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Abstract
The liver transplant assessment process involves a complex set of tests and clinical reviews to determine suitability for liver transplantation. We had an assessment process involving a 3-day inpatient stay and often experienced difficulties admitting patients to the prebooked bed due to a lack of inpatient bed availability.
We aimed to change the process from a 3-day and 2-night inpatient stay to a 1-day day-case stay to reduce the demand for inpatient beds.
Planning the new assessment process involved negotiations with many department staff to establish prebooked timeslots in 1 day. The improvement project was tested and refined through Plan-Do-Study-Act cycles. The liver transplant assessment team used their established once-a-week meeting to learn what went well and to agree on revisions to the process for further testing. The process involved several adaptations, such as the removal and changing of individual time slots, reinforcement of early notification once patients had finished their tests and scheduling a separate outpatient appointment to provide time for junior doctor clerking and blood tests.
The new day-case and outpatient coordinated liver transplant assessment process resulted in a reduction of inpatient hospital bed utilisation from an average of 257–20 inpatient bed days per annum. This reduction in inpatient bed utilisation was maintained for 3 years with a similar level of patient satisfaction. The cost avoidance was calculated at £381.96 per patient, which is a 63% reduction in cost. Assuming an average number of patients being assessed per annum of 110, this would result in an average cost avoidance of £42 016 per annum. The carbon footprint was calculated with an average reduction per patient from 618 kilograms of carbon dioxide equivalent (kgCO2e) to 179 kgCO2e.
This project has highlighted how to change a complex inpatient assessment process to an alternative day-case and outpatient approach and could be considered useful learning for other inpatient assessment services, not just liver transplantation.
- Healthcare quality improvement
- Transplantation
- Cost-Benefit Analysis
- Patient satisfaction
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
This is the first quality improvement project that we are aware of evaluating the effect of changes from a 3-day inpatient to a day-case and outpatient liver transplant assessment process.
WHAT THIS STUDY ADDS
This improvement project shows that changing the transplant assessment process can reduce inpatient bed utilisation, costs and carbon footprint.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Changing from inpatient to a day-case and outpatient setting to undertake complex transplant assessments may be considered in other specialised transplant centres.
Problem
Liver transplantation is a successful treatment for all types of liver failure, some non-liver failure indications and liver cancer.1 In the UK, liver transplantation is performed in seven specialist centres. Within our liver transplant service in the north-east of England, we perform in the region of 40–50 liver transplants per annum. The liver transplant assessment process is an important part of this service, as it informs patients of their suitability for liver transplantation.2 We undertake around 100–120 liver transplant assessments per annum, and this process is supported by a multidisciplinary team including hepatologists, liver surgeons, anaesthetists, liver transplant coordinators, dietitians and transplant social workers.
Prior to COVID-19, the liver transplant assessment process involved prebooking patients into a dedicated liver unit inpatient ward for a 3-day and 2-night inpatient stay. The main problem with this inpatient assessment process was the difficulty of admitting patients to the prebooked beds. This difficulty was due to the lack of bed availability associated with high inpatient bed occupancy and urgent or emergency admissions gaining greater priority for the limited beds available. This pressure on beds was managed by the liver transplant coordinators, who spent large amounts of time negotiating a bed for admission with hospital bed managers. Often, this lack of bed availability results in the admission taking place on a non-liver unit ward or the assessment not taking place. This limited inpatient bed availability was a constant problem; it was highly likely to continue and identified a need to improve the process.
Once the patient was admitted to an inpatient bed, the required complex set of tests and reviews were then arranged in an uncoordinated ‘last minute’ way. This uncoordinated booking approach caused some patients to miss their required tests during the 3-day admission, resulting in further journeys and admissions to the hospital to complete all tests. Patients often reported a feeling of not knowing what was happening on different days, and the liver transplant coordinators spent a great deal of time requesting tests and reviews to try to ensure all parts of the assessment were complete. Often, patients had three or four tests squeezed into the final afternoon of their stay or they were discharged home without having completed all their tests. This uncoordinated approach was causing patient and staff dissatisfaction, which further identified a need to improve the process.
Our project aimed to reduce demand on inpatient beds over 12 months by providing a coordinated 1-day liver transplant assessment process.
