Improving patient referral pathways in ENT patients

Dr. George Williams, Dr. Tabitha Unsworth-White &

Miss. Hannah Light

1 Introduction

The SHO led ENT emergency clinic is a format used throughout NHS trusts to triage individuals with conditions needing to be seen in a timely manner. Conditions range from severe otitis externa, which needs to be seen within a week, fractured nasal bones needing manipulation after 7 but before 14 days, and foreign bodies in ears, which can be left for weeks in certain circumstances. The authors aim to implement a list of conditions to be booked into this clinic, highlighting those which need to be seen as an emergency on-call and ensuring conditions needing consultant-led specialist outpatient clinic review are referred appropriately.

2 Method

To investigate whether a patient had been referred to the SHO led clinic appropriately we looked at the clinic diary, the patient’s booked and the ailment they were referred for. We compared this to the list of conditions that should be seen in the clinic and those that should be seen elsewhere. We collated the data for one week before cycle 1 and after every cycle from there on.

The first cycle was the creation of a poster of conditions that should be seen in the clinic, and those that should be seen via other pathways.

The second cycle was to alter this poster to inform SHO colleagues of particular time frames that some conditions should be seen within.

The third cycle was an educational element of teaching incoming SHOs about the poster and which conditions should be seen in the clinic.

A driver diagram highlighted where in the referral chain changes could be introduced:

1) A poster detailing where different conditions should be seen.

2) Addition of the time frame that these conditions need to be reviewed in.

3) Teaching SHOs regarding the use of this poster and the common conditions seen.

3 Results and Analysis

Data was collected from the ENT emergency clinic diary booking system over three separate five-day periods. Weekends were not included due to reduced staffing. 44 patients were seen during the first cycle, 32 (72.7%) patients were deemed to have been booked correctly. Following implementation of the poster and education of the ENT team responsible for booking appointments, 41 (89.1%) patients were booked correctly in the second cycle. This increased to 100% (26) in the third cycle, this cycle included fewer patients due to the inclusion of a bank-holiday. The most common conditions seen were Otitis externa with 31 cases, recurrent epistaxis (19) and manipulation of nasal fracture under anaesthesia (12).

4 Conclusions & Going Forward

The creation of a clinic poster established a clear referral pathway ensuring patients were seen in a timely manner and were reviewed in the appropriate clinical setting. The results collected demonstrate that by the third cycle, all patients were being triaged to the correct service and the emergency clinic was not being overbooked with inappropriate referrals. Further cycles should include the change to new SHOs to ensure they are aware of the poster and continuing to follow its guidance. Going forward we are aiming to audit emergency clinic telephone calls to ensure that these are also appropriately dealt with.

Maximising our ‘peak flow’: how QI supported a redesign of community pulmonary rehab services in Milton Keynes

Alison Stirton-Croft, Lisa Pitam, Kiaya Watson, Jennifer Hammond, Susan Gaynard, Home 1st Therapies, Community Health Services Milton Keynes

Introduction

CNWL provides community based Pulmonary Rehab services in Milton Keynes. The service was suspended during 2020 due to the pandemic, and when it restarted in April 2021 it faced large waiting lists with long waiting times for patients.

Aims

In addition to our stated improvement aim, we wanted to:

• Ensure we provided a safe service for all patients referred for community based pulmonary rehab.

• As well as seeing patients within 90 days, we needed to ensure that all venues were Covid safe and that patients felt safe enough to take part in group sessions.

V. Kopanitsa1, S. Flavell2, J. Ashby 2, I. Ghosh2, S. Candfield2, U. Srirangalingm2, L. Waters2

• Strengthen relationships with partners across the whole system to support patients with respiratory conditions.

1. University College London (UCL) Medical School;

We faced the dual challenge of clearing our historic waiting list, and ensuring we had capacity to manage ongoing referrals into the service. Even before the pandemic the service was struggling to see patients within 90 days from referral, as per British Thoracic Society guidance. 1 High demand also affected partners providing support for pulmonary rehab and respiratory issues across the system. We agreed we would need to rethink the way in which we provided our service across Milton Keynes. QI provided a structure for us to work through ideas for change.

2. Central and North West London NHS Foundation Trust

Methods

Starting in June 2021, we set an aim to clear our historic waiting lists and to ensure that:

By the end of 2022, all patients referred for Pulmonary Rehab services would be seen within 90 days of referral.

• We used QI methodology (Model for Improvement)2 to structure our work around changes to processes, pathway for patients and accessibility to the service.

• 5 PDSA ramps and a total of 14 cycles allowed us to test and establish changes.

• We gathered feedback from patients, staff and partners throughout our work to inform next steps.

Discussion and Results

A Driver Diagram helped us to see our system and identify where we needed to make changes.

PDSA cycles allowed us to test a number of ideas. We have now worked through 5 key ideas which are reflected in these PDSA ramps.

One of our ramps shown in more detail. Starting small, we worked up until we were sure things worked. We’ve now made this part of our business as usual operating model.

As we tested a number of ideas, we started to see our waiting lists come down. Recent rises have been in line with increases in referrals (e.g. when we took on hospital patients) and have been managed in a timely way.

We wanted to see all patients in under 90 days from referral. You can see that our new approach means we are now seeing patients faster than before the pandemic. (our Service was suspended from Apr 2020 – Mar 2021 so there is no data for this period in the graph).