Shine

Transforming chemotherapy services to enable patients to have greater involvement in, and responsibility for, their own treatment

Problem

The 2009 National Chemotherapy Advisory Group report noted that patients are not as involved in their care as they could be. In part this is because they are unable to absorb all the information they are presented with but also they are not enabled to participate in such issues as recording their own treatment toxicities.

Proposed solution

• Collaborating with users to develop a chemotherapy patient informational DVD
• Further develop a patient touch screen self assessment and link this to the electronic chemotherapy pathway
• Routine patient monitoring of side effects of chemotherapy in real time by extending mobile phone pilot
• Produce information outlining the project and explain to patients the expectation that they develop a greater sense of involvement and control.

Expected benefits and outcomes

• Patients will be more actively involved in the chemotherapy pathway and will develop greater control over their condition
• Time spent by clinical staff in information giving and assessment time will be reduced
• Unplanned admissions following chemotherapy will be reduced.

Conserving a scarce resource and improving outcomes: blood conservation for primary joint replacement

Problem

Major orthopaedic procedures may cause significant blood loss and give rise to the need for allogeneic blood transfusion (ABT). ABT is associated with transfusion errors, haemolytic reactions, lung injury and disease transmission, and prosthesis infection. Our arthroplasty ABT rate (24%) is lower than the national average, but higher in certain subgroups. Our highest ABT rates (up to 60%) occur in patients who have pre-operative Haemoglobin <13 g/dl. Patients who received ABT were hospitalized 5.5 days longer on average that patients who received no allogeneic blood.

Proposed solution

We will make sure that all patients scheduled for primary joint replacement have their Haemoglobin concentrations optimized to >13g/dl before surgery, and by implementing an evidence-based transfusion limitation strategy during and after operation.

Expected benefits and outcomes

We expect to be able to reduce the transfusion rate in at-risk patients by half. This may reduce hospital admission days and expenditure on complication management.

Outcome measures

• Time spent on assessing and treating patients
• Drug cost
• Transfusion rates
• Length of stay
• Postoperative complications.

Implementation of a virtual cardiology clinic to support demand management and enhance speed and quality of care for new patient referrals as part of an integrated modern outpatient service

Problem

A sustained increase in demand for cardiology outpatient and diagnostic services requires alternative methods of demand management that address the needs of patients and GPs while supporting the delivery of referral to treatment targets and efficiency savings.

Proposed solution

In this context a virtual clinic will integrate a number of novel approaches to flexibly manage referrals other than traditional outpatient clinic visits. It offers the chance to increase overall capacity and promote better access to secondary care clinicians to support GPs in their patient management. It will also make more efficient use of existing capacity to ensure that the system allows rapid assessment for those patients who have more urgent needs.

Expected benefits and outcomes

From a service perspective, it will allow more efficient use of clinician time and reduced inappropriate referrals and diagnostics. Measurements of effectiveness will use both quantitative and qualitative measures. The former will use existing systems such as the Patient Administration System and activity data captured to report performance with some adaptations to capture office based decisions and email / telephone elements. Qualitative data will be captured using focus groups (both GP and patient groups) and patient reported outcome measures.

Reducing harm through the use of a safety care bundle in the first week of admission to inpatient mental health wards

Problem

Acute inpatient mental health services are demanding environments. In a national audit, three-quarters of nurses and more than a third of service users reported that they had been subject to violence or threats. Similarly, a recent survey of over 7,500 people using NHS mental health acute inpatient services indicated that less than half (45%) always felt safe on their ward and 16% did not feel safe at all. Incidence of self harm, violence and aggression lead to emotional distress, extended lengths of stay, time lost through staff sickness, greater use of medication, close observations (patients are nursed one-to-one) and physical interventions.

Proposed solution

We have two combined ideas. First, to implement a care bundle for the first week of admission which includes a structured risk assessment flagging up risk in the first three days of each patients’ hospital stay. In cases of a high or very high risk, staff use preventive measures from a list provided on the risk assessment form. Second, the use of structured safety briefings to communicate risk in handovers and multidisciplinary team meetings.

