Discharging patients; does it need to be done by a doctor?

Abstract Funding Acknowledgements None Background Patients undergoing angiography and percutaneous coronary intervention (PCI) were historically reviewed post procedure by a member of the medical team who assesses the patient’s suitability for discharge and completes the discharge letter. Over the past 10 years, the number of patients admitted for these procedures as day cases has increased significantly. In addition, there has been an expansion in nursing roles in the UK with the development of a variety of clinical nurse specialist (CNS) posts which have taken over many of the traditional medical roles. The majority of patients undergoing elective angiography and PCI are admitted to a day case unit at this tertiary cardiac centre. There is no designated medical cover for the unit and medical staff from the acute cardiac unit are called to review patients and complete their discharge paperwork in addition to their other duties. This frequently results in delayed discharge and patients going home without a discharge summary. It was therefore proposed that suitably qualified CNSs could be trained to discharge these patients and others undergoing day case cardiology procedures. From June 2017, the CNS team took over the role of reviewing patients post procedure and completing the discharge letter. Purpose The aim of the study was to evaluate if CNSs were able to discharge patients and provide a timely and effective service following elective cardiology procedures and to obtain patient feedback. Method Data on the number of patients reviewed by the CNSs from June 2017 to the end of December 2019, were prospectively collected in a dedicated database. A pilot study of patient experience was carried out in January 2020. Patients were given a questionnaire which asked about the explanation they received from the CNS regarding the procedure they had undergone, if their medication was reviewed and discussed with them, and if they received a discharge summary to take home. Results 1287 patients were reviewed by the CNS team during the above period. 811 (63.0%) patients had undergone angiography and 423 (32.9%) PCI. Informal feedback from the staff working on the day case unit included that patients were discharged earlier, had improved knowledge about their procedure and that the discharge letter was more detailed when completed by the CNS team. Eight patients completed the pilot questionnaire. Six were discharged by one of the CNS team, one by a doctor and one patient was not sure who did their discharge. All patients were very satisfied with the process and the information they were given. Conclusion Experienced CNSs can deliver high-quality, timely discharge of patients following cardiology procedures. This process is being used as a template to expand nurse-led discharge to other areas in cardiology. Patient experience will continue to be audited with a larger sample size in 2020.

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Non-medical prescribing of systemic anticancer therapy in a multidisciplinary team oncology clinic

British Journal of Nursing ◽

10.12968/bjon.2019.28.11.715 ◽

2019 ◽

Vol 28 (11) ◽

pp. 715-720 ◽

Cited By ~ 1

Author(s):

Philippa R Hand (née Davies)

Keyword(s):

Patient Experience ◽

Nurse Practitioners ◽

Multidisciplinary Team ◽

Positive Impact ◽

Nurse Specialist ◽

Medical Team ◽

Specialist Care ◽

Care Services ◽

The Uk ◽

Living With Cancer

The number of people diagnosed and living with cancer in the UK continues to rise, placing increasing demands on specialist cancer care services. The incidence and prevalence of neuroendocrine tumours (NETs) has increased. An NET remains a rare cancer requiring specialist care and the clinical nurse specialist (CNS) team is ideally placed to support these patients. Oncology clinics are becoming increasingly pressured and the need to think of innovative ways of reducing pressure while maintaining and enhancing the patient's experience is important. A new multidisciplinary team (MDT) systemic anti-cancer therapy (SACT) clinic for NET patients was developed that incorporated a CNS SACT non-medical prescriber (NMP) to improve patient experience and reduce the number of oncologist clinic reviews. Methods and analysis: the clinic was designed and a protocol developed to help ensure safe practice and support for the CNS NMP. The patient experience was prioritised and the medical team was involved in the design. All NMP SACT prescriptions were reviewed and questionnaires were given to patients after 3 months. A questionnaire was also given to all oncologists within the clinic and to the oncology pharmacist for analysis. Findings: 29 SACT NMP prescriptions for 15 patients were written. Patient and medical colleague feedback was positive. Discussion: this experience has helped to highlight the positive impact of innovative clinics that combine the expertise of both independent nurse practitioners and the medical team. This has paved the way for further clinics of this kind within the author's trust and the NET service.