Background
To identify patients’ suitability for transplantation, a complex set of tests and reviews are required. This includes blood tests, echocardiogram, CT of the abdomen and pelvis and a cardiopulmonary exercise test to assess physiological reserve. The specialist reviews include a dietitian, anaesthetist, hepatologist, surgeon, social worker and psychologist. The aims of this complex assessment process are to (1) confirm the hepatological diagnosis, (2) confirm medical treatment has been optimised, (3) confirm that transplantation remains the most appropriate option, (4) evaluate mental and physical health comorbidities, (5) identify any contraindications and (6) ensure the patient is fully informed.1 Once all tests and reviews are complete, the patient’s results are discussed at a multidisciplinary meeting to inform the outcome of the patient’s suitability for liver transplantation.
Prior to COVID-19, the process to complete the complex set of tests and reviews for a liver transplant assessment was to admit patients for a 3-day and 2-night inpatient stay. However, admitting patients to a hospital inpatient ward bed was often difficult due to limited bed availability. Once the COVID-19 response was initiated in March 2020, these difficulties intensified. The shortage of hospital inpatient beds is a well-recognised problem in the UK.3 4 A suggested strategy to overcome this problem is to do things differently by exploring potential substitutes for hospital beds. Together, this supported the need to change the assessment process, looking for a solution to reduce the reliance on inpatient beds.
A review of the literature identified that the amount of time a liver transplant assessment process takes and the setting where the patient is based vary by the transplant centre. One centre in the USA provides information to patients that this process can take up to a week.5 The British Liver Trust provides guidance on the transplant assessment process, which involves about 2 days and is carried out in different hospital settings, including inpatient, day-case and outpatient settings.6 A previous quality improvement project changed the assessment process for living donor kidney transplant assessments to a comprehensive 1-day assessment process for all tests and found a considerable and sustained increase in their outcome measure of the rate of living donor kidney transplantation.7
Due to the limited liver transplant assessment literature prior to commencing our improvement project, we contacted other liver transplant centres to establish how their assessments were undertaken. We found that the six centres offered variations in their approach. Every centre required the same tests and reviews; however, the processes were different. Four centres had inpatient-based assessments. One was a 5-day inpatient assessment, with the main reason for this being the large distances travelled to the assessment unit. Two centres used the outpatient department as these were supra-regional centres and used hospitals more local to the patient to perform some tests, then the liver transplant centres reviewed the patient once tests were complete. This outpatient assessment process was delivered to reduce travel times for patients, to better use inpatient beds and to develop better relationships with the referring centres.
We then visited two liver transplant centres to provide a more detailed review of their liver transplant assessment process for outpatients. These visits proved very useful for learning about some similar processes, such as the types of tests and reviews required. The process of a 1-day assessment was identified as a strong possibility for change for our service.
One of the strategic objectives of our organisation is to explore ways to reduce the carbon footprint.8 The NHS’s carbon emissions are equivalent to 4% of England’s total carbon footprint, and action is called for to reduce this burden.9 We were therefore sensitive to this burden and keen to ensure we positively impacted a reduction in our carbon footprint.
Measurement
Inpatient bed utilisation
Data collection focused on the main outcome measure, which was the utilisation of inpatient beds. The number of inpatient beds occupied by each patient was a data item already routinely collected within an Excel spreadsheet for each patient undergoing a liver transplant assessment. These data were completed by one of the two liver transplant nurse specialists and were updated weekly. The spreadsheet of liver transplant assessment patients was regarded as the central information hub for all patients and deemed highly accurate by the team, increasing the reliability of the data. Data were collected in a consistent way throughout the study period and with each patient entry, there was no missing data, increasing the reliability of the data.
To meet our aim of reducing demand on inpatient beds, data were collated and monitored continuously from 1 April 2017 to 31 March 2023. Prior to making any changes, 3 years of data were reviewed retrospectively to check for unusual patterns in activity and to be more confident with the baseline activity.
Patient satisfaction
To gain an understanding of the patient experience of our existing service prior to any change, we designed a patient satisfaction survey. The survey consisted of six questions focusing on a five-point rating scale on the overall assessment process, information provided, views on the option of a 1-day service, time with team members, travel for assessment, overall outcome of the assessment and provided opportunities for open comments. The survey was distributed in April 2020 by post with a prepaid return envelope. Patients included in the survey were all patients within a 12-month period (April 2019–March 2020) who had undergone a liver transplant assessment regardless of whether or not they were listed for a liver transplant. Patients who were deceased were excluded.