Expected benefits and outcomes

We want to reduce the incidents of harm to patients and staff by 20% in the Llanfair Unit, Cardiff by December 2010. We predict that this will lead to a reduction in sickness and absence and reduced length of stay reclaiming costs in the region of £27,452–£77,452 over the year.

A radical restructuring of antenatal care for high-risk pregnancies

Problem

For the growing population of women with medically complex pregnancies, high quality antenatal care is crucial for good maternal and fetal outcomes. At least 40% of any pregnant population are ‘high-risk‘ (complex) pregnancies. Despite several drivers for change, the traditional 50+ year old model of antenatal care in the UK remains virtually unchanged. Vast resources are wasted on repetitive low-value, fragmented clinical activity with no clear evidence of effectiveness. With no local or national framework, complex pregnancies often receive inconsistent advice, unnecessary follow-ups and duplicated investigations or interventions of little proven benefit. Concepts of team structure and patient-centred care are invariably absent.

Proposed solution

• Replace all consultant-named antenatal clinics with condition-based team-structured clinics
• Each clinic should be staffed by a small multiprofessional specialist team led by a consultant and experienced, empowered midwife with expertise in that condition
• Non-specialist trainees to be present in a learning capacity only, rather than for unsupervised service delivery
• Close collaboration with primary care utilising agreed algorithms
• New service to be underpinned by our unique Compendium with evidence based guidelines, care pathways and patient information leaflets for each of 80+ complex pregnancy conditions.

Expected benefits and outcomes

• To provide top quality, patient centred, condition-based evidence-led team-structured service
  
• Increased clinical effectiveness
• Efficient use of existing resources, with significant waste reduction
• Offer continuity of care and consistent advice with improved patient satisfaction
• Increase capacity to meet increasing demand by streamlining service
• Reduce complaints and litigation.
  

Rehabilitation for operated cancer

Problem

Curative lung cancer surgery removes a substantial portion of normal functioning lung to ensure clearance of cancer and the incision disrupts the chest wall. Both lead to a loss of function and reserve which puts the patient at risk of complications in and out of hospital. The current rate of post-operative pulmonary complications (PPC) is 15%. Once you develop a PPC, mortality increases from 0.5% to 12%, ITU admission rate increases from 1.5% to 26% and length of stay increases from 5 to 14 days.

Proposed solution

A programme will identify potential surgical candidates several weeks before surgery, optimise their physical status, prepare them for the inpatient journey and support their recovery after surgery. This will include pulmonary rehabilitation, smoking cessation, dietary advice and patient self-management.

Expected benefits and outcomes

Aim: To develop a rehabilitation programme that will improve and support the recovery of patients who have undergone curative lung cancer surgery.

Key benefits

• Reduction in post-operative pulmonary complications from 15% to 12%
• Reduced length of inpatient stay
• Reduced intensive therapy unit admissions
• Reduced high dependency unit length of stay
• Reduced mortality rate
• Increased patient quality of life.
  

Transformation of urology outpatients

Problem

The current urology clinics at Charing Cross Hospital are not always easily accessible or efficient in their design because of variable access times for diagnostics, high follow up rates, complicated sub-specialism of clinics and they are difficult to navigate via Choose and Book. This results in a system that is often confusing for patients, not easily accessible for GPs and not an effective use of resources.

Proposed solution

The complete redesign of urology outpatients through the introduction of true one-stop clinic models and open access scheduling within 24 hours for GPs.

Expected benefits and outcomes

• Easier access to clinics and facilitated understanding for patients
• Shorter waiting times for appointments and diagnostics
• Reduction in unnecessary follow up activity
• Greater flexibility for GPs and improved integration with primary care.

PErineal Assessment and repair e-Learning System: an internet based training package (PEARLS.net)

Problem

In current clinical practice there are considerable variations in both suture materials and techniques used for repairing childbirth-related perineal trauma despite guidelines and evidence to support best practice. The identification, correct classification and suturing technique used to repair perineal injury are procedures that require knowledge and skills to make sure that the procedure is carried out correctly to minimise postpartum morbidity.

