Article Text
Abstract
Early discharge and follow-up for medical admissions could facilitate reduced length of stay and improve patient satisfaction. However, evidence to confirm this is lacking. Peterborough City Hospital (PCH) designed an early ward discharge clinic (EWDC) service embedded within its acute medicine department to provide clinicians with the opportunity for a prompt clinical review following a hospital admission.
Across three cycles, several interventions aimed to improve the utilisation of clinic, appropriateness of referrals and reduce the number of missed attendances. Our work has demonstrated that a service such as the EWDC can provide ample opportunity for early review of patients which could reduce the rate of readmissions and improve services. Interventions to date have improved the utilisation of the clinic, reduced the number of patients not being aware of appointments and provided training opportunities for junior clinicians. Data has also suggested a high level of patient satisfaction from using the service.
Further research is needed to confirm the use of such services in reducing readmissions and mortality, however, results from clinics at individual units such as PCH provide useful insight until such data is available.
- Hospital medicine
- PDSA
- Quality improvement
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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
Patients admitted under medicine may benefit from early discharge and follow up services however evidence to confirm the benefit of such services is lacking
Existing evidence has been unable to confirm whether such services improve the care of medical patients especially when considering a range of medical conditions.
WHAT THIS STUDY ADDS
This study provides an example of a service which has provided significant opportunity for review of patients recently discharged from hospital.
Interventions shared in the study have improved service utilisation, reduced missed attendances and provided training opportunities.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The data shared here indicates that such services improve patient satisfaction but further research is needed to demonstrate benefit in reducing readmission and mortality.
Problem
For inpatients who are mobile and clinically improving but not entirely recovered, an ambulatory pathway could be considered a helpful way to get patients home promptly with an early general medical follow-up. With this in mind, Peterborough City Hospital (PCH) established a service to facilitate the early discharge of patients from the hospital under the knowledge of rapid follow-up. The hypothesis was that the service would reduce readmissions and improve patient satisfaction. Setting the service up to involve internal medicine trainees (IMTs) would also provide an environment for training and completion of work-based assessments.
This project looked to review the impact of the new service and identify opportunities for improvement. Specifically, this project aimed to increase the use of the early ward discharge clinic (EWDC) with a target of 100% of slots being booked and reduce inappropriate referrals to the service to zero. The work also aimed to reduce the number of missed attendances.
Background
Well-timed outpatient follow-up following discharge with an acute medical condition has been promoted as a method for reducing readmissions and mortality. The days following a hospital admission are often a vulnerable period, so timely follow-up for the right patients could potentially expedite discharges and prevent a new presentation to the hospital.1 However, following a review by the National Institute for Health and Care Excellence (NICE) in 2018, no robust evidence concerning general medical patients was identified to confirm this.2 NICE made no recommendation on post-discharge early follow-up clinics and advised further research. In addition, existing research on early follow-up clinics has largely focused on single conditions such as heart failure with evidence suggesting that such programmes can reduce costs and readmissions.3 4 Our team wished to contribute to the research in this area by exploring if the newly established service at PCH was providing positive value for patients and the wider Trust, which may provide useful insight to other departments. The work would also provide evidence on the use of early follow-up clinics in a wider range of conditions.
PCH’s Ambulatory Care Unit (ACU) is the location of acute medicine’s ambulatory services. This includes patients referred from the emergency department (ED) or the community and concerns several key patient pathways. The EWDC takes place in the ACU under the supervision of the acute medical consultant covering the unit that day. The clinic takes place in the mornings from Monday to Friday and is run by an IMT. The trainees are arranged to rotate through EWDC on a weekly basis. At the time of commencing the service, there were six slots available for booking per morning session. The clinic can be accessed by patients admitted under any medical specialty at PCH and was established in April 2021.
Referrals are made electronically by the referring practitioner with details on the current admission, plan on discharge and what is required when the patient attends EWDC. Patients should be seen within a week of being discharged. IMTs can discuss cases with the registrar or consultant based in ACU and are able to use the clinic as an opportunity for work-based assessments.
Following a review in EWDC, patients are discharged back to the community or if required are referred on for specialty input. In the case that the patient requires readmission, ACU has an established pathway for this to take place.
Measurement
To robustly review the impact of the EWDC, several measures were identified. With each review of the service data would be collected considering patient demographics, source of referral, reason for referral, quality of the referral, patient attendance and missed attendance rates (including reasons for missed attendance if relevant). Results were measured through a retrospective review of clinic attendance. This included a review of the EWDC electronic record to consider attendance and missed appointments.
