Otolaryngology Head & Neck Surgery Auckland City Hospital Green Lane Clinical Centre Bren Dorman, FRACS Clinical Director Otolaryngology Head & Neck Surgery Auckland District Health Board Auckland
Challenges: Increasing FSA referral volumes: population increases Variable quality of referrals Primary care interactions: referrals, guidelines, follow-up What ORL conditions can GPs manage? System complexities causing inefficiencies Need for specialised equipment in managing complex patients Shorter hospital stays: day stay and outpatient procedures Pressure on specialised and scarce clinical resource.
Patient pathway A. Appropriate and efficient referrals B. Focused and time-efficient surgery C. Effective and efficient follow-up care Referral Improvement project Vertigo Pathway Sinusitis Pathway In-clinic local anaesthesia Pathways Surgery prioritisation Follow-up improvements Clinical leadership by specialty Self mgmt GP visit Diagnostic Pre-admit Referral Triage FSA Surgery Ward Follow-up & book Discharge Self mgmt information Checklists Referral guidelines Triage guidelines Patient information Follow-up protocol ToC/ Followup instructions Treatment guidelines GP care instructions Monitoring protocol Self mgmt information Patient experience
Impact Action Evidence Referral improvement project Incomplete referrals Referral formats inconsistent Delays to referral triage, missing referrals Dizzy audit: 22/84 audited appointments were for patients with BPPV Implemented standard referral templates for ORL across region Defined criteria and minimum requirements for referral acceptance Published and communicated to primary care Quality and completeness of referrals Vertigo referral pathway and ereferral template design CT Head for Sinusitis Virtual FSA
ereferral site - Otology Criteria
Vertigo pathway & video
CT Sinusitis virtual FSA Access to Diagnostics primary care direct referral for CT scan for Sinusitis Includes minimum criteria Virtual FSA for all patients, about 15 per month done Referral triage to now include (positive) scan, resulting in decreased virtuals
Impact Action Evidence Local Anaesthesia procedures Best practice evidence In-house experience Reviewed inpatient procedures: Current time taken for GA procedures Developed protocols for scoping and laser procedures Set up procedure rooms in-clinic Trained staff 650 procedures done since end of 2010 Currently 30-35 per month Time saved Cost impact
Impact Action Evidence Follow-up improvement project Audit: 40-60% of follow-ups in ENT not deemed necessary in its current format Audit: GP follow-up is an alternative for about 20-40% of follow-ups Ratio of follow-up to FSA varies between clinicians Follow-up routines after surgery (e.g. FESS) vary between clinicians Defined follow-up protocols for common conditions Established nurse phone clinic for Head & Neck monitoring Repatriated non ADHB patients for follow-up in own DHB Redesigned clinic outcome form Established scheduling policy to reduce priority for follow-up Nurse clinic Outcome form Protocols
Head + Neck nurse phone clinic Long term, stable patients Enrolment process Escalation policy Evidence based phone questionnaire Results: Saving clinician and patient time
New ORL clinic outcome form More prominent placement of Discharge options, including patient directed, home DHB repatriation and transfer to GP Include purpose for follow up (reason) and alternative methods for follow up delivery (phone or virtual) Nurse follow ups
Other ORL improvements SCRUM how we manage our capacity to meet production and waiting time targets with minimal waste MOS how we manage the service
Conclusions Importance of engaged clinical leaders Challenge of allocating time to change initiatives Role of data collection and management Making sure patient is kept central Overcoming funding challenges