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P073 Interactive rheumatology biologic self-injection video advice using an SMS based video resource: successful implementation during a pandemic

Rheumatology ◽

10.1093/rheumatology/keab247.071 ◽

2021 ◽

Vol 60 (Supplement_1) ◽

Author(s):

Pritesh Mistry ◽

James Bateman ◽

Kay Hughes

Keyword(s):

Interactive Video ◽

Low Cost ◽

Successful Implementation ◽

Nurse Specialist ◽

Learning Technology ◽

Day Case ◽

Complete Evaluation ◽

Education Material ◽

Strongly Agree ◽

The Uk

Abstract Background/Aims The COVID-19 pandemic has resulted in a number of changes in practice in the UK, including the reduction in routine day-case attendances for intravenous rheumatology treatments. Due to redeployment and resultant staff shortages, we required alternatives to day case attendance. The usual face-to-face education that normally supports this was not possible. Methods In March 2020, we identified patients receiving monthly intravenous tocilizumab on our day-unit and planned a supported transition to weekly subcutaneous self-injection. We designed, planned, storyboarded, video-recorded, and piloted a 15-minute tocilizumab self-injection interactive video resource, using evidence-based educational methodology. This included: an introduction; explanation of the change and context; a one-minute video of our nurse specialist self-administering a sample injection; a close-up injection video; local logistical information and contact details, and a voluntary anonymous web-based evaluation. The interactive resource was searchable and contained links to supporting information, including a link to manufacturer patient education material. The intervention received rapid institution and pharmacy approval for distribution. We sent it via SMS message to our cohort of patients using a commercial partner (HealthComm UK) from 8.4.20, using an established method we have recently described. Simultaneously, we made it publicly available on our departmental website. We collated feedback and usage metrics over an eight-week period (8.4.20 - 3.6.20). Results We identified 69 patients eligible to switch to self-injection; all were sent the SMS link. Our resource was viewed by 39/69 patients (57%) via the unique SMS link, a total of 97 times (mean 2.5 views/patient). Others watched it on our website, 534 views, by 283 unique visitors (1.9 views/visitor). In total, 24/69 patients (35%) returned a complete evaluation of the video, 16/24 (67%) felt more confident injecting after watching the resource. Age ranges in deciles (number) was: 40-49, (5); 50-59, (6); 60-69, (8); >70, (5). Likert scores for satisfaction with the resource (1=strongly disagree; 5=strongly agree) were as follows: video ease and playback (4.1); improved confidence of self-injection (4.0), usefulness of SMS methodology (4.3), usefulness of interactive resource over video (3.7). A number (9/24, 38%) had never self-injected any medicine. Most completing the evaluation (18/24, 75%) viewed the resource on mobile phones. Written feedback, where given, was positive in 18/19 (95%) cases, one patient identified they could not watch the video. Conclusion The COVID-19 pandemic has increased the use of telerheumatology resources. We have demonstrated that interactive video resources are a rapid, acceptable, and useful method of delivering rheumatology education. This intervention is low cost (£0.01 per SMS) and we used existing e-learning technology already licensed to our hospital at no additional cost to the department, other than staff time. Our findings have implications for other aspects of rheumatology self-care and we call for further research in this area. Disclosure P. Mistry: None. J. Bateman: None. K. Hughes: None.

