Abstract
Introduction
Clinicians covering six older people’s medicine wards reported feeling burdened by requests for weekend review of patients without clear indications, reducing time for patient care. We aimed to standardise the process to streamline reviews, freeing up clinicians to deliver optimal care.
Methods
We developed a new electronic weekend handover process using existing capabilities within our electronic patient record. The COM-B behaviour change method was used with a focus group of clinicians including PAs, residents and consultants to identify targets to change behaviour. Fifteen potential tests of change were considered. Four were implemented over multiple PDSA cycles.
Key changes included:
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Mandatory documentation of review priority (1,2,3 or discharge)
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Clear documentation of review indication with recommended actions
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Embedded mock examples of best practice to nudge behaviour
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Engagement through meetings and informal senior/peer influence
We collected weekly data for four months on: patients put out for review, number lacking a clear indication, and the number missing prerequisite actions. A survey of clinicians was performed.
Results
The number of reviews remained stable but the number of patients with no clear indication for review decreased from 11.5 to 2.5. Respondents rated the new system at 7.72/10 globally compared to 3.2 for the old system. 78% felt that the reason they were reviewing patients was clear. 72% found prioritisation easier. 87% of users of the old system reported quicker review times – none thought it was slower.
Conclusion
A structured electronic system using existing capabilities, informed by behaviour change and quality improvement methodology reduced the number of patients put out without clear review by 78%. Satisfaction with the new system was high and time was released for direct patient care. Further tests of change are planned to drive further improvements in safety and quality, but existing changes have been sustained and success shared with the organisation.
Comments
Handover burden
The handover burden in hospitals is too high and increasing clarity behind why a patient may need a review reduces the stress upon the doctor who has to do a weekend review (of a patient they have never seen!)
It would be interesting to re-review this cohort and see if handovers remain clear after changeover/new set of doctors within the hospital
We are planning to re-audit…
We are planning to re-audit as we had noticed since August changeover of doctors there has been a decline in the quality of information given for the reason for review and confusion regarding the priority system. We plan to explain the system again during a departmental lunchtime meeting and also go to the wards on a Friday to check everyone understands what is expected.
However it has definitely been an improvement on the previous system, and reviews are more focused.
Well done
Well done. I agree further cycles of audit would be a great idea and looking at senior participation. We use a similar proforma for our Friday ward rounds and it prompts DNACPR and escalation decisions.
Stealing this!
Nice project which I think could be really helpful in our trust.
Thanks for the note about needing to include in rotational inductions. Such a good point.
I glad that this may be…
I glad that this may be useful in other trusts too!
We have a few copies of the SOP taped on each of the wards, and also use peer influence through permanent members of staff such as PAs which is helpful.
The confusion can come when locum doctors are covering weekend shifts who haven't worked that particular shift since the change, and therefore we are also looking at senior input on the weekends from the on call registrar to check people know where to find the list and what the priority system means.
Thank you
Really helpful.