Context This work was undertaken in a chidren’s ear, nose and throat (ENT) service; one of the largest and most specialised in the UK.
Problem Paediatric ENT outpatients had a long waiting list and significant follow-up backlog. The ENT Service performs a large number of adenotonsillectomies (T&A) so this the focus for potential improvement.
Assessment of problem and analysis of its causes Data were obtained from electronic records for a sample of patients who had tonsillectomy and/or adenoidectomy in November 2014–January 2015. Records were analysed for whether patients meet criteria for surgery, whether surgery could be done elsewhere, what follow up had consisted of and whether this affected the clinical outcome.
There were 219 patients with tonsillectomy and/or adenoidectomy in November 2014–January 2015, of which 48 were analysed in detail. The average number of days from referral received to first outpatient appointment was 79.8, confirming the original problem of long waiting times.
It was not possible to determine from documentation whether patients met criteria for surgery. Out of area patients whose surgery could have been done elsewhere were only 3.7% of patients.
Follow up was planned for 46 patients, with planned time until follow up documented for 32 patients. Follow up was planned for average of 62.4 days after surgery, but average actual number of days from surgery to follow up was 88.9.
Telephone follow-op was planned for 19 patients. Of 19, 5 were booked for clinic appointments after telephone follow up, 10 were discharged, 4 did not attend (DNA). Of total 44 follow up (telephone and outpatient, including DNA), follow up changed management for 13 (30%), and 27 patients were discharged from clinic (61%).
Intervention Reducing the number out of area patients whose surgery could be done elsewhere may help but this alone would not greatly reduce waiting lists, so intervention was not focused here.
The two interventions are: increasing use of telephone follow up, and trailing open follow-up, in which families are given specialist nurse contact details to contact if any concerns and quickly booked into clinic if needed, will be trialled for suitable T&A patients.
Open follow up is proposed as a high proportion of patients are discharged at follow-up with no change to management.
Study design This work is not conducted as formal research.
Strategy for change The baseline results were discussed with a lead consultant and service manager, prompting a plan to trial open follow up. The baseline results were also presented at a departmental meeting, where the ENT team agreed to increase use of telephone follow up immediately and begin to use open follow up in subsequent months. A third ENT specialist nurse was appointed, who will help with increased telephone follow up.
Measurement of improvement The original outcomes of time from referral to first appointment, planned and actual time to follow up, mode of follow up and outcome of follow up will be recorded for patients undergoing T&A in December 2015–January 2016, as the changes have been implemented since November 2015. These will be compared with baseline data to evaluate the impact of the interventions.
Effects of changes Interventions have only recently been implemented; results following these changes will be presented.
Lessons learnt It is impossible to assess whether patients meet criteria for surgery, as frequency of symptoms is not usually recorded in detail. It may be helpful to document according to criteria in future to assess whether children are undergoing surgery appropriately according to guidelines.
Message for others Telephone follow up is safe, effective, and helps to reduce outpatient clinic waiting times. DNA rates for telephone follow up are comparable to outpatient follow up. Open follow up may represent a new means of reducing waiting lists whilst providing effective post operative follow up.
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