Improving Patient Flow by Chris Isles

Dave Pedley gave an excellent talk two Wednesdays ago on Tackling Crowding in Emergency Departments, triggered no doubt by the number of times recently we have been running at 100% bed occupancy with patients sitting in chairs in the Emergency Department because there were no free cubicles.

The nightmare scenario for us all as the clock ticks inexorably towards December 2017 is that the same thing happens when our fabulous new hospital opens and the TV cameras, newspapers and journalists begin to salivate at the prospect that something goes wrong (there will be no story to report if the transition to the new hospital goes smoothly and there are no corridor patients).

The chances that something could go wrong are actually quite high and the problem is almost entirely medical by which I mean the large number of frail older people living precariously in the community who fall, become immobile, incontinent or delirious and require at least some form of assessment but often admission to hospital.

The omens are not good.  Dumfries and Galloway has the second highest proportion of people in Scotland who are aged 75+ and living alone.  Our Health Intelligence Unit have shown that despite numerous initiatives and new ways of doing things the Medical Unit would be sailing perilously close to 100% bed occupancy if we moved into the new hospital today. (See me previous blog on the new hospital here)

During his talk Dr Pedley showed a powerful 5 minute video by Musgrove Park Hospital in Somerset entitled Tackling Exit Block ie their hospital’s inability to move patients through ED because of numerous interrelated system failures.  (https://youtube/WX1YwKIkWzA).  Musgrove Park ‘s Top Ten Reasons Why People Cant Leave Hospital were as follows:

  1. Discharge delayed so patient can have lunch
  2. Carer/relative can’t pick them up till after work
  3. Nurses too busy looking after other patients to arrange discharge
  4. Waiting for transport or refusing to leave without free transport
  5. Waiting for pharmacy
  6. Waiting for ward round
  7. Waiting for blood or scan results
  8. Waiting for discharge letters
  9. Packages of care planned for late afternoon/early evening
  10. Patient doesn’t want to go to the assigned bed in community hospital

During discussion a number of solutions to our own recurrent difficulties with patient flow were proposed.  These included tackling all of the above in addition to attempting to educate the public about when and when not to attend ED.  My own view is that this might be as fruitless as King Canute sitting in his throne on the beach and attempting to stop the incoming tide on the grounds that any patient who comes up to ED and is prepared to wait up to 4 hours and possibly more to see a doctor or a nurse must feel they have a very good reason to be there (one often quoted reason being that they could not get an appointment to see their GP).

There were some illuminating moments.  We asked Patsy Pattie whether Dynamic Daily Discharge was still as effective as it had been when it was first rolled out.  She replied that some wards needed support on embedding the process.  Dr Pedley praised staff for their firefighting skills on those occasions when patients were unable to access cubicles in ED which prompted Philip Jones, our chairman, to say that a corporate rather than firefighting response was needed.  Many heads nodded in agreement.

A corporate response might mean fixing lots of little things in order to make patients flow through the system more speedily.  Dynamic Daily Discharge could then become an established part of ward routine rather than an optional extra; the paperwork in the medical assessment area might need to be simplified to allow nurses to move patients into the body of the ward more quickly; a nurse on each ward might be designated to carry the ward phone rather than allow it to ring endlessly in the hope that someone else will pick it up; clinical teams would actively consider how patients might get home;  consider community detox for alcohol withdrawal; patients earmarked for discharge might move to the dayroom unless physically unable to do so; hospital taxis might take people home if relatives or patient transport cannot do so; patients could be issued with a prescription to take to their local pharmacy if new medications are required or go home with immediate discharge letter to follow if not.

To these solutions I would add fully funded Ambulatory Emergency Care and Comprehensive Geriatric Assessment services together with more and better social care and a commitment to fill the hospital with more staff on public holidays (of which there will be four within one month of the new hospital opening).

The Chief Executive of Musgrove Hospital finished her contribution to the Exit Block video by saying ‘we need every single member of staff to understand their responsibility in ensuring patients flow through our hospital so that we can discharge them home as quickly and as safely as possible’.  Who could disagree?

Professor Chris Isles is Sub-dean for Medical Education and is a Locum Acute Physician.