Proposed solution

The main aim of this project is to develop a multidisciplinary web-based e-learning package to enhance practitioners' knowledge and skills in perineal assessment, repair and management in order to reduce associated morbidity and improve women’s experiences of maternity care.

Expected benefits and outcomes

• Develop iPEARLS module: iPEARLS is an interactive multimedia rich e-learning module suitable for web-delivery
• Develop and commission PEARLS.net:  an online virtual training system that delivers iPEARLS module as a web-based e-training course with the required learning support functions
• PEARLS.net peer review
• PEARLS.net clinical evaluation: the effectiveness of PEARLS.net as a self-paced training tool is evaluated by measuring the knowledge and skill level enhancement of a multiprofessional representative sample of practitioners before and after receiving PEARLS.net training.
  

Creating a replicable improvement programme to facilitate multidisciplinary teams in providing nursing home residents with the right care in the right place at the right time

Problem

There are a large number of admissions to Central Manchester Hospital Trust from nursing homes. Common issues are chest and urinary tract infection, poor control of chronic diseases and underlying problems with eating and drinking sufficiently.

Proposed solution

The proposed solution is to run an improvement programme focused on quality of care for nursing home residents in three homes with a further three joining the programme after six months. Within one year, 240 nursing home residents in Central Manchester will be actively case managed. Within two years every nursing home resident in Central Manchester will be actively case managed.

Expected benefits and outcomes

• The programme will involve monthly measures to track the improvement and three workshops at three monthly intervals
• Residents will have up-to-date screening results for their chronic diseases, nutritional status and medication review
• Reduced admission for residents in nursing homes covered by the initiative
• There will be no inappropriate hospital admissions of nursing home residents.

Use of multidisciplinary team training to improve use of early warning scores in acute surgical wards

Problem

Early warning scores have been introduced throughout our trust. However, evidence from clinical incidents within the trust has shown that errors are being made in calculation of scores, appropriate action is not being taken in response to raised scores, suboptimal teamwork is introducing delay and escalation is not always being instigated appropriately. This has resulted in harm to patients.

Proposed solution

We will provide ward-based multidisciplinary team training in the use of early warning scores and escalation of care for the deteriorating patient.

Expected benefits and outcomes

• Our aim is to improve patient safety and clinical outcomes
• Evaluation will comprise of pre and post-intervention measurement of the use of early warning scores
• Level of adverse events using the Global Trigger Tool
• Unplanned intensive care admissions
• Length of patient stay and staff absentee rates.

Evaluation of a computer based system for the pre-operative medical, nursing and social assessment of patients undergoing elective surgery

Problem

Patients admitted for elective surgery undergo pre-operative assessment to identify potential problems prior to surgery. This process traditionally requires multiple professionals to record answers, often to the same questions, on multiple pieces of paper.

Proposed solution

We have designed a computer interview system which has branching logic within the system to modify the questionnaire according to the clinical situation. The system extends into areas such as consent, a truly innovative move. It produces multiple versions of printouts either in narrative English or in a way similar to a traditional nursing admission record.

Expected benefits and outcomes

• Improvements in efficiency
• Savings in cancelled operations
• Savings for ward nursing and junior medical staff time
• Improvements in patient safety
• Baseline data will be acquired for evaluation of surgery in large number of patients whose outcomes are not currently systematically recorded.
  

Development of a ‘WorkingWell’ service for NHS staff with musculoskeletal disorders and related psychosocial problems: facilitating stay at work or return to work; reducing sickness absence; reducing direct and associated costs to the primary care trust; improving the health and well-being of all staff

Problem

North West workers top the regional absence league and the health service has the highest rate of sickness at 11.7 days per employee (CIPD, 2009) with an average cost of £1.7 billion (Boorman, 2009). Among all workers the main causes of both short and long-term absence are musculoskeletal disorders and back pain (CIPD, 2009) and unnecessary staff absence through preventable ill-health, delayed intervention, and the use of agency staff amounts to an avoidable waste of resources (Boorman, 2009). Existing services for Salford PCT staff are suboptimal and the overall effectiveness can be questioned.

