PVDU - Project Red

 

Background

The Sheffield Pulmonary Vascular Diseases Unit forms part of the National Pulmonary Hypertension Service, and has been developed to deliver highly specialised quality care.

The PVDU is a quaternary referral service with approximately 1,200 patients on their books. These are widely spread over a geographical area that extends from the Midlands to Teesside, and from North Wales to Humberside. The patients all suffer from a form of pulmonary hypertension or pulmonary arterial hypertension.

The department offers a multi-disciplinary service that encompasses respiratory medicine, cardiology, and interventional radiology, nursing, pharmacy, imaging, and therapy services.

Patients can be treated as outpatients or, if necessary, as inpatients. Both the outpatient and inpatient services are currently located on Ward M2 of the Royal Hallamshire Hospital.
 

Assessment

A multidisciplinary team was created to undertake an assessment of the microsystem using the 5Ps framework (purpose, patients, process, professionals, and patterns). This assessment included data from hospital systems, direct observations, and measurements to help generate a high level process map showing the urgent inpatient pathway.

Purpose

“To establish an equitable inpatient pathway for all urgent patients, regardless of source. This should be standardised and apply for 24 hours a day, 7 days a week. It should also provide an optimal patient and staff experience.”

Patients

The team collected demographic data for all patients, plus dates, admission times, and length of stay data. A pathway mapping a patient’s journey prior to their inpatient stay was mapped, with outpatient appointments and GP visits detailed alongside notes about problems and delays.

Process

A high level process map was used to detail every step of a patients journey along the urgent inpatient pathway. This map was then used to identify issues, and help the team work towards resolving them.

Professionals

The team spoke to the staff members involved in the service to ask them the aspects that were good or ‘not-so-good’, as well as suggestions for how they can improve. They said:

  • Discuss patients on waiting list after every ward round meeting.
  • Reduce the number of outliers that occupy beds.
  • Add a tickbox on transfer form to remind the transferring hospital to send enough medication.
  • Develop an electronic record.

Patterns

As issues are explored, it frequently becomes apparent that more data is required to accurately document what is happening within the microsystem, and to ensure that improvements are being suitably deployed to generate the best response for patients. The data analysed by the team includes bed occupancy patterns, the number and duration of telephone calls received, and the time taken to repatriate patients after deciding that they are medically fit enough to go home.

Diagnosis

Data analysis and discussions from the initial assessment determined six emergent themes to be addressed as part of the improvement plan.

  • An urgent inpatient pathway – Many patients do not live in the local area, and require transferring from other hospitals that can be over 100 miles away. There is the potential for an inequity in access to develop in the system for patients living outside of Sheffield which requires eliminating before it develops.
  • How people contact the PVDU – The routes for contacting the PVDU are convoluted, multiple, and not always responsive. This is a hindrance to effective communications.
  • Communication within the PVDU – Surveying the staff as part of the 5Ps assessment discovered that many people found it difficult to obtain relevant information, which directly impacted patient care, staff morale, and motivation.
  • Online presence of the PVDU – The representation of the service on the Internet as part of Sheffield Respiratory Medicine is unhelpful, out of date, and incomplete.
  • Repatriation of inpatients – There is concern that due to the variability in distances that many patients travel to the Trust, repatriating patients who are medically fit enough to return home is not completed in a systematic or timely fashion.
  • Emergency situations – Emergency contact details for patients receiving intravenous Iloprost and other drugs at home, and a supply of emergency equipment and information on the wards is required to improve the service.

The team generated six global aims to address the key themes within the work, plus a number of specific aims to target issues directly. Each specific aim is then linked to a change that has been implemented, and the results or feedback from that change.

For example, to improve the urgent inpatient pathway:

Global Aim: We would like to establish an equitable referral system for all urgent patients, regardless of source. This is important because we are concerned that not all our urgent patients can access our services in a timely fashion according to clinical need. We need to do this now because it is not acceptable to us that we are unable to treat everyone fairly. In addition, this issue is also affecting the way our elective patients can access out services.
Specific Aim: We aim to provide patients waiting for transfer to the PVDU with useful information so that they have a better idea of what their experience will be when they arrive.
Change Implemented: A document of patient information is emailed to the patient’s home hospital so that it can be printed out and given to the patient to read while they await transfer.
Results: This is now routinely happening, but a quantifiable measure of success is not available.

Secondly, an example for communication within the unit:

Global Aim: We would like effective interdisciplinary communication to occur 24 hours a day, 7 days a week. This is important because poor communication can lead to poor motivation.
Specific Aim: We aim to improve the nursing handover sheet so that it does not contain unnecessary and out-of-date information and transform it into something that helps us direct the care of our inpatients.
Change Implemented: Following two nursing meetings led by the matron, a new handover sheet was developed to remove unnecessary information.
Results: Initial feedback suggests that the new sheet is an improvement.

Treatment

The team developed a number of ‘change ideas’ that they wished to implement to help achieve the global aims that had been agreed during the diagnosis. Some of the more innovative ideas included:

  • Reducing the number of PVDU telephone numbers to just three essential ones, and printing them onto a ‘credit card’, which was then distributed to all patients.
  • Specialist nurses responding to answer phone messages within 24 hours, and giving specialist nurses a mobile phone during office hours to respond immediately where possible.
  • Institution of daily ‘board rounds’ on top of the twice-weekly consultant ward rounds.
  • A redesign of the patient information booklet in conjunction with junior and senior clinicians.
  • A supply of emergency equipment and information readily available on the ward.

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