Objective:
In Regional HospitalMullingar, patients presenting to the Emergency Department (ED) withabdominal pain were regularly referred to have a diagnosticultrasound (US). 45% of patients requiring a non-urgent US out ofhours were admitted as inpatients to have their scan. The averagePatient Experience Time or PET (time from patient registering in EDto discharge) for the non-admitted patients was 17.9 hours. 35%of the patients on trolleys at 8am (8am TrolleyGAR) were awaitingscans. As part of the Unscheduled Care (USC) performanceimprovement programme for Ireland East Hospital Group (IEHG), leanmethodology was applied to evaluate this patient pathway. Theaims of the study are to a) reduce the rates of admission fornon-urgent patients requiring an US, b) reduce PET for patients whowere awaiting US but were not admitted, c) Develop and implementguidelines for patients who do not require an urgent US, d) Agreereferral and prioritization system for ED patients requiring US,agreed with Radiography Department.
Methods:
A team was assembled toreview this process. Members included Medical Business Director, EDstaff (Consultant, Nursing Staff, Multi Task Attendant, Health CareAssistant, Administration Officer), Radiology Consultant and SeniorPhysiotherapist. Over a one week period, the current process wasexamined and delays in patient flow were identified. An idealpathway was then developed and guidelines were put in place to reducedelays in the pathway. A guideline for referring for an US wasagreed and a list of criteria for who was safe to discharge home wasdeveloped by the ED consultant. Two appointment slots for US werereserved each morning for ED patients who presented the previousevening requiring same. An appointment book was placed in ED torecord pre-booked appointments, the referring Doctor books them infor their appointment and the patient is provided with an appointmentletter. The patient is instructed to attend for their US and thenreturn to the ED department 2 hours later for their diagnosis andmanagement. Education sessions were provided to all involved staff. This process was reviewed at 30 days, 60 days and 90 days to ensurecompliance.
Results:
During the initial 60 daytrial, 57 patients followed this pathway. Of these 45 had a normalUS, 2 had an abnormal US where they were admitted for surgicalreview, 10 had an abnormal ultrasound and were reviewed by theSurgical Out-Patient team. Ofthe 57 patients who followed this pathway, no patients werereadmitted prior to their US appointment due to adverse events.
Quality: The number ofpatients on 8am TrolleyGAR waiting for US scans was reduced from 35%to 12%. PET times for non-admitted patients reduced from 17.9hours to 8.8 hours (51%).
Delivery:The number of patients booked for admission for non-urgent US scansout of hours reduced from 45% to 12%.
Cost:The number of patients admitted for non-urgent US scans reduced by97%, from 26 in 8 days initially to 7 in 90 days over the course ofthe study. Bed Days Used (BDU) for these reduced from 74 daysby 33 patients (Avg 2.24 days) to 14 days by 93 patients (Avg 0.14days). Over the initial 60 day period of this study, 55admissions were prevented. At an average cost of Eur900 per nighthospital stay, it is estimated that this resulted in a cost saving ofalmost Eur50,000.
Conclusion:
Followingintroduction of this new pathway, patients who attend with abdominalpain and are considered non-urgent are now discharged home overnightwith advice and with an appointment for a diagnostic ultrasound thefollowing day. This has reduced the number of patients waiting ontrolleys for scans at 8am, and has reduced the numbers of patientsbeing admitted. Due to the success of this project, it isrecommended that a similar project look at the Pathway for patientsrequiring a non-urgent CT scans.
