Background Childhood cancer incidence is increasing in the United Kingdom with an average of 1574 new cases diagnosed per year. Bone marrow aspiration and delivery of intrathecal chemotherapy are routine procedures in paediatric haematology-oncology. National Institute of Clinical Excellance (NICE) Improving Outcomes in Children and Young People with Cancer acknowledges the importance of dedicated theatre slots to reduce delays in diagnosis and therapy. To ensure high quality safe patient care efficient organisation and smooth running of procedure lists is paramount.
Context This Quality Improvement Project was carried out in the Paediatric haematology-Oncology department of a tertiary oncology hospital over 5 months. It involved oncology doctors, the anaesthetics, oncology day care nurses, theatre staff, porters and laboratory staff.
Problem There were frequent delays in starting the list and interruptions resulting in the list overrunning causing staff and patient dissatisfaction and late arrival of bone marrow and lumbar puncture samples to the laboratory.
Assessment of problem and analysis of its causes Meetings with stakeholders were held to discuss the current status, identify obstacles and possible solutions. An initial audit over one month was performed to identify the start and finish times and document the reasons for delay.
The audit highlighted the following:
Inadequate training and use of staff resources.
Poor time management
Inadequate booking system for appointments
Late sample delivery to the laboratory
Study design This was a qualitative observational study with analysis of pre and post interventional audit results.
Intervention and Strategy for Change Multidisciplinary communication with various stakeholders was key in agreeing common goals to improve efficiency and quality of the current theatre list. Using a Plan-do-Study-Act Cycle changes were gradually introduced over the next 4 months. The teams were updated by regular weekly emails and monthly meetings to discuss the next steps.
Staff Resources: Rota allocation to ensure optimal junior medical staff cover on the procedure days to allow prompt start. Improved training of doctors and allocating two doctors to a procedure list, one of whom is an experienced senior doctor who can provide immediate assistance to the junior colleague. In addition an Advanced Nurse Practioner has been appointed to start a nurse led service. Improved communication with anaesthetic collegues and availability of their contact details.
Time management: Inter-patient delays were approached by improved co-ordination amongst the recovery and day care nurses and patient transport strategies.
Booking system: With increasing patient numbers it was essential to have an improved electronic booking system. An appointment scheduler giving staggered appointment times would be introduced. Pending this, patients were encouraged to arrive before 10 am and have necessary investigations done in time prior to their procedure.
Sample delivery: Introduction of specific porters for timely collection of samples enabling quick diagnosis of new oncology children. Re-organisation of the procedure order so that diagnostic bone marrows are first on the list.
Measurement and effects of change Descriptive statistics was used and nominal variables calculated as percentages. The results are:-
85% reduction in late finish and cancelled procedures
100% of the samples delivered to laboratory by 5 pm
80% improvement in availability of pre-procedure blood results
Improved training of doctors and team morale
Lessons learnt Inclusion of patient satisfaction surveys would have enabled us to include their views and make modifications to the service.
Message for others Good planning with adherence to SMART objectives is essential
Early involvement of stake holders and agreement on common goals
To ensure sustainability we involved the permanent day care nurses and senior managers.
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