleaning up with the nurses, I would just be chatting to them and they would say, oh, I think this could be better. It’d be really nice if we did this.

And I’d always make a mental note and then go away and write it down. And then thought, how can I slowly start to introduce these changes?

And I was doing a lot of nursing consults at that time. I did a week block of consults. And I just started noticing that we had a lot of dogs coming back with gastrointestinal problems after routine procedures, routine spades and neutered. And I just thought, this isn’t normal, it’s a bit higher than it should be. And thought that this is a great place to start. So that’s how I got into it and started. And then it just snowballed from there.

Lou Northway:

It’s quite addictive, isn’t it? But it’s also super motivating. Like you say,
including the team and asking them, what do you think we should improve? It’s really nice to get them involved as well. And making the actual improvements too. If we went in and we just made the improvements without knowing and measuring where we started, how do you know how far you’ve gone?

So you said you were doing a lot of consulting in practice. And we found similar actually in mine when we first started thinking about auditing. I remember a summer, a few of the vets had said, oh, I’ve seen a dog with diarrhoea today. And then the other vet says, oh, me too, I’ve seen two. And then the nurse said, oh, I saw one as well. So in one day there’s four people reporting that there were dogs with diarrhoea.

So we thought, oh, well, actually on a bigger scale, how normal is this? We just don’t know. And then yes, it’s only when you stop and start auditing those things that you can sometimes highlight that actually it’s a far bigger problem. Especially if you are not a team that, you may be working in a practice where you’re not talking to anyone else. So yes. And what were your team’s responses when you said, oh guys, I’ve done an audit on our post-operative neutering outcomes, this is what I found. What was their response like?

Eloise Collins:

It was good actually. I don’t think I had anyone thinking, oh my god, she’s checking up on us and watching what we’re doing. Because it wasn’t about … I wasn’t looking into it and thinking, oh, is it one particular vet’s cases that these are happening to? It wasn’t that specific.

Lou Northway:

You are exactly right though, isn’t it? It’s not pinpointing what any one
person isn’t doing. It’s about what we are all doing and all the influencing factors around it. So in your case report, you alluded to all the things that you considered, so diet, timings of starvation, all of those things which can ultimately impact how happy the guts are.
And certainly we’ve been following protocols and guidelines as a profession for many years, but actually how often do we stop and think, is this still appropriate? And sometimes when you look towards the evidence base, you see a paper that’s released which is actually now you should be doing this. And you’re like, oh, great. And then you can make a small change and see if it helps.

Eloise Collins:

Yeah. I think what was interesting is when I did the audit, I didn’t tell anyone that I was doing it. I just did it. And then the practice hadn’t had any staff meetings since before Covid, so a good two years. So I organized based on the diary for us to have a staff meeting, sat down and said that I’ve done this audit and this is what our figures show about our post-op complications.

And I think nobody was really aware at that stage that there was a problem. And it was only because I was doing the majority of the nurse consults that I was seeing them back and I was aware of it. And I think our figures were far above the national average. So it was nice to have that to compare against as well because otherwise you’ve got nothing to compare against.

You don’t know whether that’s good or not. So yeah, it was like, these are the figures. And everyone found that quite interesting. And then I had gone away and I’d done all the research about the reasons why this might have happened. And then I just opened it up to the room and had a bit of a discussion. And obviously initially everyone was a bit hesitant like, oh, we didn’t really want to put our hand up and say anything. So a lot of it was me listening to the sound of my own voice for quite a long time.

But I think once people realized that I trying to help everyone and trying to benefit the practice, I think then everyone started chipping in with stuff. But I did find in staff meetings that it was generally the same few people who would contribute in them, the same few voices that would be heard. Which is why I was saying it’s really important to talk to people one-on-one as well afterwards to quieter people.

Lou Northway:

As well. Yeah, I think that’s a really good point. Yeah, no, it’s such a good point though, isn’t it? Because I can definitely relate to that. I’m always, well, unexpectedly, as I’m sure it’s no shock to you, one of the voices always in the room that speaks up. But yeah, just to consider that there may be other members of your team that aren’t confident speaking up in a room which may have really valuable feedback. So just approaching how you gain your feedback from your team in a different way. No, it’s a really good idea.

Eloise Collins:

Yeah. And I think those conversations are probably more valuable than the staff meetings I think.

Lou Northway:

Yes. And also we wanted to just touch on about making changes. So making sure that we only make a small change at a time, so we can measure whether it’s effective or not to know which change actually helped or not.