Proposed solution

A project employing an evidence-based model for tackling musculoskeletal problems, which clearly outlines the role of the worker, the employer and the health professional and provides guidance on strategies at different stages in the process using the psychosocial flags framework (Kendall & Burton, 2009).

Expected benefits and outcomes

• Improved health and well-being of staff with a speedy return to normal participation
• Reduction in sickness absence costs for staff with musculoskeletal problems
• Improvements in efficiency and effectiveness of services with increased productivity and improved levels of care and patient satisfaction.

From university to primary care: the Integration of academia into primary and intermediate care services to improve the diagnosis and management of chronic obstructive pulmonary disease

Problem

It has been documented that we have problems managing and diagnosing chronic obstructive pulmonary disease (COPD) in our PCT and currently there are twice as many admissions through our ED compared to the conventional route.

Proposed solution

We aim to enhance and distribute a complete educational package for primary care. This consists of a standalone educational tool for practice nurses and GPs. We want to provide a comprehensive pathway to aid the diagnosis and management of COPD. We will recruit a respiratory nurse specialist to lead this initiative in every GP practice and to provide education on their own spirometer and mentor the practice nurses respiratory clinics. This will help each practice form accurate disease registers, self management treatment plans and screen patients with an appropriate smoking history.

Expected benefits and outcomes

• Improvement in diagnosis and management will lead to an increase in the disease prevalence rate more in line with healthcare modelling
• A reduction in exacerbation rates and ED admissions
• Every patient will have a self-management plan.

Managing the demand for pathology tests from general practice: generating efficiencies, maintaining standards and improving patient care

Problem

There is often unexplained variation in pathology test requesting patterns, which may be attributable to a lack of clear guidelines or a lack of understanding of guidelines. This leads to tests being requested that are not required which causes unnecessary costs and unnecessary tests and inconvenience for patients.

Proposed solution

To promote consistency of practice and quality of care through education, innovation and collaboration. This will involve development of guidelines, clinical audit, benchmarking and education through master classes.

Expected benefits and outcomes

• An increased level of clinical knowledge about appropriate testing
• Improved efficiency which will reduce the amount of unnecessary requests
• Clinical risk reduced through patients not having sometimes invasive and unnecessary tests
• Reduced patient journeys for tests
  
• Real cost savings through reducing the number of unnecessary tests ordered.

The use of preoperative iron therapy in anaemic surgical patients to prevent preoperative blood transfusion

Problem

Anaemia is a common problem in surgical patients. It’s an independent risk factor for blood transfusion, peri-operative infection, mortality and longer inpatient stay. Of 7,552 patients audited undergoing total hip replacement, 15% were anemic preoperatively. Transfusion was required in 60% of anaemic patients compared with 20% in those not anaemic. In 147 patients undergoing colorectal surgery, 88 were anaemic (60%), half (47%) were transfused peri-operatively a total 162 units of blood. Non-anaemic patients received 28 units (14%) p<0.0001.

Proposed solution

Intravenous iron produces a rapid rise in heartbeat. Preoperative administration has proven effective in orthopaedic, gynecological and cardiac surgery. We have piloted the efficacy and feasibility of intravenous iron in surgical patients with anaemia. We wish to assess the effect of introducing an ʻiron first' approach in surgical patients.

Expected benefits and outcomes

• To classify anaemia in patients undergoing elective inpatient surgery
• To use preoperative intravenous iron therapy to correct preoperative anaemia
• To determine if this policy reduces blood transfusion.

Activate Your Heart

Problem

The uptake of cardiac rehabilitation across the country is low (around 35%) despite national targets. Cardiac rehabilitation is usually offered as a structured programme and there is no choice for patients. Furthermore, technology has not been widely exploited within cardiac rehabilitation services.