To gain patient feedback on the 1-day assessment process, a second patient satisfaction survey was undertaken in February 2023, after all three Plan-Do-Study-Act (PDSA) had been completed. The survey consisted of four questions focusing on the amount of time to attend the tests and investigations planned in 1 day, understanding of the tests and investigations, an overall feeling of their experience with 1-day assessment using a five-point rating scale on the overall satisfaction of the process and views on how we could improve the assessment process. It was distributed on paper to each patient at the end of their assessment day, regardless of whether they were listed for a liver transplant. Patients returned their completed survey to the day-case ward staff.
Costs
We wanted to understand the financial consequences of the change from a 3-day inpatient assessment process to a 1-day process by calculating potential cost savings. The cost savings were calculated by a trust accountant using trust’s Patient Level Information and Costing System (PLICS). Our trust follows the NHS-approved costing guidance and cost data, which is submitted to the National Cost Collection following set guidance.10 The PLICS generated a cost of £271 per day for an overnight stay in the inpatient ward for the 3-day liver transplant assessment process and a cost of £198 per day for the new 1-day day-case assessment process. The specific costs for each type of hospital admission are displayed in table 1.
Elements of day-case and inpatient stay costs
Carbon footprint
It is recommended that organisations in the UK report on greenhouse gases using kilograms or tonnes of carbon dioxide equivalent (kgCO2e) as this is the most comprehensive way to report an organisation’s emissions.11 Therefore, to calculate the carbon footprint, we used existing measures for carbon emissions for inpatient and day-case stays.12 This was 618 kgCO2e for an average elective episode for an inpatient stay and 124 kgCO2e for the average day-case stay.
Design
In March 2020, at the onset of COVID-19, we were advised to cease our inpatient liver transplant assessment service. We took this time as an opportunity to consider how we should undertake assessments once the service was permitted to resume. The learning from our visits to other centres and the results from the patient satisfaction survey identified an opportunity to test a 1-day assessment process.
The planning of this 1-day process was undertaken by the liver transplant assessment team over an 8-week period. The team included two liver transplant coordinators, two liver transplant hepatologists and one transplant anaesthetist. We reviewed all tests and reviews undertaken in the 3-day inpatient assessment process to ascertain if all were required in the new 1-day process. All the tests were necessary, so timings for each test were calculated and a timetable created for a day period from 8:00 to 17:00.
We approached the relevant department staff undertaking the assessment reviews and tests to establish if prebooking specific transplant assessment timeslots would be possible. Initially, this was not received due to the pressures of work and the concerns raised regarding patients not arriving on time, resulting in lists potentially running over. Further discussions were required to convince staff of the need for change. We used stories of how disorganised the existing process was and how patients often had a poor experience. We also provided assurance that timekeeping would be maintained by the liver transplant coordinators, with sole responsibility for ensuring patients would arrive at the departments on time. Despite the awareness of the likely challenges of maintaining timekeeping, this individual responsibility showed a strong commitment to the new 1-day process. We designed a timetable to show the various departments how we envisaged the 1-day process. All departments then agreed to test the 1-day assessment process.
Patients were planned to arrive at the day-case ward at 08:00 and leave at 17:00. No overnight stays were planned unless patients met the specific exclusion criteria for a 1-day assessment. We set the exclusion criteria for those who required paracentesis as well as a liver transplant assessment. These patients were planned to be admitted the day before the assessment process for one overnight inpatient stay. Patients required to travel over 2 hours were also excluded, as this resulted in a very long day so they were admitted the day before for one overnight inpatient stay.
We agreed to test the new 1-day assessment process every Thursday starting in June 2020. The patients chosen to test the new approach had their assessments cancelled due to COVID-19, which resulted in a backlog of patients waiting for their assessments. The patients were prioritised using their UK End-Stage Liver Disease (UKELD) score.13 Our rationale for this prioritisation was that the greater the UKELD at referral, the sooner the assessment would be planned. This score was used to help deal with the backlog of patients over an initial 6-month period and was not used to determine suitability for this new approach.
