Aim To reduce the average length of stay (LoS) of paediatric inpatients requiring discharge medication (TTO’s) on the short stay pathway (Comet).
Methods A paediatric multi-disciplinary team (MDT) used the model for improvement to identify stakeholders and key drivers for change. The Comet patient journey was mapped from A&E to discharge. Plan-Do-Study-Act (PDSA) cycles were used to reduce LoS, targeting the addition of a paediatric pharmacist to the morning ward round and use of over- label packs to facilitate nurse-led discharge for simple TTO’s required within 2 hours. Data was collected over a two week period in summer; PDSA 1 baseline data, one week prior to change; PDSA 2, one week after implementation. Baseline measurements included time taken to write, screen and dispense TTO and the average LoS. Data was collected via the electronic prescribing system (Lastword). Patients eligible for the Comet pathway were included for analysis. Results were analysed using Microsoft Excel. Ethics approval was not required for this study.
Results PDSA one; 15 patients admitted onto the Comet pathway. 67% patients were admitted outside working hours. Six patients needed TTOs, 33% were written out of hours and all dispensed by pharmacy. Average time to writing TTO 14.6 hours (16minutes-44hhours); time to pharmacist clinical screen 19.4 hours (6 minutes – 21 hours); average time for pharmacy to dispense TTO after screening 2 hours (69–203 minutes); average LoS for all Comet patients 17.6 hours (8–44) and 26 hours (14–44) for those needing TTO’s. Post implementation 12 patients were eligible for the Comet pathway. 83% patients were admitted outside of hours. Six patients needed TTO’s, 16% were written out of hours and 33% were dispensed by the nursing team. Average time to writing TTO increased to 20.2 hours (14–26), average time to pharmacist clinical screen was reduced to 10 minutes (1–98) and average time for pharmacy to dispense TTO reduced to 57 minutes (47–74). Average LoS for Comet patients was similar to PDSA 1 at 17.7 hours (3–27) but reduced to 20.8 h0urs (5–27) for those needing TTO’s.
Conclusion Increasing patient-facing time of pharmacists to improve outcomes is recommended by the Carter report.
(1)Pressures in emergency-care to free up beds for patients means we need to look for creative solutions. (2) This study found the addition of a paediatric pharmacist to the ward round increased efficiency of writing, screening and dispensing TTO’s - dramatically reducing time to screening TTO’s; and the average LoS by 5 hours. The pharmacist was aware of Comet discharges at the time of decision to discharge and was on hand to resolve medication related issues. New doctors in August could explain the increased time to writing TTO’s in the second week. Promotion of nurse-led discharge via over-label packs reduced the number of TTO’s sent to pharmacy. Limitations include2 weeks of data over summer were analysed and non-paediatric hospital activity would impact pharmacy dispensing time. Future work will test how pharmacist transcribing TTO’s on the ward round affect Los and to review pharmacist clinical interventions to assess impact on outcomes.
Department of Health. Carter report: Unwarranted variation: A review of operational productivity and performance in English NHS acute hospitals. 5thFebruary 2016.
Royal College of Paediatrics and Child Health. Standards for Short-Stay Paediatric Assessment Units (SSPAU). March 2017.
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