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Introducing day case thyroid lobectomy at a tertiary head and neck centre

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2020.7063 ◽

2021 ◽

Vol 103 (7) ◽

pp. 499-503

Author(s):

Z Sheikh ◽

V Lingamanaicker ◽

E Irune ◽

B Fish ◽

P Jani

Keyword(s):

Cost Effective ◽

Day Surgery ◽

British Association ◽

Day Case ◽

Thyroid Lobectomy ◽

Number Of Patients ◽

Same Day Discharge ◽

Postoperative Haematoma ◽

The Uk ◽

Disseminated Disease

Background Thyroid lobectomy is considered to be a safe day case procedure by the British Association of Day Surgery. However, currently only 5.5% of thyroid surgeries in the UK are undertaken as day cases. We determine if and how thyroid lobectomy with same-day discharge could safely be introduced in our centre. Methods We analysed all thyroid lobectomy surgeries performed between April 2015 and May 2019. Exclusion criteria included completion surgery, revision surgery, additional procedures and disseminated disease. Outcomes were benchmarked against surgeon-reported complications from the British Association of Endocrine and Thyroid Surgery’s 5th National Audit. Additionally, we reviewed the number of patients who met day case criteria currently in use at our hospital to determine accessibility to the service. Results In total, 259 thyroid lobectomy surgeries were undertaken and of these 173 met the inclusion criteria. There was no mortality, return to theatre for evacuation of postoperative haematoma or readmission. There was one postoperative haematoma which was drained at the bedside. Some 47 of the 173 (27.2%) patients met day case criteria currently in use at our centre. Conclusions Day case surgery provides a cost-effective solution to rising bed pressures and a coherent protocol can optimise patient safety and experience.

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Minor Morbidity after Day-Case Surgery

Scottish Medical Journal ◽

10.1177/003693309804300209 ◽

1998 ◽

Vol 43 (2) ◽

pp. 54-56 ◽

Cited By ~ 9

Author(s):

J.D. Hunter ◽

W.A. Chambers ◽

K.I. Penny

Keyword(s):

Postoperative Nausea And Vomiting ◽

Diagnostic Procedures ◽

Postal Questionnaire ◽

Nausea And Vomiting ◽

Day Case ◽

Day Case Surgery ◽

Number Of Patients ◽

Case Surgery ◽

The Uk ◽

The Impact

The number of patients and procedures considered suitable for day-case anaesthesia and surgery continues to grow and it is hoped that 50–60% of all operations in the UK will eventually be performed on a day-patient basis.1 However, minor but troublesome post-operative side effects remain common. We have examined the incidence of the most common causes of minor morbidity, namely headache, nausea /vomiting and pain occurring after a wide variety of day-case surgical and diagnostic procedures. Patient satisfaction with treatment and the impact of day case surgery on the workload of the general practitioner was also assessed. The anaesthetic records of the patients involved were reviewed in an attempt to determine if there was any association between the anaesthetic technique and an adverse outcome. A simple postal questionnaire completed on the morning after surgery was returned by 553 patients (response rate over 87%). More than 50% of respondents complained of some morbidity, with 40% complaining of pain, 19% of headache and 9% of nausea and vomiting. One third self-medicated to modify their symptoms, and in most cases (81%) this was effective. However, 6% of patients called their GP for advice and 2% received a home visit. No patient required readmission. A total of 92 patients (17%) would have preferred treatment as an in-patient. Analysis of the anaesthetic drugs and techniques suggested that the commonly used anti-emetics droperidol and metoclopramide had little effect on the incidence of postoperative nausea and vomiting. Intubation was associated with a significantly higher incidence of minor morbidity although this may be related to surgical factors.

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A quality improvement project to improve the number of section 136 GP discharge summaries from the place of safety

BJPsych Open ◽

10.1192/bjo.2021.518 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S192-S192

Author(s):

Jemma Hazan ◽

Mikail Ozer ◽

Yathooshan Ramesh ◽

Richard Westmoreland

Keyword(s):

