QI Learning Hub

Authors

Ms Karen Prunty, Clinical Nurse Specialist

Dr Kylie L’Estrange, Senior Clinical Psychologist

Prof Eleanor Molloy, Professor of Paediatrics and Consultant Neonatologist, CHI at Crumlin and Trinity College Dublin

Children’s Health Ireland at Crumlin

Background

Parental stress and posttraumatic stress disorder are well-recognised following Neonatal admissions. Enhanced communication has been highlighted as a key factor to improve parental emotional well-being during the admission. 

Method

A questionnaire was administered for parental feedback on communication with the neonatal and multidisciplinary teams. Antenatal visits, postnatal diagnosis and feedback on verbal and written communication were assessed. In addition, parents record keeping and diaries were recorded. A parental diary was subsequently developed in collaboration with parents to enhance bilateral communication and feedback from ward rounds. 

Results

Parents who received an antenatal diagnosis and an antenatal visit to the hospital, PICU and the ward, scored higher and felt more prepared compared to those who did not receive an antenatal diagnosis and were therefore less prepared for the environment of PICU.  The majority of parents were not using their own diary, however 100% of parents were using the ‘Story of Me’ milestone cards as a form of marking their baby’s progress and memory making. The draft design of the diary incorporates the ‘Story of Me’ milestone cards and parents were involved in the design of the draft diary, with three PDSA cycles with parental feedback such as areas for photos, hand and footprint, family tree area.

It is evident from the results, that parents want to know a plan for their baby, be involved in daily care of the baby e.g. nappy changes and know what the long-term implications of their diagnosis.   

Discussion

The diary helped parents to create memories of their baby in hospital, keep track of all the information they are given and enhance communication between parents and the multidisciplinary team.

Financial Implication

The cost of design and print 300 diaries is €1,500. However, as the design is also included in that quote, the cost would decrease when print is just needed on annual basis.

Parents receiving good communication regarding their baby’s care may be better prepared for discharge and building resilience that it may decrease inpatient stay and readmissions, which would decrease cost of patient stay in hospital.

Conclusion

The final design and content of diary is continuously updated with ongoing parental feedback. 

Authors

Ana Goles, Consultant psychiatrist Mental Health Rehabilitation and Recovery Team

Kerry Mental Health Service

Background

People with serious mental illnesses have a substantially reduced life expectancy compared with the general population.  The reasons for this are various, however high smoking rates in people suffering from mental illnesses exacerbate these inequalities. Intervention from health professionals has been shown to increase the percentage of smokers who stop and remain abstinent for 6 months or more therefore we decided to identify how often our clients were offered smoking cessation advice and to implement it in their regular care.

Methods

Only outpatient clients were included in the pilot project.  The percentage of quitting advice given in the last session with a medical professional was determined.  The process of reviewing clients was assessed and opportunities to give brief advice on smoking cessation was explored.  The interviews were held with clients who successfully quitted smoking in the past and their reasons were used as a motivation to encourage quitting in the smoker population.

Results

Out of 30 clients only one person quit smoking during the project implementation period.  Another four people started to contemplate the pros and cons of quitting smoking.

Discussion/Implementation

Brief advice on smoking cessation can help people suffering from mental illnesses to cease smoking or at least to start to contemplate about it.

Financial Implication

Successful smoking cessation will have financial implication for HSE and patients themselves.  For HSE, the decrease of percentage of smokers will result in decrease of hospital beds for COPD treatment, decrease in doses of psychotropic medication and decrease of disease burden (QALY).  Financial benefit for patients in reducing cost of everyday living and potential trigger for further positive behavior change.

Number of Patients

30

Further Plans

To implement changes to residents of residential facilities, i.e. group homes and high support hostels.  When implemented in residential facilities to implement it in the inpatient unit.

Authors

Adrienne Gillan, Senior Occupational Therapist, Enable Ireland

Caroline Flynn, Senior Physiotherapist, Enable Ireland

Denise McDonald, Consultant Paediatrician, Enable Ireland and CHI at Tallaght

Abstract

Historically, a diagnosis of Cerebral Palsy (CP) was considered not definitive until 2 years old, and in some children with atypical presentations, confirmed later.  However, there is now good evidence that a diagnosis of cerebral palsy or at least identification of this diagnosis being a high risk can be accurately predicted in children with known risk younger than 5 months corrected age.   Some children do not go on to develop CP however we know that they are at risk of non-CP related motor impairment and have better outcomes with early intervention. The provision of timely intervention to infants and children with primary motor impairment is established best practice.  We are falling short of meeting best practice standards.  It is incumbent upon us to address this, for the benefit of the children.