Is My Prescription Ready Yet? by Laura Graham

Have you ever pondered why this question is asked so frequently? The lifecycle of a hospital discharge prescription is rather complex, hopefully I am going to highlight the current process, and why it matters for everyone to be mindful of it in order to help improve it.
• Patient identified as being suitable for discharge within 48 hours, via a daily dynamic discharge meeting or ward huddle (planned) or during a ward round (often unplanned)
laura-g-1 Doctor finalises typing the prescription which also includes a summary letter of the admission using the inpatient notes, electronic prescribing system (HEPMA) and any other relevant info e.g. lab findings/scan results/social work info/referrals for follow clinics etc. Most prescriptions are started prior to discharge, but only submitted to the pharmacy team once finalised (doctors have the option not to submit to the pharmacy team where possible, for example a nurse could dispense simple prelabelled medicines from the ward). Average time 20 minutes

laura-g-2Clinical pharmacist performs an initial prescription check–
which means that they are happy that the prescription is accurate, cost-effective and safe for that patient. On surgical, medical and care of the elderly wards this happens at ward level using the initial medicine reconciliation (list of medicines that a patient was actually on admission), inpatient notes, any relevant investigations, and by speaking to the patient which helps detect any discrepancies or further issues. The medicines are sorted into either ward stock, pharmacy stock, medicines to be labelled on discharge or the patient’s own medicines to be returned (note we try to only supply any new or changed medicines to improve efficiency & reduce confusion for the patient) Average time 30 minutes

• Amendments are required in 75% of DGRI prescriptions by the prescriber for various reasons e.g. Wrong inhaler device selected, interacting medicine, out of stock medicine prescribed, incorrect legal requirements documented, non-formulary medicine started with no documented rationale, patient requests an alternative medicine, medicine missing from the discharge prescription that the patient was previously on. This percentage just highlights the complexity of the process and does not reflect lazy doctors. Average time 15 minutes.
• Prescription and medicines are taken to the pharmacy department on the lower ground floor by a porter or auxiliary nurse (no designated service). Average time 10 minutes
laura-g-3Prescription is dispenesed then accuracy checked, relevant medicines are supplied, labelled and any pharmacy stock returned by a pharmacy technician. It is then accuracy checked by a different staff member, usually a checking pharmacy technician, before the patient copies of the discharge prescription are printed and an electronic copy is emailed to their GP. Note the dispensary also produces prescriptions for other areas such as out patient clinics, peripheral hospitals, prelabelled ward medicine packs, controlled drug orders, therefore there is often an invisible workload already there. Average time 60 minutes.
• Prescription identified as ready & collected from pharmacy by a nurse checking the ward Cortix board for the live status of when a prescription is ready (green pill icon) or pharmacy will call the ward if it requested urgently. The prescription must then be collected from pharmacy by a porter or nurse. Average time 10 minutes
• Registered nurse goes through the prescription with the patient on the ward. Average time 10 minutes
Are you still awake? Me neither! So on an average day it takes around 2-3 hours from when a patient has been told that they are going to home, to their prescription being ready, and that is only if we get each of the 8 steps correct. In practice, there is usually a delay in one or more of the steps which can be very frustrating for the whole team and the patient. The exact point of the delay varies each time due to external factors such as staffing levels, the POD system not working, no designated prescription porter service, a high number of patients admitted, complex polypharmacy, high risk medicines, poor documentation or planning. We do have quicker variations of the above cycle,but only for patients deemed to be at a lower risk of medication errors, such as arranged admissions where prelabelled medicine packs are available for nurses to dispense straight from the ward for simple medicine regimes, such as painkillers.
The most crucial part of the whole process, I would argue, is talking to the patient. It is well documented that 50% of patients do not take their medicines as prescribed, for various reasons, perhaps lack of understanding, their regime is too complex or they get unbearable side effects. Up to 10% of hospital admissions are due to medicines, again perhaps due to side effects or treatment failure by not taking the correct regime. The most common medical intervention in hospital is to prescribe or alter a medicine. We also know that 25% of medicine reconciliation lists are incorrect on admission and 75% of discharge prescriptions require amendments. Our current I.T systems are very useful in isolation, but information often must be copied from one system to another making mistakes easy and slowing us down significantly. Here in lies the problem; the communication of what a patient was taking when they came into hospital, verses any changes made during their hospital stay is not always fully documented, especially for patients already on several medicines (polypharmacy). Medicines are poisons when not used correctly or with extreme care. Why does it matter if we get a few medicines wrong or miss off their bisoprolol 2.5mg daily, who cares?
I want my prescription now and I want to get home!
Currently the pharmacy team are spending too much resource focusing on rectifying problems at the point of discharge, resulting in avoidable delays. We have completely revamped the way we work by:
• Becoming paperless for our pharmacy team communication (via notes on HEPMA) and documenting any relevant information within the inpatient notes
• Constantly developing a semi electronic discharge prescription & workflow system (eIDD & eIDL)
• Developing a triaging process for emergency admissions; so that only relevant patients are followed up during their inpatient stay, as we need to focus on where we have the most impact which is admission & discharge
• From this week, investment has enabled the triaging service for emergency admissions to be extended to 7 days a week, this will improve the number of patients seen on admission by the pharmacy team (currently only 10% with a weekday service) to allow any medicine related issues to be identified earlier.
• This investment also includes a hospital pharmacist now working with primary care to follow up any complex issues or referrals from the hospital team on discharge
Discharge times matter to us all. So what can you do the improve this?
• Follow the national medicine reconciliation process when clerking in, if you do not carefully check what medicines a patient is actually taking on admission, this will cause delays in their discharge when the junior doctor is trying compare the admission and discharge medicine list for any changes.
• If you are reviewing a patient, look at the medicine reconciliation list, if there is not a clear plan documented for each medicine, challenge it and ensure someone reviews it. It will soon become common practice not to ignore any lists which do not include a dose or a plan.
• If you prescribe a medicine, document an indication, plan and review date. Never assume that it is obvious, telepathy is not a skill! Everyone has different knowledge.
• Also think about ‘realistic medicine’, could you manage to take the regime that you have just prescribed?
• Listen to patients during a medicine administration round, if they think something is wrong, please check as we are all human and errors happen.
• Encourage patients to bring their medicines into hospital, it reduces missed doses, unnecessary ordering of medicines and highlights any compliance issues (our pharmacy technicians check them against the HEPMA system)
• If you are a patient, please ask at every opportunity, what medicines you are being given and why. It matters to all of us that there is a clear rationale and plan for everything.
• If you want to check if a prescription is ready, view the colour of the pill symbol on your ward’s cortix board before calling the pharmacy team, as this delays us
I apologise that the blog today was not an easy read, but if you have any further ideas for improvement then please contact us at

