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:
- Give patients a ‘predicted date of discharge’ (PDD) to help plan care that is timely and necessary.
- Introduce ‘Weekend plan stickers’; to provide continuity over 7 days a week
- Devise a protocol to complete discharge summaries and medication checks 24 hours, prior to discharge
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.