WHERE THIS HAPPENED: Homerton University Hospital NHS Foundation Trust

Hydroxyurea is the gold standard treatment for prevention of vaso-occlusive crises in patients with sickle-cell anaemia. It has a narrow therapeutic index and dangerous side effects including cytopenias. There is high variation in dose–response across the population. Therefore, a robust outpatient monitoring programme is crucial to ensure efficacy and safety of treatment. However, there has historically been difficulty engaging the target population in regular laboratory test monitoring programmes. This project aimed to ensure that all patients on hydroxyurea had routine blood tests at least once every 2 months which were reviewed and acted upon within the 3-year project life cycle.

A specialist haematology nurse prescriber clinic service was introduced, first informally, and then formally to take blood tests, alter medication dosing, prescribe it and then write a clinic letter. The mean number of tests per patient per year rose from 0.21 at baseline to 9.05 after 2 years of the formal nurse prescriber clinic. This led to an associated increase in dose changes from 0.23 to 1.45 per patient per year. This improved the number of patients on the optimum dose of hydroxyurea.

Furthermore, due to increased confidence in the outpatient monitoring, the total number of people being prescribed hydroxyurea increased from 26 to 42. Restriction of prescriptions to only those enrolled in the service has prevented unmonitored patients being at risk of the potential toxicities associated with doses that are too high. The introduction of a formal nurseled clinic has improved the safety, efficacy and compliance and increased the number of patients on the gold standard preventative treatment for vaso-occlusive crises in sicklecell anaemia.

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WHERE THIS HAPPENED - Royal Bournemouth HospitaL

The colorectal services at The Royal Bournemouth Hospital needed to adapt to meet the extra demand on fast-track patient referrals to the outpatient department, as a consequence of the changes in the National Institute for Health and Care Excellence (NICE) guidance on cancer referrals in June 2015. Learning from other units, a telephone assessment clinic (TAC) triaging patients straight to colonoscopy was trialled. A Plan–Do–Study–Act (PDSA) methodology was used. A baseline study showed that fast-track colorectal patients referred from their general practitioner (GP) were taking on average 30 days until they received their colonoscopy.

This quality improvement project focused on sending fast-track colorectal GP referrals through a straight-to-colonoscopy TAC. The results of this intervention showed an improvement from GP referral to colonoscopy. Both PDSA cycle 1 and PDSA cycle 2 showed an average of 24 days. This reduction of 6 days was a promising improvement in a 62-day patient pathway, so funds were accessed to invest in a temporary full-time TAC nurse appointment to allow more data to be collected. PDSA cycle 3 showed a reduction of the average from referral to colonoscopy to 19 days and a reduction in the variation. This outcome will be sustainable, as the TAC role is now a permanent position.

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WHERE THIS HAPPENED -  Royal United Hospital NHS Foundation Trust, Bath

The Royal United Hospital, NHS Foundation Trust, Bath, (RUH) is a busy district general hospital, providing secondary healthcare for 500000 people across the South-West of England. The surgical take is busy and varied. Two consultant-led, post-take ward rounds take place each day in the surgical assessment unit (SAU), a 19-bed admissions unit that takes direct admissions from general practitioners and the emergency department. The bays are overseen by a ward manager (senior nurse), and three to five staff nurses with an equal number of healthcare assistants.

The daily ward rounds include the team of junior doctors on the take that day, as well as a senior SAU nurse. Because of the fast-paced nature of the ward information may not be documented or communicated effectively, and this can impact on patient safety. There is also a degree of variability in the way the ward round is conducted, depending on the lead consultant for that round.

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WHERE THIS HAPPENED -  Royal Cornwall Hospital

The handover of large numbers of medical patients, during on call periods when staffing levels are reduced, is a challenge for all acute medical services. At the Royal Cornwall Hospital, a large district general hospital, we identified that foundation doctors were reviewing medical inpatients during weekend on call periods with limited written handover information. We chose to address this problem by developing an intervention, a weekend handover sticker, and piloting it. We used the review of documentation to measure improvement and feedback from users to assess the processes involved. Use of the weekend handover form improved the written communication between weekday and weekend teams.

The number of weekend plans documented in the notes increased from 15% to 84%and the provision of a patient summary within the last 7 days increased from 26% to 94%. The feedback from users confirmed it was a useful intervention and 100% (15/15) of doctors and nurses responded positively to the question “Do you think the weekend sticker should be introduced and used at the weekend for all medical patients?”

The feedback also identified concerns regarding additional workload for weekday ward staff and this has led to ongoing work to try and ensure that the weekend handover form continues to be used effectively to maintain an improved level of written handover information for on call staff. While we have not included a direct measure of patient care, we hope that by improving the quality of written handover information we are acting to ensure patient information is shared effectively, with likely positive impact on patient care.

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