The record from the admission was also reviewed to establish the appropriateness of the referral and to consider evidence that the patient was informed of their appointment prior to discharge. To confirm that the patient was aware of their appointment, it needed to be documented that the patient had been informed in the medical notes. For referrals to be deemed appropriate, they needed to meet the inclusion and exclusion criteria of the service. Most notably this required a patient to be mobile enough to attend ACU. The referral contents should also not include requests to review imaging results, chase multidisciplinary meeting outcomes or ask for specialist tests to be requested.
Readmission rate and mortality within 6 months of clinic review were also considered. The service was reviewed shortly after its introduction and following each successive change to consider the impact of the ongoing improvement work.
Design
Our team considered a range of interventions to improve the service. It was hypothesised that reminders to the medical staff in the format of teaching and a ‘Dos and Don’ts’ poster would promote the use of the service and ensure the clinic was being used appropriately. To reduce DNA (Did Not Attend) rates, teams would be issued with inclusion criteria for referrals to ensure patients being referred were able to attend ACU. It was felt by the team that patients often missed appointments due to not having the mobility to attend the clinic or lacking transport. By encouraging referring teams to consider these logistical factors, more patients would be able to attend their appointments. Additionally, details on booking and informing patients of their appointment time would be suggested. To ensure that improvements were sustainable, regular teaching would need to take place to coincide with the rotation of junior doctors in medicine at PCH.
Overall, the focus of our team was to offer robust education on the use of the service, opportunities for reminders on how to conduct the clinic and ensure the wider medical division remained up to date on the development of the EWDC through regular clinical governance meetings.
Strategy
PDSA (plan, do, study, act) cycle 1
The aim for the first cycle was to establish initial data on the service and explore steps to improve attendance and reduce DNA rates. This cycle was conducted following the service implementation considering clinic attendances between April and September 2021. Following a review of the initial data, it was felt EWDC was not being used to its full potential with many slots not being booked. Key recommendations following this included a reminder to all medical specialties of the role of EWDC and how to make a referral. A ‘Tips, Dos and Don’ts’ poster was circulated to remind clinicians of the working practice of the service including what to do in the event of DNAs and what was considered an appropriate referral. The inclusion and exclusion criteria for reviewing a patient in the EWDC were emphasised to reduce the number of inappropriate referrals, namely reminding all clinicians making referrals that patients need to be physically mobile to attend the clinic. A further review was planned for 2022.
PDSA cycle 2
For cycle 2, the aim was to review the impact of the recommendations from cycle 1 and to consider further changes. Our hypothesis was that the previous recommendations would have improved the number of EWDC slots being used and reduced the number of inappropriate referrals. Clinic attendances between June and September 2022 were reviewed. The number of EWDC slots being used was shown to have improved and the range of specialties making referrals to the service had increased. This demonstrated that making efforts to share the role of EWDC had increased awareness of it as a service.
The data also indicated that the number of inappropriate referrals had reduced, however, there was an increase in the number of DNAs. Recommendations following this were to focus on reducing the number of DNAs. A detailed review of patients missing their appointments indicated that patients may not have been informed appropriately of their appointments and that some of the patients referred were not able to attend (for example, not being ambulatory). Recommendations therefore included issuing physical appointment cards on discharge to all patients with a booked EWDC appointment and ensuring all clinicians understood the logistical requirements for patients attending ACU (patient mobility and transport). It was hypothesised that this would reduce the number of DNAs to EWDC.
PDSA cycle 3
The most recent review of the EWDC service took place for patients attending between April and July 2023. Results indicated a further reduction in inappropriate referrals and a minor improvement in the number of DNAs. Importantly, it was noted that there was a significant improvement in the number of patients who failed to attend their appointments being contacted by the clinician conducting the clinic. However, there was a drop in the number of EWDC slots being booked indicating a requirement to once again share the role of the service with the medical division. The team considered that the rotation of the junior doctors in April could have impacted awareness of the service.
Given DNA rates remained high, a further set of recommendations was made to focus on this aspect. To address the possibility that patients could forget about their appointment, text messages for patients with a booked EWDC appointment were recommended. This was available to patients who had opted into the text service with the Trust. Additionally, training was offered for ACU coordinators to ensure patients being booked into EWDC were appropriate. It was hypothesised that by enquiring about a patient’s mobility and transport at the time of booking, that more patients would be likely to be appropriate candidates for the clinic.
Results were presented at the local clinical governance meeting to ensure the medical division were up to date on what was considered best practice for EWDC. Finally, an ongoing plan was made for recirculating the ‘Tips, Dos and Don’ts’ poster to capture doctors that had newly rotated into medicine (figure 1).
