Transformation in practice

Beaumont Hospital Director of Nursing, Marie Keane explains  how the hospital provided 35 additional ‘new’ OPD clinics and cut patient LOS  to less than Healthstat targets without any additional resources.

Beaumont Hospital has been able to add on 35 additional ‘new’ OPD clinics without any additional resources and reduce the LOS for patients to under the Healthstat National LOS targets, as a result of two major hospital initiatives, Marie Keane, Beaumont Director of Nursing, told the HMI Forum.

Marie Keane
Marie Keane

Speaking on “Transformation In Practice” she said the guiding principles of the initiatives were improving access, improving quality and more efficient resource utilisation.

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The hospital realised that OPD was an important gateway – each year over 135,000 patients were seen, 27,000 new patients and 108,000 return patients.   There were 100 clinics per week and all disciplines/specialties were covered.

In late 2006  only 70 per cent of clinic space was being utilised, the hospital had moved from block booking to individual appointment times (but these were not being adhered to), clinics were not starting or finishing on time, some clinics were over booked, others were under booked and waiting times for some specialties were 12 – 24 months.   Also, there was a lack of discharge planning back to GPs in some of the specialties, The ratio of ‘new’ patients to ‘return’ patients was low, there were high rates (22 per cent) of patients not attending for their appointments. Patients were unhappy at the delays in clinics.

Clinic hours

It was decided to extend the ‘clinic day’ from 8 a.m. to 6 p.m., and change to three clinic sessions per day, provide additional consulting rooms and continue with individual patient appointment times.

Sixteen new rooms were added as part of a refurbishment of the OPD, 100 new clinics needed to change, 35 ‘new clinic’ spaces were created and all stakeholders consulted and brought on board. Templates of existing clinics were developed and new ones designed to suit each specialty, giving the number of new and return patients per clinic.

The result is that we have added on 35 additional ‘new’ clinics with no additional resources

“We got the co-operation and goodwill of all staff and the support of senior management, the improved physical infrastructure showed that we were serious, good communications avoided confusion and  misunderstanding, there were dedicated project resources, services for patients were streamlined and clinics were continuously audited to see how they were progressing,” she told the Forum.

“The result is that we have added on 35 additional ‘new’ clinics with no additional resources, we have expanded Nurse Led Clinics, we are continuing to monitor the changes in OPD and to review work practices and procedures. There is a continued emphasis on education and informing patients what is required of them and a focus on discharging patients to their GPs.

“In the first ten months of this year, the number of new patients seen has increased by 19 per cent compared to the same period in 2008, while the total number of patients seen has increased form 124,410 in 2004 to 129,645 (Oct2009).

Discharge planning

“In addition we  have a more patient-focused service, patients are seen in a more timely manner, clinics are running to time, extra space and time slots allows for new consultant appointments, with a  more efficient use of medical, nursing and clerical resources. A patient satisfaction study showed positive feed-back from patients and a better, less overcrowded working environment for staff.”

Keane said there was an active approach to discharge planning from OPD to GP and the hospital would shortly have the OPD clinic sessions per consultant on its website.

They were now examining options for closer ties with the community, standard referral from GPs, auditing and monitoring adherence to practice changes, extended nurse led clinics and patient education through appropriate use of TV, DVDs and information leaflets.

Major success factors included senior clinical decision making, access to diagnostics, multi disciplinary team approach

The second initiative was aimed at reducing patient waiting time in the Emergency Department.  It involved converting a 31 bed medical ward with approximately 20 long stay patients (there was an average of 1 – 2 discharges per day) into a Short Stay Unit (SSU).

The desired outcomes were the protection of the ward, despite the fact that over 40 patients could be waiting in the ED, to reduce the LOS, measure the patient pathway in hours, provide timely access to diagnostics, provide an integrated discharge plan, improved MDT /Education ownership and a micro management approach.

Rapid diagnosis

On July 27 of this year St. Patrick’s Short Stay unit was opened with 30 in patient beds including an MRSA 4 bedded cohort and a three bedded trolley area for rapid diagnosis.  The ward was open 24 hours per day seven days a week and 52 weeks a year.

The ward was for short stay emergency medical patients within an expected 3 day LOS.  There was an agreed pathway/protocol and ED patients were assessed in the trolley area.

It had resulted in an increased awareness of nursing staff re short stay, extended nursing roles (phlebotomy, cannulation and ECG have commenced  out of hours as required), there is rigorous audit, allocated  medical staff, a bed management focus on case management, increased staff morale and mixed bays.

Keane said that there were a number of unplanned outcomes as a result of opening the new unit – it had an impact on core ward activity, it had an impact on specialisation therefore it impacted on specialist training of staff, it resulted in increased long stay patients (who had been moved out of the unit) throughout the hospital, it decreased staff morale/satisfaction in other wards and it resulted temporarily in a loss of private income for the hospital.

Major success factors included senior clinical decision making, access to diagnostics, multi disciplinary team approach, general services support from portering, cleaning and catering and a guaranteed approximately 33 per cent ward bed turnover.

“The nurses in St. Patrick’s Ward have attained what all nurses in wards should attain – teamwork”, said Keane.

She said that on October 29 of this year the new unit had been opened for 95 days.     In that time 837 patients had been through the unit, the overall LOS was four days or 3.8 days if long term care patients were excluded.

The LOS of all those suffering from chest pain, acute lower respiratory tract infection, syncope and collapse, urinary tract infection, COPD with acute exacerbation, unstable angina, afib & flutter and other chest pain had  been significantly reduced to under the Healthstat Target National LOS.