Improving the timeliness of completion of discharge letters in the Surgical Triage Unit at Royal Blackburn Teaching Hospital
Improve appropriate initiation of antibiotic therapy and timely diagnosis of urosepsis through Urine Dipstick testing
Trainee Advanced Practitioner - Colorectal Surgery
Place of work
Colorectal Surgery, East Lancashire Hospitals NHS Trust
Delayed discharges from hospital have more than doubled in the last 6 years; and are thought to cost the NHS around £900 million per year, with patients reporting delays as having a negative impact on their overall satisfaction of care (Department of Health [DH], 2015 & Care Quality Commission, 2015).
In The Local Trust, a retrospective audit of 28 patients who had undergone a colonic resection within a 6 month time period showed that 25% of these patients experienced a delay with their discharge that could have potentially been avoided.
To tailor the project to service demands, the baseline audit results were categorised into the recurrence of common causes for delay:
1) No senior review/ decision to discharge when medically fit.
2) Waiting for discharge summaries and medications
3) Waiting for diagnostic tests/ results
These key themes were used alongside evidence-based practice, to form the basis of this strategic approach, to facilitate an effective discharge process and reduce avoidable delays.
This is a two-phase project, consisting of two PDSA cycles with 28 patients in each cycle, to allow comparison to baseline audit.
The processes are:
Kurt Lewin’s ‘Three stage model of change’ (Unfreeze – Change –Refreeze) has been used to plan the implementation and drive the changes forward (Lewin, 1951). To refreeze, sustain the change and embed the strategies into the organisational culture, key stakeholders were kept informed of the progress by sharing pertinent information at relevant forums. Qualitative feedback was gathered and was used to modify and improve processes; giving the stakeholders ownership over their ideas and improvements.
The project consists of two phases, using the PDSA cycle to allow for continual evaluation and contemporaneous modification (Langley et al., 2009). Evaluation was conducted using Donebedian’s process of ‘Structure, Process, Outcome’ (Donebedian, 2003).
The processes were evaluated on an individual basis and data collected from the prospective audit at each phase analysed against the baseline data to ascertain if an improvement has been made.
The implementation of the various processes should improve the discharge process, to facilitate timely care and interventions and reduce avoidable delays.
Three key learning points
1. Avoidable delays in discharge have a huge impact on patient satisfaction and also represent one of the biggest causes of avoidable compromise to the financial stability of the NHS.
2. Engaging with key stakeholders to implement sustainable strategies and processes to facilitate timely care and plan discharge from admission can help to reduce avoidable delays.
3. By reducing avoidable delays, patient flow should be improved, which will result in less cancellations for surgery and should also improve breech times for ED.
Connecting to you: Introduction of a Telephone Follow-Up Clinic for Orthopaedic patients undergoing steroid injection treatments.
Trainee Advanced Nurse Practitioner: Trauma & Orthopaedics
Place of work
Fracture Clinic, East Lancashire Hospitals NHS Trust
The CQC (2014) highlighted that Outpatient Services within East Lancashire Hospitals NHS Trust (ELHT) were not responsive to the needs of its population. The Trauma & Orthopaedic (T&O) Directorate within ELHT provides elective steroid injection treatments to an average of 1200 patients per year. These patients are followed up face-to-face with the Consultant in the Orthopaedic Outpatient Department.
As this procedure is minimally invasive, patients could be safely reviewed post-procedure via telephone consultation by an Advanced Practitioner (Wilson & Bickerdike, 2015; Department of Health [DH], 2010). Role substitution would enable the Consultant to focus on more complex patients whilst having a positive impact on clinical flow within the T&O Directorate.
To revise the existing outpatient follow-up service for Orthopaedic patients who undergo elective steroid injection treatments by introducing a Telephone Follow-Up Clinic.
The introduction of the Telephone Follow-Up Clinic has made this service more responsive to patients’ needs whilst enhancing stakeholder engagement by offering alternative methods of contact. This intervention has had a positive impact on patient waiting times and Consultant activity.
Three key learning points
1. Utilising alternative methods of patient contact ensures continuing patient participation in care
2. Communication and multidisciplinary team working are the cornerstones of excellent clinical practice
3. A robust support network is a necessity to facilitate successful navigation of the complexities of service provision
Trainee Advanced Nurse Practitioner
Place of work
Gastroenterology/Hepatology Medicine, East Lancashire Hospitals NHS Trust
Mortality rates for liver disease continues to rise rapidly, being the third most common cause of premature death in England. The Northwest of England has 4,221 per 100,000 population under 75 mortality rates considered preventable, the worst region across England (Public Health England, 2015).
Despite the increase of preventable deaths, enquiries suggest that the acute care of patients with liver disease is poorly recognised, organised and implemented, resulting in patients receiving sub-standard care with avoidable deaths. Yet, such services can be improved at a relatively low cost to the National Health Service, whilst improving the clinical outcomes for patients (The National Confidential enquiry into patient outcome and death, 2013).
To innovate, implement and transform standards of liver care with an inspirational advanced practitioner led in-reach service. Aiming to undertake advanced clinical assessment, diagnostics and leadership for patients with liver disease, improving benchmarks of care provision, supporting positive patient progression to community services.
A Liver care bundle has been developed, incorporating best practice benchmarks to guide clinical teams/treatment plans required during the first 24 hours of admission. Patients will be triaged by the trainee advanced nurse practitioner and discussed with the duty designated on-call gastroenterology Consultant Monday-Friday 09:00-17:00.
Patients will be assessed by the trainee advanced practitioner in their clinical setting, reviewed daily with plans of on-going treatment until the patient is transferred to a Gastroenterology Ward or community setting, where outpatient hepatology follow up will be arranged.
The Donabedian model of evaluating quality of care (2005) evaluated the outcomes of the project. It reviewed the outcomes of a previously completed logic model following a three-monthly trial of the care bundle in practice including how many patients are seen within 48 hours of referral, 30-day readmission rate and if the trainee ANP has inspired teams to look at sustaining change, by evaluating a post intervention knowledge questionnaire.
The advanced practitioner led in-reach service to liver patients has improved quality of care, providing sustainable, inspirational, safe and effective services to the population.
Three key learning points
1. Mortality rates for liver disease have increased 400% since 1970, fivefold increase in mortality in people aged 65 years of younger.
2. Early identification and intervention of liver disease can improve survivability and promote a positive patient flow through their hospital journey, including follow up.
3. The need for a consistent approach of support from key stakeholders that will support the influence of the project is essential.
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