Eloise Collins:

Yeah. I think one of the problems I found with the post-op complications with the gastrointestinal problems was that we changed about two or three factors at the same time. So we were like, we’ll stop feeding them chicken because that’s a common allergen. We’ll feed them a GI diet. And we’ll give Metacam on recovery. And I can’t remember what the other one was. But yeah, we changed a few things. We had a few confounding factors, so it was difficult to look afterwards and say, oh, because we changed the diet, they didn’t have diarrhoea afterwards or because we gave Metacam recovery, we didn’t have diarrhoea afterwards. So we couldn’t isolate the reason for the
improvement. But I guess, yeah, we just carried on with all of those things anyway, so I guess it didn’t really matter.

Lou Northway:

Yeah. And I thought your point about what type of diet the dogs are on is really specific. So for example, if a dog is always on a chicken and potato, sorry, a fish and potato or something more specific and then they’re coming in for the day and we are giving them, like you say, chicken, then that in itself could be enough just to tip their gastrointestinal tract over the edge  for a few days.

So sometimes now actually, like what you do as well, we ask the owners to bring in a small amount of their usual diet or we send them home sooner and get the owner to feed them as soon as they get home to try and reduce that.

But yes, that is definitely a complication. And I think sometimes also when you start thinking about complications, you automatically think of patient dying, a patient bleeding out, something really serious, don’t you? But actually it’s all those small little complications that actually do then become a bigger problem. So it’s very interesting.

Eloise Collins:

Yeah, absolutely. And what I’ve found was, because obviously you’re
collecting this data, but you need to know what your postop results are. So there needs to be some way of logging it on your PMS. So that you can just run a report and hopefully these stats come up. Because you don’t want to be going through every op individually and looking and seeing how they were in their postop checks.
It was an IVC practice I was working in. And they had their postop scoring system on a one to five. And that’s something that I really encouraged when I was trying to get this data. Because we weren’t really recording post-op scores, I was going back and I was looking individually through the clinical notes. And I was noticing that they had a very basic post-op scoring beforehand. And I was noticing that everyone was putting POA zero.

And when I actually read through the notes it was saying, oh, there is a bit of swelling, and the dog has been licking a bit, but it’s not infected so it’s fine. And they gave it a zero. And I thought, well, that’s not really a zero, is it?

That needs to be flagged up because if that’s happening for all cases, then we need to be maybe sending them home … making sure they’re going home with buster collars to follow some kind of device to prevent interference. It’s all these little things that are actually really important.

Lou Northway:

Yes. I found very similar in my practice actually when we rolled out … So years ago I did used to be that person that would sit there and go in and out of every record. It took me hours. It wasn’t particularly time effective, but I did it for a few years until our PMS system, I also now work for an IVC practice, became much more efficient and effective. And the team could input the code so I wouldn’t have to read the clinical history and make my own decision. That’s very subjective as well, interpreting someone else’s clinical notes. You can’t see the patient that’s in front of you. So I do think that’s more accurate.

But when we first rolled it out, despite the communications with the team, a few of the vets had scored a lot of threes and fours. And I was like, well on earth is going on this month. And then I looked at the records and like, no abnormality detected. I was like, well, it’s fine. And I said to them, I just wondered why you’d scored them a three. And they said, it was the third post-op check. I was like, no, it’s not, no. Anyway, so we had to just double double check that everyone was really clear with the scoring system on how we are grading them.
But it is worth, anyone that’s listening, depending on whether you’re in a corporate practice or a primary care practice, have a look at what computer system you are using and speak to your software company and see how you can utilize your data capture.

Because it’s so much more effective and efficient than you sitting there for hours, like I used to do, pulling data off. But yes, I think that’s what I was going to talk about for data capture. My brain’s gone a bit blank on that front reflecting on the hours I would sit in front of a computer. But anyway, data collection doesn’t have to be really drawn out and long either, does it? You can literally stick a piece of paper on a wall auditing post-op temperatures because that’s something else that you looked at as well, wasn’t it?

Eloise Collins:

Yeah. So that’s something that I came to, I think because of the post-op
complications, I then started looking into other things, and especially our anaesthetic sheets. And realized that, if I was looking at when Metacam was given, was it given during surgery, after surgery, and there wasn’t really anywhere on the sheet to write this kind of thing, there was nowhere to really write blood pressures. And I thought I need to change these. So I changed them for the AVA anaesthetic sheets, which I really like. It’s just one A4 piece of paper but you can write an awful lot on there. And it’s quite clear as well. And that allowed me to do the data capture as you were talking about. Because if you don’t record it then there’s no way of doing a lot of this auditing.