Proposed solution

The project will result in a sophisticated, interactive, password-protected, secure cardiac rehabilitation website to support individuals with coronary heart disease to manage their disease proactively, with interactive sessions about diet, stress management and physical activity. Adoption of technology will equip us to deal effectively with an aging population and respond to consumer demand for accurate internet based knowledge and access to healthcare professionals.

Expected benefits and outcomes

The project should provide choice and equity of access to services for patients who currently decline the offer of cardiac rehabilitation, most commonly due to travel and work commitments. Conventional rehabilitation outcomes will be employed to evaluate the project. The project should assist in achieving national targets for uptake of cardiac rehabilitation.

Outpatient operative hysteroscopy with conventional re-useable equipment: a cost effective alternative to day case theatre. Assessment of effectiveness, patient acceptability and comparative health economics

Problem

Women with menstrual problems or post-menopausal bleeding are currently investigated in a nurse led, consultant supervised, one-stop out patient diagnostic clinic where imaging with transvaginal ultrasound and hysteroscopy often leads to the diagnosis of a fibroid or polyp, the removal of which has proven benefits.

Traditionally, operative hysteroscopy has been performed under general anaesthetic using a resectoscope with an electrical cutting loop, and irrigating the uterus with an insulating solution of glycine. The equipment is re-useable and therefore not expensive. Towards the end of the last century small telescopes were developed which allowed diagnosis without dilatation of the cervix and diagnostic hysteroscopy was possible in outpatients. Development of small bipolar diathermy devices enabled operative hysteroscopy without cervical dilatation in many cases and several hospitals utilise this technology to enable operative hysteroscopy in the outpatient environment. The problem is that each electrode costs over £100 and owing to the size, its rate of tissue removal is slow. Some procedures have to be done over two sittings and there is a limit to the size of polyp which is suitable for treatment.

We recognised that conventional operative hysteroscopy might be undertaken under local anaesthetic and began to conduct operative hysteroscopy using conventional resectoscopes in our day case theatre, initially in very high risk cases. Once we realised that this was successful we then started to offer hysteroscopic resection under local anaesthetic.

Proposed solution

To transfer this experience to the outpatient setting in a responsible manner with thorough evaluation.

Expected benefits and outcomes

The benefits of the outpatient operative hysteroscopy service are many for both the patient and the healthcare provider. Currently, patients compete with the rest of the waiting list for scarce theatre time and are often squeezed onto the end of a list which can overrun leading to cancellations which causes distress and delays histological diagnosis. Managing the majority in outpatients will reduce waiting times and may allow some patients to be managed on a see-and-treat basis at the same clinic. An outpatient operative hysteroscopy will cause less social disruption than a day case admission and less stress for the patient and her family.

Not only will the overall cost of managing each case in outpatients be less than the expensive theatre environment but valuable theatre space will be freed up for other operations enabling more efficient management of the waiting list.

Electronic linkage for inflammatory bowel disease (IBD) to deliver joint access to health records (ELIJAH)

Problem

Inflammatory bowel disease is a chronic, unpredictable and relapsing disorder that causes debilitating symptoms and requires long-term specialist follow-up. This results in increasing numbers of patients under continuing care. We believe care could be improved and conventional contact reduced by giving patients greater responsibility to take decisions about their management with appropriate access to support from primary and secondary care, as necessary.

Proposed Solution

To extend access to our departmental electronic patient record to individual patients in their own home, and to their general practitioner, to enable more informed three-way communication between primary care, secondary care and the patient. Patients would be able to see their own record and make entries when their condition or treatment changes, and communicate with us when they need advice or help.

Expected benefits and outcomes

The aim is to evaluate the extent to which this shared health record will reduce demand on health resources by facilitating better communication and greater individual responsibility for health care. In a small, randomised controlled trial we will evaluate resource use, safety, effectiveness, patient centredness, timeliness and equity.  

Project Lead: Professor John Gordon Williams.