The problem that we identified was that referrals to our team are being received too late.  Referrals to the other network teams in our area are not identified as having motor impairment or at risk of motor impairment and children are sitting on waiting lists for long periods of time.

The aim of this initiative was to identify children with or at risk of motor impairment as early possible and ensure access to CP and non-CP specific early intervention, maximising neuroplasticity and minimising the negative effects of late diagnosis to muscle and bone growth, development, and function.  We set out with 2 aims:

• By June 2021, all children living in the region with or at risk of motor impairment will be referred directly to the Motor Management Service.
• By June 2021, all appropriate children referred to the service will be seen for assessment within 4 weeks of receipt of referral.

We hoped to address the referral process to the service by analysing what currently happens and identifying the key driving components.

We completed PDSA cycles that included making initial contact with stakeholders to confirm awareness of the motor service and appraise them of the current project, reviewing the referral process with referring agencies including agreed referral criteria, early screening assessments by the referrers, point of contact for referrer and obtaining parental consent at point of referral.

This quality improvement project quickly demonstrated the value of defining the aim, using data to understand the problem and implementing small changes to achieve success.  We found the referral process improved as we worked through the project as a direct result of engaging with referrers. Our engagement with them was targeted and productive as we had identified the key stakeholders and the important delays in the process by studying our own data before contact was made.  Referrers were in general glad of the contact and keen to work with us to improve the process for children and families.

Financial Implications

The project has been cost neutral to the service to date. RCPI offers the QI certificate without charge so the therapists could participate without application through the training budget. The resource to the motor service is such that the increased referral rate can be absorbed, so the initiative is running without extra staffing costs to the service.

Authors

James Glover, General Manager Primary Care, CHEast  

Dr Phillip Sheeran Purcell, GP Lead, CHN South Wicklow

Dawn Tyner, CHN Manager, Learning Site South Wicklow

Background

There is currently no Healthlink electronic referral pathway between GPs and the Primary Care Therapy teams in the South Wicklow CHN Learning Site. We propose the introduction of a new referral pathway which will eliminate ‘missing referrals’, ensure minimum client data set is mandatory and begin the process to establish a clear two-way referral communication pathway. The project aim is to introduce a referral pathway via Healthlink using a standardised referral form for Wicklow Primary Healthcare Centre GP surgeries in South Wicklow Network to two Primary Care CHN Therapy Teams (physiotherapy and social work) by June 2021.

Methods

This project will trial, study and adjust a standardised referral pathway using Healthlink as accessed by GPs to Primary Care Multidisciplinary Teams.  This will be achieved by the developing a clear client referral pathway, to reduce the type of referrals fax/email/letter, reduce delay in referral time, increase quality of minimum patient data set through use of standard referral form, to improve patient safety – and ensure right person gets the right information in the right place at the right time.    

Results

Due to the HSE Cyber Attack in mid-May 2021, which severely impacted Healthlink and HSE emails the project team encountered a significant delay implementing the new referral pathway.  The reduction in inappropriate/erroneous referrals to Physiotherapy for July 2021 is significant – at 31% less than the June 2021 figure – but is not regarded by the project team as robust from a statistical perspective given that other factors may be at play.  It is however anticipated that the reduction in errors will be more clearly demonstrated following more in-depth analysis over a longer period of time later in 2021.  

Discussion

Implementation was severely impacted by the HSE Cyber Attack and this has constrained the full rollout of the project and the testing of its various hypotheses. The most important recommendation of the project team to local management is to continue the study by testing the new process on Physiotherapy and Social Work referrals as intended by the project.  

Further Impact

This pathway is the first step in establishing a clear two-way communication pathway between referring GPs and Primary Care.  The project team propose that the immediate electronic referral and feedback will also reduce delay between referrer and recipient with real time feedback through the automatic response that referral has been received. The learning from the project will be shared within the Community Health Organisation, with the Learning Site Network Managers and with the team leading Community Healthcare Network implementation nationally.  

Authors

Ms Claire Costigan, ANP Deteriorating Patient Service

Dr Anne-Marie Leo, Consultant Anaesthesiologist

Dr Junaid Qazi, Fellow in QI & Deteriorating Patient Service

Background

Readmission to the Intensive Care Unit (ICU) is associated with increased patient mortality (6 to 27%), increased hospital length of stay, and increased healthcare expenditure.  It is estimated that 10% of ICU readmissions are preventable.  In 2019, 8.1% (32/391) of patients discharged from the General Intensive Care Unit (GICU) at Cork University Hospital (CUH) had an unplanned ICU readmission during their index hospitalisation.  The aim of this project is to improve transition of care of patients discharged from the GICU to the ward within CUH, aiming to reduce unanticipated ICU readmissions during index hospitalisation by 25% within 12 months, with an eventual goal to reduce mortality, as well as hospital length of stay in this patient cohort.  