Quality Improvement ◽

Discharge Summary ◽

Quality Improvement Project ◽

Improvement Project ◽

Time Period ◽

Progress Notes ◽

Number Of Patients ◽

Management Plans ◽

Discharge Letter ◽

Discharge Summaries

AimsA Quality Improvement project with the aim to increase the number of patients discharged with a GP discharge summary from the Chase Farm Place of Safety over a 12 month time period by 50%.BackgroundAn initial audit was conducted at Chase Farm Place of Safety (POS) to see if patients held under Section 136 of the Mental Health Act (S136) and then discharged home had a GP discharge letter completed and sent. The audit revealed that 0.02% of patients who were under S136 and discharged home did have a discharge letter sent to the GP.As a result of the initial audit, key stakeholders were contacted, and involved in the intervention design and implementation. The intervention was introduced and all doctors working in the trust were emailed the new protocolMethodWe implemented the following intervention:If a patient was registered at a GP Practice then the nursing staff in the POS copied the entry of the discharging doctor from the electronic progress notes and pasted this in to the S136 discharge template on the electronic progress notes and this was emailed to the GP.We informed Doctors to be aware that their entry would go out to the GP and should contain the following: Impression, Outcome/Plan, Specific Risk /Safeguarding concerns and specific management plans.ResultIn the initial audit the notes of all patients discharged from the POS under S136 were reviewed over a 3 month period between November and January 2018. We found that 2 out of 89 patients (0.02%) had a completed GP summary which was emailed to the GP Practice.After the intervention was introduced the notes were audited between July and September 2019. We found 33 out of 60 patients (55%) had a completed GP summary which was emailed to the GP Practice.ConclusionThere was an improvement of 54.8% in the number of discharge summaries. Further consideration needs to be given to improving this percentage and understanding what remaining barriers there are.

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Patient Experience in Home Respiratory Therapies: Where We Are and Where to Go

Journal of Clinical Medicine ◽

10.3390/jcm8040555 ◽

2019 ◽

Vol 8 (4) ◽

pp. 555 ◽

Cited By ~ 5

Author(s):

Cátia Caneiras ◽

Cristina Jácome ◽

Sagrario Mayoralas-Alises ◽

José Ramon Calvo ◽

João Almeida Fonseca ◽

...

Keyword(s):

Clinical Research ◽

Patient Experience ◽

Clinical Care ◽

Research Priorities ◽

Specific Patient ◽

Quality Healthcare ◽

Body Of Knowledge ◽

Number Of Patients ◽

Patient Reported ◽

System Sustainability

The increasing number of patients receiving home respiratory therapy (HRT) is imposing a major impact on routine clinical care and healthcare system sustainability. The current challenge is to continue to guarantee access to HRT while maintaining the quality of care. The patient experience is a cornerstone of high-quality healthcare and an emergent area of clinical research. This review approaches the assessment of the patient experience in the context of HRT while highlighting the European contribution to this body of knowledge. This review demonstrates that research in this area is still limited, with no example of a prescription model that incorporates the patient experience as an outcome and no specific patient-reported experience measures (PREMs) available. This work also shows that Europe is leading the research on HRT provision. The development of a specific PREM and the integration of PREMs into the assessment of prescription models should be clinical research priorities in the next several years.

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EPEN-24. SIOP EPENDYMOMA II: CENTRAL EPENDYMOMA MANAGEMENT ADVISORY GROUP – THE UK EXPERIENCE

Neuro-Oncology ◽

10.1093/neuonc/noaa222.161 ◽

2020 ◽

Vol 22 (Supplement_3) ◽

pp. iii312-iii312

Author(s):

Donald C Macarthur ◽

Conor Mallucci ◽

Ian Kamaly-Asl ◽

John Goodden ◽

Lisa C D Storer ◽

...