Lou Northway:

And hypothermia is something that’s really I think overlooked a lot of the time. Patient wakes up, maybe a bit slower than normal, but they go home. But we actually forget that it adversely affects their whole body systems and increases the risk of post-operative death considerably. So yes, absolutely, this is definitely something I’d encourage everybody to be monitoring very closely. And then you can have a think about what new bits of kit you might want to get to keep your patients nice and warm.

Eloise Collins:

I think, as you said, the patients wake up and even if their temperatures are really quite cold, maybe in the 35, they still recover, maybe a bit slowly, but they still recover fine and then go home. I think people think, oh, well, they were fine, so that’s okay. And I think, again, that is about education and also about, as you’re saying, the equipment that you have available to you and using it. I think that’s an important thing. I’ve been in some practices where they have a bair hugger but they don’t necessarily use it because they don’t like the fact that they start sweating because they’re sat next to it when they’re doing an anaesthetic and that kind of thing.

Lou Northway:

Yeah, no, education is a massive part of it as well, isn’t it, it’s not just
processes, but it’s the foundation knowledge around what you’re doing and why. And like what you were saying earlier about the non-steroidals, whether that positively influences a dog to have diarrhoea post-op, maybe it does, maybe it doesn’t. But if you’re monitoring blood pressure and that’s all lovely, then hopefully if you did give your dog steroidals it wouldn’t be too much of a bother. But if they then were hypotensive, you could expect that potentially their guts might be unhappy 24, 48 hours later. I don’t know. But yes, monitoring is everything. But we’re not here to do an anaesthetic lecture today anyway. As much as I feel like my brain going off on a spiral
now. And so when you were there, Eloise, your team, how was their
responses to QI as the months went by? You said that they were more
forthcoming with ideas and suggestions. Did any of the other team decide to take on other mini audits or anything like that whilst you were there?

Eloise Collins:

No. I think because it is time consuming when you’re doing it. And you do need to put aside these protected hours to do this QI stuff. And other people just didn’t have the time. You had people studying for their ECC certificates and students trying to get their MPLs done. And in a busy environment people just don’t have the time. And also they didn’t really know about QI. That was the other thing. People started to get interested when I was showing them the results. And
often I would go upstairs and be sat in the computer room just doing all of this stuff. And then sometimes I would go down and I’d do it in the prep room. People could see me doing it, and then they would come over and then start asking me questions about it. And I would have maybe students there and I would be telling them what I was doing and why I was doing it, just so it became normal for them. And they saw it happening all the time. Especially for the students, I think it’s really important. So then they go away and they think that it is normal in practice and can see what a useful tool it is.

Lou Northway:

Yeah, I think it’s game changing, isn’t it, it really does change your mindset. When you go into work and you are looking at what you are doing, every single thing you start reflecting on and thinking, oh, is that effective? Can we improve that? I’m at the stage now where I think that every practice needs a quality improvement ambassador.

Eloise Collins:

Yeah, a hundred percent.

Lou Northway:

It needs to be a specific role because it’s not something you can just do, oh, if you’ve got time; it has to be allocated because it’s super duper important. And those of you that are listing, you may not be aware, but it’s actually a requirement now in the practice standard scheme to undertake audit and other QI activities. So now is the time to open your mind, bring your team along with you for the ride and get on board the bus.

Eloise Collins:

Yeah, absolutely. And I don’t know about you, but I find in practices I find general computer literacy quite poor sometimes, I think technology takes a bit of a back burner when you work with animals. And I think that is definitely an area that we need to improve on. Not that you need to be a tech genius to do QI. But I think it is helpful if maybe you’re able to create a spreadsheet and then use the data on the spreadsheet to make…

Lou Northway:

I am totally spreadsheet illiterate, and thanks to RCVS Knowledge and all of their amazing resources, that’s how I managed to start my journey. So on the website, everybody, we have the National Audit for Small Animal Neutering and also the Canine Cruciate Registry. Those are two areas where you can actually download the spreadsheets to help you start your data collection. So you don’t have to make your spreadsheet yourself. Amazing. And then you can upload and share your data with Knowledge once you have the permissions of your employer. Benchmark and see where you’re at, and make improvements. And there’s also loads of guidance there now in
our Advice Hub where you can decide how and what you might want to
improve. It’s really exciting.

Eloise Collins:

I started off using the Vet Audit template that hey have on the RCVS
Knowledge website for my post-op complications. And I just found it really easy. You just input your data and then it does all the calculations for you. And it has a nice little chart that you can share with everyone. So that was really good. And then I thought, yeah, I can do something like this for other areas. And then I like to make bar charts or pie charts with the data that I had as well because it’s nice to have that

Lou Northway:

Visual, isn’t it? Yeah, it’s more engaging. Yeah.

