The challenge
In October 2019, the Queen Elizabeth Hospital in King’s Lynn was placing a big focus on emergency pathway flow. Typically, A&E admissions per hour would peak at midday, whereas discharges per hour would peak at 4pm. This time lag was leading to congestion in the emergency department, resulting in delays for patients in A&E and for those awaiting the arrival of an ambulance.
As part of a Trust-wide programme, all inpatient wards were asked to develop initiatives to maximise the number discharges earlier in the day.
Necton is the Trust’s 32-bedded respiratory unit. At the start of the project, we identified that many discharges were being delayed due to waits for TTOs. These would often only be prescribed on the day of discharge, meaning that it would be late in the day before medicines could be dispensed and the patient could leave hospital.
What the ward changed
We used several simple tools to break down the problem.
We started by articulating the key question to be resolved, using a Problem Definition Sheet
By considering what was in our direct control we quickly focused on our board rounds.
Whilst we held a morning board round each day to plan the next step for each patient’s care, we had struggled to embed a consistent board round in the afternoon.
We hoped that, by holding a daily PM board round, we could identify discharges due for the next day and make early preparations for these to take place in the morning.
Using a tool called the Hypothesis Tree we quickly identified the criteria necessary for a successful afternoon board round – for example, we needed a systematic approach for discussing each patient, as well as consistent representation from across the MDT.
Following this, we launched our new approach to PM board rounds. We:
• Reached agreement on who should be expected to attend from each team / service
• Worked with junior doctors to agree a consistent time that aligned with their schedules
• Created and formalised a focused agenda to guarantee consistent, concise meetings
• Worked to identify how to enable a registrar to attend each day
• Shared weekly data to enable the whole ward team to track our progress, this included number of discharges, proportion of discharges pre-12 and discharge lounge use
How it benefited patients and staff
After just six weeks, we had already noticed the impact on our discharge statistics. The average number of discharges before 12pm had risen from ~2 to 4 per week.
The daily afternoon board round helped us to identify upcoming discharges much earlier, making it easier for us to prepare patients to leave hospital early in the day. This both reduces unnecessary waiting for those discharged patients, and enables earlier admission of new patients, helping to ensure that they obtain the care they need as soon as possible.
Over time, we increasingly used the meetings to probe discharge plans.
We adopted the “5 Whys” tool in which you repeatedly ask ‘why’ to reach underlying root causes. By challenging clinical plans like this, the team were able to work to simplify them (e.g., could a procedure be done in an outpatient setting?). This helped to reduce the risk of patients spending unnecessary days in hospital.
Following this project, we are continuing to review our discharge processes. We are already looking to share discharge preparation across both day and night shifts. In addition, we are seeking to improve oxygen provision in the discharge lounge, which would allow more of our patients to use the facility.
The project team included:
• Fiona Clutterbuck, Ward manager and project lead
• Claire Kent, Ward matron and project sponsor
• Dr Subramani Durairaj, Respiratory medicine consultant
This project was supported by 2020 Delivery, one of the UK's leading public service consultancies.
You can read the full case study here