We provided a printed timetable for each patient on the day-case ward and provided a copy to the ward nursing staff.
This project was considered quality improvement, and there were no ethical concerns related to our project since the aim was to implement best practices. Patients were fully informed about the new assessment approach.
Strategy
We used a series of PDSA cycles to test out the new transplant assessment process and to learn and adapt from each change to the process. PDSA is a well-supported and useful method to implement and refine changes to processes in healthcare.14–16
PDSA 1
The first PDSA was planned from June 2020 to September 2020. The first eight patients during this period were nervous about coming into the hospital due to COVID-19, so they required support and guidance from the liver transplant coordinators on the precautions and personal protective equipment in place to protect them. The hospital was quieter due to COVID-19 restrictions, and departments were keen to rigidly keep to the appointment time slots to avoid spending unnecessary time sitting in waiting areas.
We agreed to meet as a team once a week in the first 4 weeks at a prearranged transplant assessment meeting. This meeting was attended by members of the liver transplant team, including surgeons, hepatologists, anaesthetists, dietitians, social workers and transplant coordinators. At the meeting, we discussed what went well and where we needed to improve. The transfer time between tests was not always enough. This was mainly due to delays in notification of when patients were ready to leave one department.
The first eight patients often ran over past 17:00 as the surgeon required to review the patients face-to-face often missed their appointment time due to other important surgical priorities. However, the surgeons were able to review the CT scans and document findings outside of their allocated timeslot.
Early informal patient feedback was encouraging, as the eight patients reported staff being attentive and their tests were spaced out reasonably well. They had time for food and drinks and were able to rest between some tests and reviews.
PDSA 2
The second PDSA ran from October 2020 to June 2021. We removed the time slot for the surgeon review but built in a request to contact the surgeon to review the CT scans. We reinforced the importance of early notification from departments once patients had finished their tests and were ready to be transferred to the next appointment.
During this cycle, we noted that the day was often pressurised in the morning, especially at the time the patient arrived. This was due to the lack of allotted time for the patient to be clerked and for an arterial blood gas to be taken by the junior medical staff. Not long after the patients arrived, they were transferred to a department for a test, resulting in the junior doctor making repeated visits to the day-case ward to do the clerking and blood gas.
The cardiology departments struggled to ensure patients had their ECHO test in the allotted time and requested the slot be moved to the start of the day as soon as the department opened.
The transplant coordinators often felt they did not have enough time to provide patient education on liver transplantation. However, the informal patient feedback remained positive about the 1-day process.
PDSA 3
The third PDSA ran from July 2021 until December 2022. This involved testing a separate outpatient appointment to provide time for the junior doctor’s clerking of the patient, the atrial blood gas and other blood tests. The liver transplant coordinators already ran an outpatient clinic on a Tuesday morning, and it was feasible to allocate time in their clinic. This was planned for the week before the 1-day assessment process. This outpatient appointment slot was also used by the liver transplant coordinators to provide patient education.
In response to the cardiology request to move the time slot to the start of the day, we amended the timetable to rearrange the order of the tests to accommodate this request and increase the likelihood of all tests and reviews staying within the allotted time slots.
Results
Bed utilisation data
The main outcome measure was the number of inpatient beds used. We found the 3-day assessment process used an average of 257 (range 200–319) inpatient bed days per annum with a dramatic reduction to an average of 20 (range 7–37) inpatient bed days per annum with the 1-day process (table 2).
Bed utilisation activity, cost data and carbon footprint
A small number of inpatient bed days continue to be used on an annual basis due to patient exclusions, such as patients becoming unwell between the preassessment and the 1-day assessment or patients requiring ascetic drainage. This small number of inpatient bed utilisation has been maintained at a similar level for 3 years.
Patient satisfaction data
The first patient satisfaction survey was sent to 102 patients, and 41 responded in the 3-day process. Eighteen patients responded to the second patient satisfaction survey on the 1-day process. The overall ratings of the 3-day survey were compared with the 1-day survey and showed a similar level of satisfaction (figure 1).
Patient ratings.
