Virtual Clinic Review - A Patient- Centred Mechanism for Optimising Flow Katie Cuthbertson Lech Rymaszewski Gavin Love Jane McEachan
National Programme Aims Reduce Variation Achieve reliable implementation Spread across NHS Scotland and other outpatient settings Right patient, right time, right place, right team, every time
Support National WSPFIP Team Clinical support Lech Rymaszewski Margaret Nugent Review of variation Understand current pathways of care Consider and develop real time data resources to monitor change and ensure change is an improvement Development of Evidence Base Provide clear evidence base of best practice Economic Evaluation Sharing Dedicated web page Clinical support network Patient leaflets Central site for resources
NHS INERTIA v slow to adopt change BARRIERS?
GENERIC PROBLEMS OF MEDICINE? BEST PRACTICE Everyone wants to do what is best for patients Medical culture of divergence in opinion BUT - not everyone can be right Unwarranted variation impacts negatively on overall clinical care (potential overtreatment) Costs of poor clinical decisions, both diagnostic and treatment, borne by the patient and society
If maths was taught like medicine
BETTER VALUE Docs / Nurses Casts / crutches Xrays Physio Admin / clerical Management Transport - Ambulance/taxis Porters / Domestics Estates
NHS CHANGE MANAGEMENT ELECTRONIC TOOLS CULTURAL CHANGE EVIDENCE-BASED MANAGEMENT
DON BERWICK We have to be weaned from this volume-driven system -no longer asking How much did we do today? But How much did we help today?
PRINCIPLES - a bottom-up process Start with patient clear, patient-focused aims Clinically-driven vision Grass-root consensus inclusive (Patient Information Leaflets) Real-time database > accountability allows trouble shooting + audit cycles > credibility and trust Informal communication crucial
Virtual Fracture Clinic Experience Mr Gavin Love Consultant Orthopaedic Surgeon
Traditional Fracture Clinic All new out-patient fractures/injuries over previous 24hrs Large numbers Often little done Duplication of ED work Unnecessary visit Poor training opportunity
Aims To improve patient flow To reduce local variation To bring the right patient at the right time to see the right person Free up time and re-invest
Process Expedition to Glasgow
Process Redesign Element 1 Discharge patients with agreed injuries straight from ED with self-care advice and a leaflet Paediatric clavicle fracture Buckle/torus fracture Minimally displaced radial head fractures Mallet fingers Fifth Metacarpal fractures Fifth Metatarsal fractures Adaptation/Adoption of 6 discharge leaflets
Collaboration Close liaison with ED Medical and Nursing Staff
Process Redesign Element 2 Use Velcro splints/boots All cases where clinically appropriate (saves plastering time and materials and doesn t make a return appointment inevitable)
Process Redesign Element 3 Tayside wide protocol for specific fractures agreed Apply to all ED and MIU departments Adopt as SOPs
Process Redesign Element 3 Conduct Virtual review and only see patients who need something done All new ED referrals via virtual clinic Virtual clinic daily (1 st hour of a fracture clinic) Senior nurse and Consultant XR and ED notes reviewed Letter to patient (and exercise/advice sheets) and copy to GP Nurse telephones patient after VC Brought back at the right time to the right clinic to HAVE SOMETHING DONE Virtual discharge if nothing to be done Open access giving patient Option to return
Result 6 Leaflets Snapshot audit sample size Pre-redesign 127 Post-redesign 100 21% overall reduction in weekly referrals from ED to virtual/fracture clinic
Result The 6 discharges from ED 437 NW patients from Jan-Oct Ninewells PRI Total Nov-12 1 1 Dec-12 33 33 Jan-13 33 33 Feb-13 33 10 43 Mar-13 36 12 48 April-13 49 20 69 May-13 66 27 93
Number of apts Result 300 250 200 150 100 50 0 Monthly number of Urg ent Appts - F rac ture C linic NW Urgent Median Tes t w ith 6 frac ture pres entations virtual c linic introduc ed Oct-11 Nov-1 1 De c-11 J an-12 F eb-12 Mar-12 Apr-12 May-12 J un-12 J ul-12 Aug-12 S ep-12 Oct-12 Nov-1 2 De c-12 J an-13 F eb-13 Mar-13 Apr-13 May-13 J un-13 J ul-13
Result 300 250 200 150 100 50 0 Oct-11 Nov-1 1 Monthly number of Urg ent Appts - F rac ture C linic P R I De c-11 J an-12 F eb-12 Mar-12 Apr-12 May-12 J un-12 J ul-12 Urgent Median Aug-12 S ep-12 Oct-12 Nov-1 2 Tes t w ith 6 frac ture pres entations De c-12 J an-13 F eb-13 Mar-13 Apr-13 May-13 J un-13 J ul-13
Result 80 70 60 50 40 30 pre redesign post redesign 20 10 0 cast splint
Result 100% 80% 60% 40% 20% admission from virtual return appt.from virtual discharge code from virtual 0% Feb Mar Apr
Patient Satisfaction 30 25 20 15 10 5 0 Enough info from ED-injury 29 28 24 25 26 6 5 4 1 2 Enough info ED follow-up Prefer clinic to phonecall Used contact number Happy with outcome and info Yes No
Effect on the Service Fewer patients More time for those that do attend, quality service, less rushed More direct access to subspecialist clinics Fewer inappropriate attendances More focussed Consultant led and delivered Time freed up for training of juniors Virtual clinic used as teaching clinic Adoption by plastics for all hand injuries Possibility of merging some fracture clinics in Angus Time before fracture clinic to anticipate who/what is coming and request XRs digitally in advance, streamlining their attendance
Teething Problems Very few! ED Nursing staff concerns over time/expertise to apply splints Some disquiet towards plaster room staff
Tips and Advice Ensure an adequate safety net Radiologist report for ED XRs Consultant virtual clinic review within 24-48hrs Telephone call and letter to patient Contact numbers given to patient at time of ED attendance and at virtual clinic Open door policy Paper/audit trail Normal process for GP contact with Ortho Reg continues ED Consultant can over-ride at their discretion
Summary Patient centred Patients like it Less unwarranted variation Better quality care ED like it Surprisingly straightforward to initiate
Questions?
Virtual Hand Clinic Queen Margaret Hospital, Fife
Virtual Hand Clinic Based on GRI Virtual Fracture Clinic Aims to reduce number of Out Patient Visits Streamlining of pathways Cut waiting times Improve patient understanding
Virtual Hand Clinic
Information Ganglion Mucous Cyst Carpal Tunnel Syndrome Lumps / Bumps
Information - key to patient understanding
Information - set out in black and white
Last 1 year RMS outcomes New = 56% Total Number of RMS Referrals = 1911
Last 1 year results Total number of results reviewed in virtual clinic = 1606
Last 1 year results Total number of results reviewed in virtual clinic = 1606
Tippers!
PRINCIPLES Evolution not revolution - using a bottom-up process Start with patient Grass-root consensus inclusive (Patient Information Leaflets) Real-time database > audit cycles > credibility Informal communication crucial
PRINCIPLES Evolution not revolution - using a bottom-up process Start with patient Grass-root consensus inclusive (Patient Information Leaflets) Real-time database > audit cycles > credibility Informal communication crucial