Context We undertook this improvement project in the Acute Receiving Unit (ARU) of the Royal Hospital for Sick Children in Edinburgh.
There is a fast turnover of patients on ARU. Patients are often discharged prior to all their investigation results being available. Outstanding results must be reviewed in a timely fashion to ensure appropriate action is taken. This is critical to patient management.
Assessment of problem and analysis of its cause In 2011 an audit of time to review results showed considerable delays. The median time was 13 days, interquartile range 8–19 days. This was unacceptable, and incurred considerable risks.
The main reas was thought to be the use of a handwritten diary to remind junior doctors to chase results. Other contributing factors included high workload and rapid patient turnover.
Intervention An electronic ‘workbench’ was set up to display ‘unread’ results in an alphabetical list according to patient surname. Hosted on the same system as patients’ electronic records facilitating easy review of clinical and contact details of patients and GPs, and documentation of action.
A guideline was written to outline how to set up the workbench. Allocation of a doctor to review the workbench on a daily basis was advised.
Study design We conducted a second audit in 2015. We assessed the time taken to review results, appropriateness and documentation of action taken.
Strategy for change
We presented our findings locally to the medical team. The guideline was disseminated, and discussed during the ARU induction to all rotating junior doctors.
Measurement of improvement
The re-audit showed considerable improvement in time to review, with median time 6 days, interquartile range 2–9 days. Unfortunately documentation of action was deemed appropriate in only a third.
An unintended effect of the electronic workbench is the inclusion of inappropriate results. Nearly a third of results reviewed were incorrectly displayed on the ARU workbench. This results in an increased workload, and takes precious time to resolve. Reasons for this include patients being incorrectly allocated to a consultant, and doctors ordering tests against previous ARU episodes incorrectly.
Effects of change Institution of an electronic workbench resulted in a considerable improvement. A median of 6 days is still longer than our proposed standard of 72 h. The unintended increase in workload is a significant barrier to efficiency. (See image)
We have instituted additional education and guidance to address the different contributing factors. These include clear display of the admitting consultant rota in all clinical areas to ensure correct consultant allocation. Education of nursing, medical and administrative staff has also been conducted.
Guidance has been disseminated to medical staff, and displayed in the ward doctors’ office. Progress on the workbench is discussed at our lunchtime meeting to ensure adequate resource allocation. The IT team has been involved to improve the electronic system.
Lessons learnt There are often multiple barriers to efficiency that may not be foreseen before improvement projects are undertaken. Identification of barriers is the first step to addressing them.
Multiple approaches are required to address each barrier in order to result in significant improvements in practice. The PlanDoStudyAct cycle is key to improvement, and should be repeated for maximum effect.
The importance of audit in changing practice and developing local guidance shouldnt be under-estimated.
Message for others Results Review is an important patient safety issue for all inpatient units. There’s an inherent delay in result availability, often post-discharge due to short inpatient stays. All units need a system for timely result review, communication and action.