Methods

The QI initiative incorporated follow up of post ICU patients by the Deteriorating Patient Service. Other interventions pertaining to improving communication through verbal handover, and standardisation of discharge were in the early stages of implementation, at the time of writing this report.  Interventions were planned and tested using regular PDSA cycles and the methodology that was adopted was Model for Improvement.  The project was undertaken from July 2020 through March 2021.  ICU readmission rate, process and balancing metrics were compared with historical controls.

Results

ICU readmission rate fell from 8.1% in 2019 to 4.3% (p = 0.04) during the entire study period and to 3.8% (p = 0.03) as the intervention was modified.  This however did not translate into prolonged interval between readmissions on a Statistical Process Control (SPC) chart.  61% (72/119) of patients were reviewed by the DPS within 24 hours of ICU discharge.  Median ICU length of stay was 10 days (IQR  4 - 25) during the study period compared with 6 days (IQR  3 - 15) at baseline and was not significantly prolonged because of the intervention.

Discussion

We performed a systems analysis around care of patients discharged from the GICU at CUH. It has highlighted numerous areas for improvement such as recognition of the high-risk patient, communication of risk, interdepartmental relations development, and education around what interventions may be required to help prevent readmission to ICU.  Pilot PDSAs of verbal handover of the high-risk patient and of use of the pink sticker to denote risk are promising.    

Financial Implication

ICU care is expensive.  Reduced ICU readmission rates are associated with reduced hospital costs.  We anticipate that successful implementation of this QI initiative will lead to cost savings for the hospital.   A more exact assessment of the health expenditure saving because of the intervention, will be calculated going forward, using change in hospital bed days and quality adjusted life years.

Plans for Further Development

Clinical practice of the DPS is currently on hold.  When the DPS returns, we intend to implement the following using further PDSA cycles:  1).  Formal medic to medic handover of high-risk patients, 2).  Utilisation of the Pink Sticker highlighting a patient at risk, 3).  Clinical review of all patients prior to their discharge from the GICU, and 4).  Clinical review of high-risk patients by the DPS. 

Authors

Dr John Devlin Executive Clinical Lead

Emmett Conroy National Infection Control Manager

Elaine Dunne Infection Control Nurse

Abstract

Prisons are vulnerable settings and the impact of Covid has been significant in many jurisdictions.  The Irish Prison Service introduced a range of non-pharmaceutical interventions to limit the transmission of Covid across all 12 prisons.  This project aimed to increase staff compliance with social distancing measures, in particular to reduce the numbers of staff identified as close contacts and the numbers of areas (hotspots) within the prison where close contacts occurred.

The methodology included a process review to identify how staff became close contacts and a driver and fishbone diagram to illustrate contributing factors which needed to be addressed. An initial Pareto Chart identified a number of hotspots within the prison where potential transmission was occurring.  These areas were targeted and the frequency of close contacts in these locations reduced over time.  A trend analysis using Run Charts of the incidence of close contacts and PPE breaches provided the key outcome measures of the project. A number of measures were introduced over time which reduced the frequency of staff close contacts and PPE breaches.

It is difficult to quantify the impact of these measures because of the differing prison health care systems in other jurisdictions and that non-pharmaceutical interventions complement each other.  There is a financial and social cost in implementing these measures, in particular the use of high-grade PPE.  However, it is likely that the combination of measures reduced the number of prison outbreaks, avoided prisoner hospital admissions and contributed to zero mortality.

Prison health care differs from traditional health services in that there are safety and security issues that need to be addressed.  The Covid pandemic impacted across all areas of society and provided a unique opportunity to implement a “whole of prison approach” to infection control.  The success of these Covid measures in IPS was attributed to a supportive governance structure, good communications across all levels of the organisation and peer led responsibility with staff taking responsibility for their compliance with the use of PPE and social distancing measures.

