Context The project was undertaken in the outpatient department of a general paediatric hospital, involving paediatric junior doctors and nursing staff. Stakeholders engaged were carers and infants attending the neonatal prolonged jaundice clinic.
Problem Auditof the SHO-led prolonged jaundice clinic service showed that whilst the majority of infants were adequately screened, a large number of unnecessary and repeated blood tests and clinic follow-ups were generated; causing inefficiency of service, increased cost, and unneeded anxiety for parents.
Assessment of problem and analysis of its causes Auditof 85 infants screened and followed-up in the SHO-led prolonged jaundice clinic April 2009 to February 2010 showed that in addition to the baseline screening tests, 81% of otherwise well infants had further investigations and follow-ups performed, for which there was a clinical indication in only 20%.
Presentation and in-depth discussion of audit results in the department revealed a lack of understanding of the clinic proforma and screening protocol by SHOs, leading to over-investigation with the false assumption this would aid diagnostic accuracy. The rota-system meant a different SHO was allocated to run the clinic each week, causing poor continuity and ongoing unfamiliarity with protocols.
It was proposed that an embedded nurse-led service could provide a long-term solution.
Intervention A nurse-led neonatal prolonged jaundice-clinic was created, run by four band 5 paediatric nurses with a supervisory named paediatric registrar and Consultant available during clinic if additional input was required. The nurses were trained using a 3-stage induction programme in the clinical and operational aspects of running the clinic, and a new clinic proforma was developed. This was followed by a staged phase of observation, subsequent paediatric registrar-led supervision, and ultimately nurse-led independent practice.
Six 30 min appointment slots were scheduled per week, during which nursing staff completed the clinic-proforma, performed investigations, chased and conveyed results to parents and sent a GP letter.
Study design Audit and observational study of service outcomes were undertaken 6 months after implementation of the new service.
Strategy for change Prior to implementing the service approval was sought from the paediatric nursing manager and the clinical head of the Trust’s Women and Children’s directorate. No extra funding was needed as there was no additional requirement in staffing or clinic-hours. This took 18 months to implement.
Measurement of improvement An audit of the nurse-led jaundice clinic was performed measuring the same outcomes as the doctor-led clinic audit in 2010. In 2013 only 18% of infants had additional investigations performed and 100% of these had a documented clinical indication (81% of infants had additional investigations in 2010 with 20% having clinical indication). 92% of infants had stool colour check performed (51% in 2010), 100% had spilt bilirubin performed (91% in 2010) and 100% had clean catch urine dip performed (81% in 2010). 5% of infants in 2013 were followed-up (30% in 2010), and overall 8% had identified pathology (5% in 2010).
Effects of changes The nurse-led clinic has led to a significant reduction in unnecessary investigations and follow-ups, and consistency of service for families. Nursing skills and clinic-efficiency were optimised. The cultural challenges of shifting from a doctor to nurse-led service were overcome with a focus on organisational values and collaborative multi-disciplinary working.
Lessons learnt The core skills and strengths of different team members can be harnessed to overcome organisational inefficiencies and improve the quality of patient-care. Empowering nurses to run the clinics using transformational leadership enhanced multi-disciplinary team functioning.
Message for others Changing a system is possible with multi-disciplinary team working. Audit is a valuable tool for identifying problems and assessing change.
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