Laura Graham is a Clinical Pharmacist at NHS Dumfries and Galloway

Daily Dynamic Discharge (DDD) by Patsy Pattie & Carole Morton

“Daily Dynamic Discharge is to improve the timeliness and quality of patient care by planning and synchronising the day’s activities”.
(The Scottish Government, Edinburgh 2016)

The 6 Essential Actions for improving unscheduled care was launched in 2015. The 6 actions were identified as “being fundamental to improving patient care, safety and experience for the unscheduled pathways”. One of these actions is “Patient Rather Than Bed Management”. This approach requires the multi disciplinary team working together to plan and synchronise tasks required to ensure a safe dynamic discharge process, aligning medical and therapeutic care, discharge earlier in the day and transfer back to the GP in time, reducing the length of stay in hospital.

Why do we need it?
The recent day of Care Audit in September 2016 indicated that 30.5% of patients in hospital beds did not require acute hospital care. These patients should have been transferred to another area for continued care or discharged home.
For some health professionals, too many conflicting demands on time often results in optimising work in such a way that may seem logical to the individual, especially if you are covering across wards, but may not be optimal for patient flow. This mis-synchronisation can cause delays and increase the length of stay for patients. Where there is a clear priority of order of tasks for that day, each individual team member plays their part in ensuring the priority tasks for patients is actioned or completed, which works for the patient, thus reducing delays in discharge or transferring the patient.

Who is doing it?
Ward 10 was nominated as the Exemplar ward for DGRI and implementation commenced in early September 2016. Early indications show that time of day discharges are taking place earlier in the day around mid afternoon. Prior to the introduction of DDD 27% of patients had been discharged by 4pm, in the four weeks since implementation the figure has almost doubled to 49%.

When are we doing it?
Each DDD ward huddle usually takes place at 9am each morning. Some wards have incorporated a DDD catch up meeting into their afternoon handover huddle.

What are the benefits?
The DDD approach promotes proactive patient management for today and preparing for tomorrow’s activities i.e. increase accuracy on our discharge position and increase awareness of the need to create capacity at key points throughout the day.
This is aligned to The Royal College of Physicians acute medical care “The right person, in the right setting – first time” (please see link below).
A recent quote from Vicki Nicoll, SCN ward 10:
“DDD for us has had such a positive impact on the ward as we are finding patients are being seen by all members of the Multi Disciplinary Team (MDT) in a timelier manner.  The patients are being discussed rather than going from one weekly Multi Disciplinary Team meeting to the next.  Interventions are being done more timely from all members.  We have noticed that length of stay has reduced and patients that you would normally presume would be with us for some time seem to be getting home quicker. We recently had a patient who was a complex discharge and I personally thought the patient would have passed away in the ward, but everybody pulled together and we were able to return the patient home.  Sadly, she passed away at home, where she wanted to be with her family”.

“DDD has taken away the thought that nurses should do everything when in fact it is everyone’s job to work together to ensure that the patient is on the right pathway”.

DDD is currently being rolled out to most of the acute wards in DGRI and a test of change commenced on 21st November in Annan Community Hospital. Implementation at the Galloway Community Hospital is planned for mid December.

We all have our part to play in the planning of a safe discharge for our patients, DDD enhances our current processes, promoting an MDT approach with teams working collaboratively and more robustly.

Patsy Pattie works in the Acute Services Improvement Team and Carole Morton is an Assistant General Manager Acute Services for NHS Dumfries and Galloway