Objectives:
Our Lady’s Hospital in Navan provides a general acute hospital service to the Meath catchment area and an Orthopaedic and Rheumatology service to the North East.The purpose of a recent RIE (Rapid Improvement Event) which ran from December 2016 – March 2017 was to target medical cohorts where average length of stay (AvLOS) was >14 days and most particularly the cohort for > 30 days and to scope discharge facilitation for these patients. Required improvement themes were to reduce AvLOS by 20%, reduce bed days lost by delayed discharge by 20%,close unfunded escalation beds and improve predicted discharge date (PDD) compliance by 30%. A delay in health care professionals (HSCPs) receiving appropriate referrals from doctors at ward level was flagged as a major issue in lengthening the patient journey from assessment to discharge. A baseline audit of two outcomes was measured over a 2 month period (Feb-Mar 2017) which reviewed both the appropriateness and timing of referrals to physiotherapy.
Method:
Prior to this RIE the physiotherapy policy only allowed for doctors to refer for physiotherapy assessment. A new policy was drawn up in conjunction with the Physiotherapy Manager, a number of senior physiotherapists and the Hospital Manager. This new policy aimed to facilitate Clinical Nurse Managers/Clinical Nurse Specialists (CNMs/CNSs) to refer appropriate patients for inpatient physiotherapy assessment and treatment. As per initial policy it also stated that if the referral was completed before 11am, the physiotherapist would aim to see that patient that same day which facilitated earlier triage and intervention. Education sessions were completed among nursing staff to highlight these changes. By implementing and piloting these changes it was hoped it would expedite the turnaround time from a patient being assessed to discharge.
Results:
202 medical and 30 nursing referrals were audited. 79% of medical referrals were deemed appropriate versus 11% inappropriate. 73% of nursing referrals were appropriate versus 7% inappropriate. Reasons for inappropriate referrals were identified as patient independently mobile on ward, no change in baseline level of mobility compared with previous admission, day of discharge referrals, patient had self-discharged, patient requiring orthopaedic review prior to physiotherapy assessment. There were also a large number of duplicate referrals, 10% medical and 20% nursing. This highlights the need for further communication at ward level and the importance of the use of visual management boards identifying whether a referral has been completed for a particular patient to a particular discipline. With regard to timing of referrals 119 referrals were audited with 47% of referrals received before 11am and 53% after 11am.
Conclusions:
This pilot study which involved change in the physiotherapy referral system to include the acceptance of nursing referrals is considered to have benefitted our referral process as appropriate patients are now identified earlier in their episode of care. Furthermore, as a result of this audit changes have also been made to the physiotherapy referral form allowing the referrer to include more specific information. It is anticipated to re-audit these outcome measures over the next six months and to evaluate the new changes.
References:
Health Service Executive (2017) Healthcare Pricing Office. Acute Medicine Programme Ireland
Department of Health (2016) Health in Ireland. Key trends 2016