Regular teaching to coincide with junior doctor rotations with a focus on the major changeover in August 2024 is hypothesised to ensure sustained impact of improvements to date. Reminders on what is considered an appropriate referral will be facilitated with frequent circulation of the poster. Cycle 4 is planned for autumn of 2024 and will consider if the above actions in addition to recommendations to address DNAs has had a positive impact.
Results
Over the course of three cycles, 1416 EWDC bookings were reviewed. The age of patients across all cycles ranged between 17 and 97 years old. For each cycle the mean age of patients reviewed was 61, 63 and 64 respectively. Over the period of study a huge range of patients were seen in the EWDC with 130 different diagnoses on discharge. On their discharge from the hospital prior to EWDC 70% of patients had a single diagnosis, 27% had two diagnoses and 3% of patients had three separate diagnoses. The most common discharge diagnosis subsequently reviewed in EWDC was acute kidney injury. The remaining top five problems included community-acquired pneumonia, urinary tract infections (including pyelonephritis) heart failure and hyponatraemia.
There was a range in length of stay (LOS) of patients referred to the service. Across all three cycles 22% of patients had a LOS of less than 24 hours and 38% had a LOS of less than 48 hours. 15% of patients had a LOS of over 7 days.
Each cycle was reviewed according to the previously described measures. Following each test of change, a further sample of clinic attendance and case notes were reviewed. A summary of results can be seen in table 1.
Cycle 1 considered attendances from April to September 2021, a total of 423 patients. Most patients were referred by the acute medicine team with the remaining patients referred by other medical teams and 21 patients by ED. Of the 423 patients, just under a quarter failed to attend their appointment. For over half of these patients, no evidence that a phone call was made to them during the clinic was found.
Within 1 month of the EWDC review, 50 patients (12%) were readmitted. Of the readmissions, 26 of these were related to the same condition as the EWDC review. These were most commonly related to heart failure, chronic liver disease, upper gastrointestinal bleeding (UGIB) or symptoms of unresolved infection.
Over the 151 days reviewed, EWDC had a capacity for six patients per day and therefore 906 appointment bookings (capacity was later increased to eight patients per day). Therefore, less than half of EWDC capacity was being used.
Cycle 2 considered 589 appointments between June and September 2022. Most patients were still referred by the acute medicine team, however, referrals from other specialties did increase following the interventions in cycle 1 and likely explains the reduction in the number of patients referred with an LOS of less than 48 hours.
The quality of referrals was noted to improve following the interventions in cycle 1 with only 4% of referrals being inappropriate.
Considering DNAs, these increased from 24% to 28%. However, 69% of these patients were called during the clinic which was a significant improvement. 51 patients (9%) were found to be unaware of their appointment indicating a need to still focus on this.
The readmission rate within 1 month of clinic attendance was the same as cycle 1. However, when only the DNAs were considered the readmission rate was found to be higher at 20%. While patients not attending EWDC are more likely to be readmitted, it is hard to attribute a reduction in readmission by attending the clinic to the service alone.
During the time frame of the review, there was a capacity for 688 patients. Fulfilment had therefore significantly improved following the interventions to 86%.
A survey of IMTs at PCH indicated that 80% agreed or strongly agreed that the EWDC had a positive impact on their training. IMTs who had been placed in PCH between 1 and 3 years were surveyed with the range of clinics attended being between 2 and 23.
Cycle 3 considered patients attending between April and July 2023. This included 404 appointments. Acute medicine referred 45% of patients with an improvement in the number of other specialties using the service. Notably, there was a larger proportion of patients seen in EWDC with heart failure along with UGIB and cellulitis. However despite this increase in chronic disease, the readmission rate remained 12%.
The number of inappropriate referrals was reduced further to 2%. However, fulfilment of clinic capacity was noted to reduce from 86% in cycle 2 to 73% in cycle 3. The junior doctor changeover occurring prior to data collection for cycle 3 could have impacted this fall in utilisation.
Considering DNAs, 110 (27%) of patients failed to attend. A call was made to 95% of these patients which was an improvement from cycle 2. Only 22 patients were unaware of their appointment details following the interventions in cycle 2.
Mortality throughout the three cycles ranged between 6% and 9%. We would suggest that patients being referred to EWDC carry a high degree of comorbidities, particularly those associated with multiple admissions such as heart failure and liver disease. Therefore, the population referred to EWDC is likely to carry a higher mortality rate than the wider range of medical admissions.
Considering the DNAs only, the readmission rate was 18%. Given the improvement in the appropriateness of referrals, most patients meet the inclusion and exclusion criteria of the service. This would suggest that a similar cohort of patients who are missing their appointments are more likely to get readmitted compared with patients who do attend. This indicates the EWDC has a positive impact on reducing readmissions. However, as discussed above further work would be needed to confirm this.