Keyword(s):

Survival Rates ◽

Target Volume ◽

Advisory Group ◽

Subtotal Resection ◽

Str Analysis ◽

Oncological Treatment ◽

Beneficial Effects ◽

Number Of Patients ◽

Pathological Review ◽

The Uk

Abstract Paediatric Ependymoma is the second most common malignant brain tumour of childhood with approximately 50% of cases recurring. It has been described as a “surgical” disease since patients who have undergone a gross total surgical resection (GTR) have a better prognosis than those who have a subtotal resection (STR). Analysis of the UKCCSG/SIOP 1992 04 clinical trial has shown that only 49% of cases had a GTR, with 5-year survival rates for STR of 22–47% and GTR of 67–80%. As part of the SIOP II Ependymoma trial the UK established a panel of experts in the treatment of Ependymoma from Neuro-oncology, Neuro-radiology and Neuro-surgery. Meeting weekly, cases are discussed to provide a consensus on radiological review, ensuring central pathological review, trial stratification and whether further surgery should be advocated on any particular case. Evaluation of the first 68 UK patients has shown a GTR in 47/68 (69%) of patients and STR in 21/68 (31%) of patients. Following discussion at EMAG it was felt that 9/21 (43%) STR patients could be offered early second look surgery. Following this 2nd look surgery the number of cases with a GTR increased to 56/68 (82%). There has been a clear increase in the number of patients for whom a GTR has been achieved following discussion at EMAG and prior to them moving forwards with their oncological treatment. This can only have beneficial effects in decreasing their risk of tumour recurrence or CSF dissemination and also in reducing the target volume for radiotherapy.

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P17 An audit of Trakcare discharge times for Laparoscopic Cholecystectomy

BJS Open ◽

10.1093/bjsopen/zrab032.016 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

Author(s):

Jacob Rapier ◽

Steven Hornby ◽

Jacob Rapier

Keyword(s):

Laparoscopic Cholecystectomy ◽

Length Of Stay ◽

Initial Data ◽

Best Practice ◽

Average Length ◽

Accurate Data ◽

Day Case ◽

Average Length Of Stay ◽

Number Of Patients ◽

Elective Laparoscopic Cholecystectomy

Abstract Introduction Nationally 61,220 Laparoscopic Cholecystectomies are carried out annually. Those carried out as day-cases reduce providers’ costs and increase income through the best practice tariff. The system in our trust to record discharges is ‘Trakcare’. The aim of this audit was to accurately measure the discharge times of patients undergoing elective Laparoscopic Cholecystectomies, to try and reduce the number of patients recorded as having an overnight stay by accurate data collection. Methods Initial data was collected for all elective Laparoscopic Cholecystectomy discharge times on Trakcare, over a 1 month period. This data was then re-audited prospectively both from Trakcare and discharges reported by nurses/patients. A comparison was then made of Trakcare against reported discharge times. Results Initially 54 operations were recorded, with 30 completed as day cases (55.6%). The re-audited data (on Trakcare) recorded 47 operations, with 15 completed as day cases (37.91%). Of these discharges we were able to capture 26 (55.32%) manually, and 11 were completed as day cases (42.31%). Measuring these 26 with the same operations on Trakcare we were unable to show a difference in the number of cases completed as a day case (11 vs 11), with only a 33 minute decrease in the average length of stay. Conclusion Trakcare is a reliable tool for measuring the date of discharge for patients. The recommendations in are: scheduling surgery for a time pre-13:00 shows a higher proportion of patients discharged the same day, and continue to use Trakcare to record discharge times.

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Public Interest in Knee Pain and Knee Replacement during the SARS-CoV-2 Pandemic in Western Europe

Journal of Clinical Medicine ◽

10.3390/jcm10051067 ◽

2021 ◽

Vol 10 (5) ◽

pp. 1067

Author(s):

Arne Kienzle ◽

Lara Biedermann ◽

Evgeniya Babeyko ◽

Stephanie Kirschbaum ◽

Georg Duda ◽

...