Cost data
The average cost per patient for the 3-day inpatient process was calculated from 2017–2018 to 2019–2020 at a cost of £609.83 (table 2). The average cost per patient for the new day-case process was calculated from 2020–2021 to 2022–2023 at a cost of £227.87 (table 2). This demonstrates a saving of £381.96 per patient, which is a 63% reduction in cost. Assuming an average number of patients being assessed per annum of 110, this would result in an average cost savings of £42 016 per annum.
Carbon footprint
The carbon footprint was calculated with an average reduction per patient from 618 kgCO2e to 179 kgCO2e (table 2).
Lessons and limitations
Our quality improvement project achieved its aim of reducing the utilisation of inpatient hospital beds by introducing a new coordinated day-case and outpatient liver transplant assessment process. This reduction in inpatient bed utilisation has been maintained for 3 years, providing a good level of confidence that the changes have resulted in a sustainable improvement. This reduction in inpatient bed utilisation contributes to the current shortage of hospital beds by providing an evaluated substitute for day-case beds for a transplant assessment process.
The testing of the new process using PDSA at a time when COVID-19 started was advantageous to this quality improvement project. Together, they provided the team with time to consider and plan a new approach, prior to trying it out, plus the ability to test and adapt a new coordinated process.
A real benefit of using PDSA was how the transplant assessment team was able to use their existing multidisciplinary team meeting structure to continuously evaluate the tests of change by sharing patient feedback and listening to staff feedback on the parts of the process that were working well and not so well. The team also took time to identify further change ideas for the process and agreed on the need for further testing using PDSA cycles. The changes suggested and tested in subsequent PDSAs, such as the adjustment to the timetable to support departments to keep to the time slots, reminding departments of the importance of early notification once patients had finished their tests and providing time for the medical clerking, worked well and continued to provide ways to maintain the multidisciplinary staff’s buy-in with the new approach.
Introducing a day-case and outpatient liver transplant assessment process does not appear to have impacted overall patient satisfaction. Further work to understand why patient satisfaction did not improve would be useful and, if explored, could contribute to further improvement strategies to increase satisfaction.
We were unable to totally remove the utilisation of inpatient beds for liver transplant assessment patients. This was due to a small number of patients becoming unwell between preassessment and the day-case assessment and patients requiring ascetic drainage. However, these patients only required admission to an inpatient ward for one night following their assessment.
The cost consequences of this improvement project were calculated with an annual average saving of £42.016, which is a 63% reduction in cost. It should be noted that these savings are indicative and not cash-releasing; however, if sufficient bed days could be saved across several initiatives, then a proportion of savings could be realised by, for example, closing a ward overnight.
This quality improvement project plays a part in one of the top three current NHS priorities, which is a focus on recovering productivity and improving patient flow.17 By demonstrating a reduction in the utilisation of inpatient beds and saving money without impacting patient satisfaction. We have also highlighted how to calculate the carbon footprint associated with changes in hospital activity and how process changes to a patient assessment service can contribute to the avoidance of carbon footprint.
One limitation of this project is that it was conducted at a single centre. The project has not been spread within our organisation due to the highly specialised nature of liver transplantation.
Despite the single-centre approach, this improvement project highlights how to change a complex patient assessment process that was fully reliant on inpatient beds to an alternative day-case and outpatient approach and should be considered by other assessment services, not just liver transplantation.
Conclusion
Changing the liver transplant assessment process from a 3-day inpatient process to a day-case and outpatient process showed a reduction in inpatient bed utilisation. It also demonstrated a 63% reduction in cost with an annual saving of £42 016. In the future, it will be important to explore other healthcare assessment processes to identify where this type of change in process could be spread to improve patient flow and save costs.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
We would like to thank and acknowledge the hepatology team at Freeman Hospital. Particular thanks to Dr Emily Bonner for their input into the design of the liver transplant assessment day, Dr Mhairi Donnelly for assistance with the patient satisfaction survey and Laura Middlemiss for supporting carbon footprint awareness.
Footnotes
Contributors Study design and implementation: PRS, LM, EC and SD. Data acquisition, analysis and interpretation of data for the work: PRS, AR and VK. Draft manuscript preparation: PRS, AR and VK. All authors reviewed the results and approved the final version of the manuscript: PRS, AR, LM, EC, SD and VK. AR is the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.