Redesigning the Patient Pathway for Vestibular Services. Caroline Rae Vestibular Audiologist

Transcription

1 Redesigning the Patient Pathway for Vestibular Services Caroline Rae Vestibular Audiologist

2 Tayside Audiology and Balance Services (TABS) Population Covered: 405,721 Location: Dundee, Scotland NHS Tayside

3 The Project Aims Establish, using process mapping techniques, if the new audiology direct access clinic for Labyrinthitis or Vestibular Neuritis leads to quality improvement for this patient demographic. Objectives Use a Systems Engineering Initiative for Patient Safety Model as a framework for system redesign Carry out a Hierarchical Task Analysis on the patient journey Use a Systematic Human Error and Reduction and Prediction Approach to identify any errors in the system Carry out a clinical audit of the new audiology led direct access clinic

4 But First... The human balance system Even distribution of weight which enables someone to remain stable and upright Allows us to focus whilst moving and identify our orientation in space with respect to gravity Taken for granted but relies on a complex set of sensorimotor control systems including, somatosensory, visual and vestibular The Vestibular System Bilateral input Vertigo illusion of movement The dizzy patient

5 The Dizzy Patient Vertigo and Dizziness rank among the most common reasons for attending primary care Lifetime prevalence of 17 30% As common as headaches or backaches Labyrinthitis/Vestibular Neuritis Viral infection which affects the inner ear Rotational Vertigo Nausea/Vomiting Diagnosis History, Hearing Test, Vestibular Assessment Treatment Vestibular Rehabilitation Early intervention

6 Quality Improvement Highest quality services to those that require them. Built around caring compassionate staff and services, clear communication, effective collaboration between clinicians, patients and others involved Safety and efficiency are a high priority An increasing partnership between health services, human factors and systems engineering allowing for system redesign Patient journey can be long patients, care givers, family members, healthcare practitioners, GPs, ENT consultants, audiologists, health psychologists, and physiotherapists Several handoffs

7 Initial Patient Pathway Patient initially attends GP Referral to ENT Triaged for otology dizzy clinic Attends ENT clinic Hearing test by Audiologist History by ENT Bedside assessment Further tests requested Attends Audiology clinic for assessment Report back to ENT Attend ENT clinic for diagnosis Attend Audiology clinic for rehabilitation exercises

8 MULTIPLE REFERRALS/HANDOFFS INCREASED RISK OF REFERRAL BEING MISSED MULTIPLE APPOINTMENTS LONG WAITS

9 Patient initially attends GP Referral to ENT Triaged for otology dizzy clinic Attends ENT clinic PTA by Audiologist History by ENT Bedside assessment Further tests requested Attends Audiology clinic for assessment Report back to ENT Attend ENT clinic for diagnosis Attend Audiology clinic for rehabilitation exercises

10 New Pathway Patient initially attends GP Referral to ENT triaged for Audiology Attends Audiology clinic for assessment Hearing Test, History, Vestibular Assessment Attends Audiology clinic for rehabilitation exercises How did we get to this point and is the clinic beneficial?

11 Systems Engineering Systems Engineering Initiative for Patient Safety (SEIPS) Framework for understanding the structures, processes and outcomes in health care anchored within human factors Components include person, tasks, tools and technologies, physical environments and organisational conditions Interactions between different factors produce different outcomes LOOK AT THE SYSTEM AS A WHOLE!

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13 Audiologist Person Tasks Tools and Technologies Physical, Cognitive Tasks involve direct Electronic referral and Psychosocial patient care, care management aspects described coordination, system, clinical above all come in indirect patient portal online case to play. care and no patient note system. TOPAS Audiologist must be care. patient strong enough for Administration management patient manual tasks are as system, AuditBase handling, important as patient experienced patient handling. management enough to be aware system, of testing Aurical equipment inaccuracies or non for pure tone organic patients audiometry and and have good tympanometry, motivation and Computerised support from Head Dynamic of Service and ENT Posturography, vhit Physical Environment Physical layout of the Audiology department, Soundproof room for pure tone audiometry assessment, Clinical room for vestibular assessment, rooms with black out blinds for vestibular assessment and rehabilitation Organisation Interaction with ENT consultant, Interaction with Audiology Head of Service, BSA protocols for assessment, Local protocols for Audiology and Vestibular assessment and typing up documentation Patient Patient knowledge, ability to give a good history, present symptoms, ability to cope with assessment, support system Log of symptoms (diary) Vestibular rehabilitation Relaxation exercises Patient information leaflets, vestibular rehabilitation exercise booklet Lighting conditions and falls/tripping hazards at home for carrying out vestibular rehabilitation exercises Access to department and vestibular rehabilitation