Financial Implication

It was difficult to quantify the economic costs and benefits of the project. Covid measures required new work practices, restricted prison regimes and significantly greater use of PPE. These work practices were likely to be less efficient than those that applied pre-Covid, and restricted prison regimes entail a social cost. However, the reduction in staff close contacts would result in fewer staff cases, a reduction of staff absenteeism arising from Covid and less outbreaks involving staff and prisoners. While the project focussed on a small number of Covid control measures, namely reducing the number of staff close contacts, it likely contributed to the outcome where no prisoner required hospital admission and there were zero fatalities

Authors

Joe Garvin, Consultant Surgeon, Associate Clinical Director

Mary Barrett, Assistant Director of Nursing Perioperative

Caroline Cuniffe, Admissions Department Staff Officer, IPMS Lead

Background

The current project was undertaken to study and improve the booking process in the surgical day unit (SDW) at Portiuncula University Hospital (PUH). This process developed in an ad-hoc manner, lacks flexibility and an ability to respond to variations in patient flow leading to increased waste, poor utilisation of surgeon, nursing, ancillary staff, and theatre time.

Methods

We utilised stakeholder analysis and a communication plan for key stakeholders which included the surgical secretaries and booking office staff. We constructed a process map and identified key tests of change which were implemented using the PDSA format (Plan, Do, Study, Act). These involved making the key stakeholders central to the booking process. Data was collected weekly from the SDW for two three-week time periods pre and post intervention, analysed and run charts created to identify initial trends and the impact of interventions.

Results

Baselines mean SDW occupancy rate was 18 patients. This improved to a mean of 25 by study end.

Discussion/Implementation

The project resulted in a more efficient coordinated SDW process which supported the full utilisation of the available SDW trolleys.  This in turn led to more timely access to day care procedures for patients, increased staff satisfaction and engagement. 

Financial Implication

The increase in utilisation has had a positive financial gain for the hospital; Fixed costs have remained the same, but more patients have been treated utilising the same resources. This also results in a cost saving to the Health Service. Under current arrangements waiting list patients would subsequently have been offered treatment in private hospitals under the National Treatment Purchase Fund (NTPF).  

Number of Patients Affected

We successfully increased the throughput of patients by 7 per day or 35 per week. 

Conclusions/Plans for Further Development

We plan to roll out these improvements to other specialties that utilise the SDW. We will seek to get further patient involvement in the design of this process. We plan to design a process to link procedures with booking and scheduling times in the future which would also help when optimising lists. 

Authors

Danielle Bracken, Quality & Safety Advisor

Dr Albi Chalissery, Consultant Neurologist

Helen Cornelissen, Occupational Therapist Manager

Background

Currently, patients of Connolly Hospital requiring neurorehabilitation are not having their rehabilitation needs met post discharge as there is no existing out-patients therapy service. Therefore, the service provided by Connolly Hospital to the patients in its catchment area is not equitable, efficient or consistent with those services and best practice as occurs in other parts of the country.

Methods

We established an occupational therapy outpatient service which provided neuro-rehabilitation intervention (via a blended approach of telehealth, home visits and OPD visits) within 2-4 weeks post discharge for patients presenting with neurological conditions to Connolly Hospital in order to improve their neurological outcome.

Results

Outcome Measures
All patients (four) had improved neurological and cognitive outcomes post therapy intervention.  

Process Measures
In total, 45 therapy sessions (30 Telehealth, 5 Home visits, 10 OPD visits) were provided to four patients, all with different neurological diagnoses. A total of 62.5 therapy hours were spent by a senior occupational therapist who provided neurorehabilitation (33.25 direct and 29.25 indirect hours). On average therapy lasted a duration of 15.5 weeks per patient (range 10-28 weeks). On average therapy was provided 6 days post discharge for patients that had been in-patients.

Financial Implication

It cost €1,775 in total (based on therapy hours spent and the senior occupational therapist’s hourly rate) to provide an occupational therapy neuro-rehabilitation programme to four patients.  

Number of Patients Affected

With limited resources, we provided post-acute occupational therapy neuro-rehabilitation to four patients, however, a 1.0 WTE senior occupational therapist working as part of a fully resourced, MDT, Early Supported Discharge team for patients with neurological diagnoses other than stroke, based on the numbers of Traumatic Brain Injury (TBI) admissions for instance, per year to Connolly Hospital and factoring in the maximum therapy hours available, we would have the potential to provide post-acute neuro-rehabilitation as part of an ESD service to circa 104 patients per annum. 

Future Recommendations

Our future vision for Connolly Hospital patients with neurological diagnoses would be the expansion of the service to include the full MDT and commence the process earlier, whilst the patient is still an in-patient as part of a programme of early supported discharge for a cohort of patients with mild-moderate neurological impairment, age 65 years or younger with the potential for improved outcome and a neurological diagnosis other than stroke.