Eloise Collins: Visual. Yeah, definitely. I think you don’t even have to be good with maths. So when I was doing my perioperative temperatures, I would color code things. So if it was borderline it would be a green; and then if it was half a degree lower than that, it would be orange; and then half a degree lower it would be red. So just at a glance you can be like, oh, there’s a lot of orange here or there’s a bit more red.

Lou Northway:

Yeah, it’s a really good idea.

Eloise Collins:

So you don’t necessarily have to sit there and work out percentages and statistics. You can’t just color code it like that.
Lou Northway:

Yeah, no, it’s really, really good. And I hope everyone that’s listening feels inspired to get cracking now as well. What’s next?
Eloise, you have just changed job roles now and I was just wondering, going forwards, how do you plan to use QI ongoing professionally?

Eloise Collins:

So yeah, I’ve just started working as a night nurse, doing a lot of emergency and critical care work in a hospital. And I think they had someone doing some clinical audits beforehand, but I think they have been on maternity leave for a while and no one else has really picked it up. So I have been asked to help them with QI stuff. Try and stop me. Before they know it, I’ll clinically audit the place within an inch of its life.

Lou Northway: They’ll walk in on Monday and you’ll be like, I’ve got a list of ideas just here, these are the things I’ve already started for you. I’ll be back tomorrow night and I want to know all what you think.

Eloise Collins:

Yeah, they’re going to regret asking me. So yeah, I think that’d be good. And I think one thing, especially for emergency and critical care is, I want to start introducing significant events auditing as well. I think that’s really important. Not just the things that have gone badly, but things that have gone well as well. And using them as learning and training opportunities. So maybe if a patient crashes, some people potentially go into a bit of a panic mode. And then when it’s all calmed down afterwards you think, oh, maybe I should have intubated quicker, maybe I could have got those meds into that animal quicker, that kind of thing. And then thinking, well, why didn’t we do that? Is it a training issue? Is it a system problem? So I think significant event auditing is really important.

Lou Northway:

Yeah, me too. That’s something actually in my practice that’s on the agenda for this year to do more of. And yeah, I completely agree. And like you say, not just the things that go wrong, but the things that go well. So why did it go so well that day? We’ve done this before and normally it’s more of a struggle, but why were we firing on all cylinders? What was different? So no, it’s super exciting.
So we’ve been talking for ages. I feel like we could talk until the midnight to be honest and bounce ideas off of each other. But you need to go back to work and you’re probably extremely tired after last night’s night shift. But what are your final top tips for anybody that’s thinking of starting QI or their first project?

Eloise Collins: Yeah, for a first project I think don’t overwhelm yourself. I think it’s very easy to find it overwhelming with all the stats and figures. Just start on something pretty basic. I do think post-op complications is a really good place to start, especially because of all the good resources that are on RCVS Knowledge. Really helpful. Definitely helped me when I was starting because these are things that we’re doing day in, day out and they are routine procedures. And you can get good data capture for these things. Then it’s
easy.

And then also they’re quick wins as well. So you can monitor it for a month. You’ve got your benchmark figures. You can then take that to your staff meeting or to your head nurse or clinical director. And then on a month by month basis you can then produce these audits and you can very quickly see when things are changing. And then implement things and then very quickly see things improving. So I think it’s really good for the team to see things improving. It’s really good for morale and for compliance with your auditing as well.

Lou Northway:

And it’s nice to be able to share things with owners as well, isn’t it. So, if they ask you for example, oh, what’s the risk score associated complication rate for my pet’s operation? You would have a national benchmark and then you’ve also got your practice benchmark as well if they’re interested. I’m sure clients will be asking those types of questions more in the next couple of years as they see much more interest in facts and figures these days.

Eloise Collins:

Yeah. And the IVC do their patient safety award as well, which is what I was working towards with the practice. Which helps with the QI as well because I could show that, because we’re doing this QI, it’s enabled us to get this award for the practice. So yeah, if you’re an IVC practice out there, it’s a really good initiative to get involved with I think. I don’t know if you’ve done it in your practice?

Lou Northway: We haven’t done it actually, no. But maybe it’s on the list. Well, thank you so much for giving me some of your time this afternoon and waking up especially to talk to me. I do appreciate it. I hope that everyone listening has thoroughly enjoyed it. I’d like to say congratulations again for your amazing project and amazing work. It was very comprehensive. You’ve covered so much. And I advise everyone that’s listening to go on over and have a read of Eloise’s project. Details of the RCVS Knowledge Awards for
2023 are coming very soon. So keep your eyes peeled. And we will speak to you soon. But thanks so much, Eloise.

Eloise Collins: You’re welcome. Thanks. Nice to talk to you.

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