Keyword(s):

Knee Osteoarthritis ◽

Knee Pain ◽

Knee Replacement ◽

Knee Arthroplasty ◽

Public Interest ◽

Western Europe ◽

Surgical Care ◽

Number Of Patients ◽

Primary Knee Arthroplasty ◽

The Uk

Due to the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic, a large number of elective knee replacement procedures had to be postponed in both early and late 2020 in most western countries including Germany and the UK. It is unknown how public interest and demand for total knee arthroplasties was affected. Public interest in knee pain, knee osteoarthritis and knee arthroplasty in Germany and the UK was investigated using Google Trend Analysis. In addition, we monitored for changes in patient composition in our outpatient department. As of early March in Germany and of late March in the UK, until the lockdown measures, a 50 to 60% decrease in relative search frequency was observed in all categories investigated compared to the beginning of the year. While public interest for knee pain rapidly recovered, decreased interest for knee osteoarthritis and replacement lasted until the easing of measures. Shortly prior to and during the first lockdown mean search frequency for knee replacement was significantly decreased from 39.7% and 36.6 to 26.9% in Germany and from 47.7% and 50.9 to 23.7% in the UK (Germany: p = 0.022 prior to lockdown, p < 0.001 during lockdown; UK: p < 0.0001 prior to and during lockdown). In contrast, mean search frequencies did not differ significantly from each other for any of the investigated time frames during the second half of 2020 in both countries. Similarly, during the first lockdown, the proportion of patients presenting themselves to receive primary knee arthroplasty compared to patients that had already undergone knee replacement declined markedly from 64.7% to 46.9%. In contrast, patient composition changed only marginally during the lockdown measures in late 2020 in both Germany and the UK. We observed a high level of public interest in knee arthroplasty despite the ongoing pandemic. The absence of a lasting decline in interest in primary knee arthroplasty suggests that sufficient symptom reduction cannot be achieved without surgical care for a substantial number of patients.

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Day case laparoscopic cholecystectomy: Identifying patients for a ‘COVID-Cold’ isolated day-case unit during the pandemic

Journal of Perioperative Practice ◽

10.1177/1750458920977418 ◽

2021 ◽

pp. 175045892097741

Author(s):

Zoe Hinchcliffe ◽

Imran Mohamed ◽

Anil Lala

Keyword(s):

Laparoscopic Cholecystectomy ◽

General Hospital ◽

Univariate Analysis ◽

District General Hospital ◽

Day Case ◽

Patient Factors ◽

Surgical Services ◽

North Wales ◽

Selection For ◽

The Uk

Background The UK practice of laparoscopic cholecystectomy has reduced during the COVID-19 pandemic due to cancellation of non-urgent operations. Isolated day-case units have been recommended as ‘COVID-cold’ operating sites to resume surgical procedures. This study aims to identify patients suitable for day case laparoscopic cholecystectomy (DCLC) at isolated units by investigating patient factors and unexpected admission. Method Retrospective analysis of 327 patients undergoing DCLC between January and December 2018 at Ysbyty Gwynedd (District General Hospital; YG) and Llandudno General Hospital (isolated unit; LLGH), North Wales, UK. Results The results showed that 100% of DCLCs in LLGH were successful; 71.4% of elective DCLCs were successful at YG. Increasing age ( p = 0.004), BMI ( p = 0.01), ASA Score ( p = 0.006), previous ERCP ( p = 0.05), imaging suggesting cholecystitis ( p = 0.003) and thick-walled gallbladder ( p = 0.04) were significantly associated with failed DCLC on univariate analysis. Factors retaining significance (OR, 95% CI) after multiple regression include BMI (1.82, 1.05–3.16; p = 0.034), imaging suggesting cholecystitis (4.42, 1.72–11.38; p = 0.002) and previous ERCP (5.25, 1.53–18.00; p = 0.008). Postoperative complications are comparable in BMI <35kg/m2 and 35–39.9kg/m2. Conclusions Current patient selection for isolated day unit is effective in ensuring safe discharge and could be further developed with greater consideration for patients with BMI 35–39.9kg/m2. As surgical services return, this helps identify patients suitable for laparoscopic cholecystectomy at isolated COVID-free day units.

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