Our main project aims were to increase the use of EWDC, reduce inappropriate referrals and decrease DNAs. The run chart (figure 2) demonstrates that while there was a small drop in clinic use in cycle 3, there has been an improvement overall and inappropriate referrals is now close to zero. DNA rates remain higher than we would like but importantly nearly all these patients are now being contacted by the clinic clinician.
A final piece of work looked to review the patient satisfaction of the service. 56 patients completed a survey following their care in September 2023. Questions were asked regarding their overall experience, their satisfaction with the care provided, their preferred method of care and if they would use the EWDC service again. 89% of patients surveyed reported their experience as ‘good’ or ‘outstanding’ with 95% preferring the use of EWDC compared with staying in hospital for a longer admission. 100% of patients were satisfied with the care provided and 96% would use EWDC again.
Lessons and limitations
The results across the three cycles so far indicate an improvement in the utilisation of EWDC and a reduction in inappropriate referrals following our interventions. Additionally, while the rate of DNAs remains higher than desired, the vast majority of patients are being contacted via telephone. Work will continue with the planned interventions from cycle 3 to reduce the rate of DNAs and remind clinicians on how to use the service to its best capability. The team hypothesise that some patients are still being referred to EWDC who are not ambulatory or who lack transport to attend clinic. Additionally, a small number of patients still remain unaware of their booked clinic at the time of discharge. If the service is to be used to the best capacity, both aspects must be addressed. Overall, despite the service not being used to 100% of its capacity, it has still provided considerable opportunity for an early review of appropriate patients.
Patients who missed their appointments were identified to have a higher rate of readmission than those attending. This would suggest that the EWDC service reduces the rate of readmissions, although limitations to this conclusion are appreciated and further work would be needed to confirm this. A comparison group of patients not using the service would provide further evidence to either support or refute this but is unfortunately not within the capabilities of this work. This would also be required to confirm if such a service does indeed reduce the LOS for patients. Over the course of our work the number of patients with a LOS of less than 48 hours actually reduced likely due to the increase in a number of specialties outside of acute medicine taking advantage of this route for follow-up. Overall, we have not been able to prove if this service reduces readmissions or LOS and would suggest further research is needed.
Our team also accept inconsistency in the data collection period for each cycle. The variation reflects the timing of the interventions and capability for the work within the team. Seasonal variation is possible due to the inconsistencies, however, all cycles fall in the spring to summer period which minimises potential impact.
Positively, the majority of IMTs find attending the clinic useful for their training. Attendance counts towards clinic totals for trainees and provides an opportunity for work-based assessments. Additionally, the patient survey results indicate that service users are happy with the care they are receiving from EWDC.
Conclusion
This work has presented the impact of a new service in a district general hospital aiming to facilitate the opportunity for early follow-up. Referrals have supported the discharge of patients who have largely had short stays in hospital providing an additional safety net and aimed to reduce readmissions. The service also provides a training opportunity for doctors as an additional benefit.
Previously, NICE had not identified any robust evidence to indicate early follow-up after discharge reduced mortality or improved patient satisfaction. Additionally, in their review most studies reviewed were specific to patients with heart failure. While our work involves a much smaller patient group, the service has reviewed patients with a range of conditions and we would propose that the utilisation of the service has improved patient satisfaction. However, further work is needed to confirm the use of such services reduces the LOS or readmission rates.
Challenges encountered include the number of missed attendances, largely attributed to patients not being aware of their appointment. Work will be continued at PCH to improve awareness of appointments for patients being discharged and ensure they are reminded to attend. With the next rotation of junior doctors, further education will also be offered to sustain improvements to date and ensure awareness of the service.
Timely follow-up clinics for the correct patients can facilitate discharge under the assurance of an early review. Such services promote patient satisfaction and have the added benefit of providing a supporting training experience for IMTs. Until further research is undertaken to confirm the use of early follow-up in reducing readmissions and LOS, discussion of results from such clinics at individual units such as PCH continues to provide useful insight.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
This work was registered with trust audit department and did not require any ethical approval.
Acknowledgments
The team would like to thank Dr Dimple Shah for her work at the inception of the project.
Footnotes
X @Georgia_Kate7
Contributors GKG and TA contributed to the design of the project and its implementation, analysed results and wrote the manuscript. SNC designed the service and its implementation, supervised the project and edited the manuscript. GKG is the guarantor of the manuscript.
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 or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this quality improvement work.
Provenance and peer review Not commissioned; externally peer reviewed.