14 Hierarchical Task Analysis Before improvements can be identified for a process, the process s anatomy or steps must be understood The HTA is highly structured easier to produce graphically and easier to revise as the mapping progresses. It offers flexibility in representing goals which did not correspond to specific acts at specific times represents ongoing issues that could be triggered at any time such as seeking help from a peer, patient education or tasks that are purely cognitive. A flexible tool that can be adapted to a variety of situations and needs. It can be used when modifying an existing design or creating a new design In this case used for process mapping the current and redesigned clinics

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16 SHERPA The systematic human error reduction and prediction approach (SHERPA) It is a human error prediction technique that analyses tasks and identifies potential solutions to errors in a structured manner. The technique has been applied to pilot error, the use of consumer products, vending machines being an example and to reduce the risk of errors during surgeries. SHERPA uses the bottom level action of the HTA as its inputs. These are the operations or task steps carried out to achieve the higher level goal.

17 Task Step Error Probability Criticality Remediation 1.3 Referred via online referral management Communication low low Ensure GPs are aware of Referral Management Protocols 3.4 Patient added to system Communication low low Check up in place to make sure all appointment added to system 5.1 Notes Requested Communication low low Data stored electronically too 8.1 Referral form filled out Communication low low Letter also sent 6.2 Marked as arrived on AuditBade Communication low low Physically check patient has arrived 11.1 Referred back to Communication low low ENT 17.1 Brief history Communication low low Continuous care form one clinician

18 Clinical Audit (New Clinic) 30 Clinics 107 Patients 4 DNA 3.74% 103 Attended 5 Referred to ENT Longest wait (days) Shortest wait (days) Average wait 4.85%

19 Waiting lists The clinical audit data for the audiology led direct access clinic are very positive and promising. These patients initially waited just over 100 days for their appointment and towards the end of the trial were waiting just over 20 days. The average wait over the span of this clinic was 37 days. Meeting national legislation guidelines Missing out some of the steps of the original ENT pathway and utilising the skills sets available has helped to reduce waiting times dramatically and allow patients to be seen and treated quickly. The HTA shows that the vestibular patient is added to the waiting lists three times during their pathway. Each time this happens there are inherent risks, particularly with risk of the referral being lost in the system or increased patient waits. most of the referrals for vestibular assessment are seen within 6 8 weeks but there is a distinct possibility of a long patient journey for the vestibular patient before they even reach vestibular rehabilitation.

20 DNA s The national average DNA rate for first outpatient appointment is 10%. Interestingly the highest rate for DNA in national averages was for ENT. It is thought that each outpatient DNA costs NHS Scotland 120 The DNA rate for this clinic is a third that of the national average at 3.74%, again showing that altering the patent pathway has proved beneficial. Referrals There are only a few patients referred back to ENT, this is generally linked to inappropriate information on the referral letter or patient request to see an ENT Consultant.

21 Skills Mix One of the biggest benefits of the Audiologist led clinic is the better use of available resources. This means that skilled, well trained Audiologists can be used for this clinic. The average specialist Audiologist will still cost over half that of a newly hired consultant and a quarter of a more senior consultant.

22 Conclusions The results show that vestibular patients with vestibular neuritis or labyrinthitis can be well managed by Vestibular Audiologists. This has been shown in the clinical audit and the HTA. The HTA has been shown to be beneficial in mapping the clinic pathway even though this is not always used in health care settings. This is still a new clinic and there are still some aspects that can be put in place to improve it but this looks very promising for the future and the benefit of the HTA is that this can grow and change as the clinic grows and changes.

23 Thank you for listening