We’re delighted to announce that the winning submission for the CSSC Service Development Prize 2020 was from The Royal Wolverhampton NHS Trust for repurposing space within the emergency department (ED) to help cater for patients requiring urgent paracentesis, blood or iron transfusions.
Nurse-led Day-case Gastroenterology Service in the Emergency Department
The Royal Wolverhampton NHS Trust
This application outlines how a space within ED was re-purposed for performing paracentesis and infusions when existing services couldn’t cater for patients with severe ascites requiring urgent paracentesis, as well as urgent blood or iron transfusions which couldn’t be accommodated into the current day-case service. As a result, admission avoidance, early treatment, and follow up were enabled with significant financial contribution to the Trust.
Clinical Practitioner in Gastroenterology
Outline of the challenges to our service and why we needed to change
A nurse-led day-case service had previously been established in Gastroenterology that catered for elective, non-urgent patients. This service provided ascitic paracentesis for patients with chronic liver disease and various intravenous infusions such as blood transfusion, specialised biologic infusions for patients with inflammatory bowel disease, magnesium and phosphate infusions, and iron infusions. The service had facilitated a patient-focused, timely, and responsive clinical pathway for day-case treatment without the need for hospital admission. However, patient surveys identified a need for access to an urgent service via the emergency department (ED), as the existing service could not cater for patients attending ED with severe ascites requiring urgent paracentesis who could not be accommodated into the current day-case service and patients with a new diagnosis of symptomatic anaemia needing urgent blood transfusion/iron infusion. This gap in provision resulted in unnecessary patient admissions, some of whom were palliative in the terminal phase of their illness, with delays of 3-4 days for drain insertion following admission due to need for availability of trained clinical staff.
How we overcame the challenges
Existing but unused space within ED was re-purposed for performing paracentesis and infusions. A patient pathway was created in ED that streamed patients with severe and symptomatic ascites without other complications into the re-purposed space where they could be paracentesed and discharged. Patients with symptomatic anaemia were also streamed into this area. Suitable patients attending ED late in the day were sent home with instructions to attend the day-case space for their treatment, thereby facilitating admission avoidance. The day-case space was completely managed by a team of gastroenterology nursing staff who admitted patients, performed paracentesis and infusions, and discharged patients with appropriate follow up arrangements with clinical teams or for repeat procedures/infusions as necessary. Nursing staff were redeployed from the gastroenterology ward with training given to new staff. Support was provided by the Trust to backfill vacancies as a result. The new capacity was additionally utilised to accommodate existing patients needing paracentesis or infusions as well to minimise redundancy. Medical Consultant staff provided oversight and troubleshooting if needed. Nurses were registered on the ED PAS admission system as named care providers in order to facilitate nursing admission and discharge without need for a sign-off process by a doctor.
During a 12-month period (April 2019-March 2020), 535 patients were treated in the ED day-case facility (164 (31%) paracentesis, 345 (64%) infusions, and 26 (5%) blood transfusion). Admission avoidance, early treatment, and follow up were enabled as a result of this service with significant financial contribution to the Trust. An ultrasound machine was additionally purchased and nursing staff performing paracentesis started training in ultrasound with a view to performing ultrasound-guided paracentesis for patients with loculated ascites. This novel intervention was also initiated with a view to deliver ultrasound-guided paracentesis for inpatients with loculated ascites, thereby minimising delays in waiting for interventional radiology-assisted paracentesis.
Key learning points and how this can influence other teams
- Teamwork: nursing, medical, admin, ED
- Developing confidence amongst nursing staff in performing medical procedures, learning new skills with oversight by Gastroenterology Consultant staff
- Admission avoidance, thereby leading to patient satisfaction, prompt treatment and follow up and a reduction in the risk of complications due to delayed treatment
- The trained nursing staff supervise junior doctors in learning to perform ascitic taps and paracentesis and sign off their competencies
This is a novel nurse-led service that has changed our practice completely, with upskilling of nursing staff and a truly integrated service with no boundaries between nurses and doctors.
Three reasons why it’s an improvement
Better for patient – the right environment, care provided by trained staff in a timely manner, greater access to service, overall improved patient journey and experience.
Better for staff – nurse, not consultant-led, empowers nursing staff with greater training opportunities, supporting recruitment and retention. Reflects close collaborative working with nursing, medical, and management teams to solve local problems.
Better for Trust and NHS – cost savings realised through efficiencies in reduced admission and bed days. Innovative service in the Ambulatory Emergency Care setting. Seen as a model of excellence by other Trusts and Organisations in other countries.
Contact details for more information
Department of Gastroenterology, McHale Building, New Cross Hospital, Wolverhampton, WV10 0QP