Context This project was undertaken by a junior doctor working within the General Paediatric department of a District General Hospital.
Problem Newborns with feeding difficulties and weight loss are a common sight on Paediatric wards. Whilst working on such a ward, I felt that a significant proportion of these admissions were avoidable and that, if better managed, admissions could be shortened. This study sought to address this, with a particular focus on the potential resultant financial savings for the Trust.
Assessment of problem and analysis of its causes Through retrospective evaluation of handover documents, 74 admissions between 01/01/14 and 31/12/14 were identified. 68 patient notes were reviewed, with information collected from documentation of the birth, postnatal period and subsequent admission to the Paediatric ward.
Average admission lasted 2.8 days (range: 1–8), with 191 admission days in total for this cohort. Average weight loss at presentation was 11.65%. 80.8% were otherwise medically well and 97% were term babies. Sodium levels on admission were examined (Figure 1).
Breastfeeding rates fell from 92.6% on discharge from the postnatal ward to 85.2% at re-admission. By final discharge, this had fallen further to 63.2%. 22% received formal breastfeeding support during admission, waiting on average 36 h for this support.
These findings suggested significant scope for reducing admissions in this group. The majority of newborns admitted were both term and otherwise healthy, with only 27.9% hypernatraemic, suggesting huge potential for them to be managed in the community.
The lack of timely breastfeeding support almost certainly prolonged admissions. These admissions cost the trust an estimated £91,680, and occupied numerous cubicles; a limited commodity on paediatric wards. In addition, the reduction of 22% in mothers solely breastfeeding by discharge implied significant opportunity for improvement.
Intervention With these results I met with the Chief Financial Officer of the Trust. Together we developed a business model to finance a Breastfeeding Counselling service 7 days a week on the Paediatric ward.
Induction of all new doctors was also tailored to highlight the appropriate admission criteria for this cohort.
Study design The study was a retrospective observational study, examining notes of newborns admitted with feeding difficulties.
Strategy for change Implementation of the above business model is now underway. Initial calculations suggest net savings of £10–20,000, not including the potential savings from reduced admissions resulting from education of the medical team.
Presentation at the Departmental audit meeting allowed ideas to be sourced from the multidisciplinary team as to what interventions would be most powerful.
Measurement of improvement I plan to re-evaluate newborn admissions using the same study design after the new 7-day service has been underway for a 6 month period. At this time, a decision will be made regarding ongoing funding
Effects of changes This study has led to hugely increased awareness of this group of patients and difficulties in their management. This study enabled an estimation of the financial cost to the Trust, allowing a realistic, sustainable business model to be created. Initial findings suggest this intervention will vastly improve patient experience and enable vital financial savings.
Lessons learnt I have learnt the impact of engaging an entire multidisciplinary team within the process of change. By obtaining feedback throughout this project, I was able to come up with simple and efficacious interventions.
Message for others I would encourage other trainees to feel able to approach members of the Trust management with ideas and suggestions, allowing their day-to-day clinical experiences to enact change.
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