Quality Improvement

Background: Patients triaged as routine, discharged home from Intermediate Care Units (ICUs) in areas of West Sussex wait  approximately 4 weeks or more until rehabilitation continues by the Community Therapy Team (CTT).

Introduction NHS England (2023a) and NHS England (2023b) call for minimal delays, effective coordination processes and sharing of information for timely rehabilitation in intermediate care settings. Local patient feedback indicated poor patient satisfaction and increased clinicians anxiety regarding risk of deterioration due to long waits (Lewis A., 2018).

Aim To improve average wait times for routine ICU patients’ discharge, for ongoing community therapy input, to within 1 week by July 2024, while maintaining patient safety and improving patient satisfaction.

Methodology: Quality improvement methodology, using stakeholder engagement was used to determine the cause for long wait times for home therapy. PDSA cycles were engaged to determine if improvements could be made without a loss of quality of care, or impacting patient safety, while improving patient experience. These involved formal communication channels between teams and using a therapy assistant for an initial home assessment where assessments had already been undertaken by registered therapists on the ICUs. Patient satisfaction surveys were undertaken to understand the experience of transition home.

Results: Baseline data indicated that waiting time for home therapy varied between 18 - 59 days, from discharge. After the initial PDSA cycle, waiting time reduced to between 4 - 10 days, and after the second cycle waits reduced further to between 3 - 7 days. Patients’ satisfaction improved significantly with shorter waiting times for therapy once home.

Conclusion: Therapy assistant initial visits at home reduced waiting times to within a week, and patients’ satisfaction improved with shorter waiting times. Patient safety was not compromised as there were clear protocols for appropriate escalations for unregistered staff.

Introduction:

Falls in older people are associated with multifactorial risks which are often preventable. Last year there were over 220,000 emergency admissions for falls in people aged 65 years and over in the UK. Improving how we assess such patients on admission may help to ameliorate these risks and prevent future admissions.

Method:

The aim of this quality improvement project was to identify weaknesses in our acute risk assessment of multifactorial falls and to improve on these. We completed a retrospective case note review for 68 patients in their first 48 hours of admission. As an analytical framework, we adopted the NICE guideline: ‘Falls in older people: assessing risk and prevention’ which details twelve key parameters of risk assessment. For each patient we sought to determine whether these parameters were assessed or missed. After the first audit cycle, we found four guideline parameters which were commonly missed during the acute admission phase. An educational intervention was subsequently organised for medical staff at a departmental level and corroborating posters were placed around the acute areas of the hospital. Two months later a second audit cycle was undertaken which assessed the same parameters and looked for improvement.

Results:

There were notable improvements in four areas. The assessment of visual impairment increased from 32.4% to 42%. The documentation of patients’ perceived risk of falling improved from 37.3% to 60.9%. Osteoporosis risk assessment rose from 32.4% to 63.8%. The completion of Lying/Standing BP demonstrated the most significant increase, from 14.7% to 44.9%.

Conclusions:

The results suggest that a tailored educational session and a poster campaign have increased overall awareness and improved the risk assessment of multifactorial falls at a central Birmingham Hospital.

Introduction: Discharging patients from hospital is a complex process which requires multiple professions and processes. Late afternoon discharges can lead to admission bottlenecks and contribute to emergency department overcrowding. Focusing on discharging patients earlier in the day, can contribute to greater flow through the hospital and greater patient satisfaction. Leeds Teaching Hospital Trust (LTHT) aims to achieve 70% of discharges before 3pm. The Specialist and Integrated Medicine (SIM) department care for frail elderly patients who are at increased risk of harm following prolonged stays in the emergency department and were discharging 30% of patients before 3pm.

Method: To gain greater understanding, a survey was conducted amongst various staff members to understand their perceptions of why delays occur in patient discharge. A deep dive into discharges after 3pm was also conducted to identify avoidable delays. This enabled multicomponent interventions to be developed with the team and enacted across SIM. These included:

- Education about the importance of timely discharge

- Community discharges prioritised in pharmacy the day before

- 'Golden patient' identified on wards for morning discharge.

- Promoting utilisation of the discharge lounge

- Recognition of achievement for wards

- Recruiting of junior doctors to lead individualised ward QI projects to improve earlier discharge

- Involvement of senior leaders to have buy in from consultants and senior managers

- Discharge boards being utilised.

Results: SIM achieved a 12% improvement in number of discharges before 3pm which has been sustained despite increasing pressures on the department. This is the highest median ever achieved by the department.

Conclusion: Achieving patient discharges earlier in the day is complex and requires a multifocal approach from multidisciplinary professionals. The interventions used were based on an in depth look at data and developing an understanding of the perceived and actual barriers from the team themselves.