New-onset movement disorder in the immediate postpartum period

This case report describes a woman who developed involuntary, uncoordinated movements of her face and limbs following a spontaneous vaginal delivery, complicated by postpartum haemorrhage. Using systematic assessment with multidisciplinary team input, a differential diagnosis was proposed and relevant investigations were undertaken. Atypical eclamptic or generalised seizures were excluded clinically and neuroimaging ruled out an intracranial vascular event such as stroke or venous sinus thrombosis. Local anaesthetic systemic toxicity was managed empirically with intravenous lipid emulsion and intravenous fluids. A diagnosis of drug-induced dyskinesia was made, most likely secondary to ondansetron, with which dystonias and myoclonus have been described. This woman's symptoms were transient and resolved within 2 hours.This case presented a complex differential diagnosis, highlighting the paucity of guidance available. We propose a diagnostic algorithm to aid in the identification of acute involuntary movements in pregnancy and the puerperium.

1088 A QUALITY IMPROVEMENT PROJECT TO IMPROVE END OF LIFE CARE DOCUMENTATION ON A CARE OF THE ELDERLY WARD

Introduction

The National End of Life Care Strategy highlighted the need for individualised care plans accessible to the multi-disciplinary team. Care planning tools have been shown to improve documentation, with proformas providing a systematic approach to recording EOL discussions. Our initial staff survey highlighted a lack of familiarity with required EOLC documentation. We aimed to increase awareness of existing documentation proformas and to improve EOLC documentation on an elderly care ward.

Methods

A Driver Diagram increased understanding of the principles underlying excellent EOLC and aided development of change ideas. The Model for Improvement allowed identification of measurable aims. 20 patient notes were reviewed fortnightly, including patients who had died since the previous intervention.

Results

Three PDSA cycles were completed, changes were measured by evaluating patient documentation. The first PDSA cycle involved providing training to nursing colleagues. Step-by-step teaching on the use of Cerner EOL documentation demonstrated a 15% increase in completed care plans. The second cycle (placing posters around the ward) - detailing how to access and document care plans resulted in a 5% increase. The third cycle (25% improvement) involved education sessions for ward doctors.

Conclusions

Comprehensive documentation is key to ensuring good EOLC, as it enables continuity of care and improves MDT communication. Withdrawal of the Liverpool Care Pathway resulted in a need for individualised care plans. Active interventions including face-to-face teaching were more effective than passive (posters) in improving documentation. Limitations included small sample sizing, likely due to a lack of engagement with questionnaires and inclusion criteria. Only documentation of deceased patients was analysed, excluding patients discharged home or transferred to hospice. We aim to extend to other elderly care wards and to integrate documentation training into junior doctor induction. A review of existing EOL proformas and their ease of access may also be considered.