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Improving Gastroenterology care – South Eastern Health & Social Care Trust

Dr Jenny Addley on behalf of Ulster Hospital Dundonald for excellence in service delivery in responding to challenges in care at a gastro unit.

Authors and Institution

Dr Jenny Addley, Gastro Consultant
Dr John Eccles, Gastro Consultant
Dr Rachel Rutherford, Gastroenterology Specialty Doctor
Mrs Adele Nicholls, Gastroenterology specialist dietician
Mrs Noelle Power Gastroenterology specialist dietician

Ulster Hospital, South Eastern HSC Trust

Challenges

Similar to many Gastroenterology units across the UK, our services were under pressure from both inpatient and outpatient perspective. Our main challenges included:

Increasing length of stays for inpatients, identified to be often attributable to delays in getting investigations , in particular inpatient endoscopy, carried out. Also, it was felt that patients were often kept in for a prolonged stay to ensure results continuing to improve as could not rely on rapid outpatient clinic reviews following discharge.

From an outpatient perspective, several challenges were identified and these included :

  • Endoscopy demands increasing
  • Increased red flag referrals
  • Outpatient  clinic waiting lists increasing in length
  • Suspected cancer targets difficult to meet
  • Increased admissions- felt often to be due to prolonged outpatient waiting lists for some chronic disease eg inflammatory bowel disease
  • Admissions for procedural work- long delays as difficult getting beds for elective admissions- eg liver biopsies and no fibroscanner available to aim to reduce liver biopsy numbers for non focal biopsies
  • Burden of liver disease, increasing Alcoholic liver disease, in particular recurrent admissions.Studies carried out on a sample of frequent attenders with admissions for alcohol detoxification showed staggering results.
  • 7 admissions per person in 5 years
  • Average length of stay 21.2 days
  • £7165 per stay
  • £105,334 per person over 5 years

 

How we managed the challenges

As a team, in 2017, we identified the key areas that we needed to address:

Inpatient turnaround, rapid access to outpatient clinics and investigations especially endoscopy and improvement in services for patients with alcohol related disease.

Aims:

  1. Set up a rapid access Gastroenterology service
  • Consultant and middle grade led service with senior decision making
  • Prevent admissions –early Emergency department discharge
  • Direct referrals to rapid access hub- nutrition/oncology/procedures
  • Medical assessment unit in reach to facilitate early discharge
  • Earlier discharges with confirmed reviews for results follow up
  • Rapid access to endoscopy
  • Multi disciplinary teams under one roof
  • Community teams eg dietetic linking in
  • Cross hub working eg rapid access oncology / palliative care clinic overlaps

The patient cohorts targeted for the ambulatory gastroenterology service  would include:

  • Painless jaundice
  • Acute non infective diarrhoea
  • IBD flares
  • Stable upper GI bleeds
  • Feeding device problems
  • Ascitic drains liver and palliative
  • Gastro ward discharge follow up

 2. Development of an alcohol care team:

  • Multidisciplinary team with an interest in alcohol related conditions
  • Improve services for patients with alcohol related brain damage for appropriate placement following discharge from hospital
  • Review of Management of alcohol withdrawal policies within the acute hospital to improve safety for patients including development of inpatient documentations and flowcharts for guidance of prescribing
  • 7 day services for alcohol liason teams
  • Set up multidisciplinary forum for difficult cases
  • Develop a fibroscanning service

3. New consultant working structure for management of inpatients:

  • Gastroenterology Physician of the week model
  • Daily consultant ward rounds
  • Senior decision making
  • Multidisciplinary twice daily board rounds
  • Early discharges
  • Improve triaging of Gastroenterology patients to appropriate wards

Evaluation and Outcomes

1 Rapid Access Gastroenterology Unit

This was developed in a previously used hospital ward, it was refurbished to house a large waiting area, reception area,  five clinical rooms and two  bays with six ambulatory spaces in each . Close work with IT allowed us to develop an online robust referral system with clear referral criteria and same day consultant triaging.The service was initially opened up to those being discharged from hospital and attending for review. It has now been scaled up to take referrals from the emergency department, all hospital departments, provide rapid access endoscopy and fibroscanning.527 patients were seen in the unit in the first year from January 2018.

Current services running:

  • Three rapid access consultant led clinics per week
  • Specialty doctor clinics
  • Dedicated registrar session per week- designed with an educational perspective in mind to allow Gastroenterology  registrars to bring patients to clinic to see, with consultant support
  • Ascites drain clinic
  • Two Dietician led clinics per week
  • Rapid Access endoscopy list in place, second list commencing April 2019
  • Daily phlebotomy service
  • Fibroscanner service Commenced March 2019

2. Inpatient services

 Gastroenterology Physician of the week Model in progress with a dedicated consultant covering the gastroenterology wards Monday to Friday. Clinics and lists are cancelled for the consultant ( with team backfilling ) to allow consultant to focus on  the ward. All patients are seen by the consultant on a daily basis, with senior and rapid decision making, and has been shown to improve discharge rates and reduce length of stay for our gastroenterology inpatients.  Two  board rounds take place per day have been introduced and occur at 9 am and 3 pm each day- these are compulsory and attended by all medical , nursing, and allied health professional staff to ensure maximal efficiency with respect to patient turnover. All inpatient bleeding cases are dealt with promptly by Physician of the week ,and by doing so, proceed to endoscopy rapidly. Education in our unit is a focus, and the junior medical staff benefit from consultant teaching throughout the week.

3. Alcohol Care team

As a team, we visited several units across the UK providing services for patients with alcohol related disease including alcohol related brain disease (ARBD).

We have identified core members essential for the team and set this up:

  • Consultant Gastroenterologist/Psychiatrist/ED Consultant
  • Substance Misuse Liason Nurses and Addiction Managers
  • Ward managers- AMU /Gastro
  • Pharmacist
  • Dietician
  • Representative Alcohol and You

To date the following has been achieved:

  • Screening plan implemented throughout hospital to identifying those at risk of excess alcohol
  • New referral site developed online with rapid response for the addictions team
  • Regional guidelines for alcohol withdrawal produced with participation from our Trust
  • New trust specific alcohol related documents produced including clear guidance and flow charts on alcohol withdrawal management for both wards and outpatients
  • ALN appointments and seven day working set up
  • ARBD Pilot carried out with funding to develop a two bedded inpatient ARBD unit
  • Fibroscanner purchased

What were the learning points and how can this influence other teams?

  1.  Developing a service requires analysis of current service to identify flaws
  2. Identifying the aims of the service being developed
  3. Clear planning, ensuring essential infrastructure in place before a service launched such as referral criteria, referral mechanisms,admin and clerical support, staffing to support the proposals
  4. Starting with small changes, proving concepts, and moving forward with the service
  5. The importance of  a multi disciplinary approach for a successful service
  6. Accepting that all processes take time and not to lose heart when things move slowly
  7. Using all experience and advice available to you , from IT to colleagues in finance department
  8. Seeking feedback from colleagues and patients on developments as they progress