Reflective Review M3 01 Solving problems and making decisions 2

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M3.01 – Solving problems and making decisions

Introduction and Background
The Health Board was established in 2009 following the integration of the two former NHS Trusts and two Local Authorities’. The Vision was to ‘Create Altogether Healthier Communities’ by aiming to prevent ill health, protect good health and promote better health’ through working with partners to provide services as locally as possible and reducing the need for hospital inpatient care wherever feasible.

The acute service at one of the District General Hospital provides assessment of functional need and implements interventions to enable patients to safely leave hospital. A small team of qualified and unqualified staff covers the 430 beds the District General Hospital.

As a senior qualified team member, I am responsible for four busy surgical, neurological and cardiac wards. I am also responsible to the clinical development of junior and unqualified staff members. I review the length of time a referral is waiting to be seen, picking up referrals due to breach waiting targets as agreed by management. I generally hold a larger caseload than other team members and support my team with complex referrals and a high referral turn over.

Description of the problem
Referrals to the service are made primarily via ward nursing staff and other members of the multi-disciplinary team. Patient information is entered into a referral book and then non-qualified staff members collect the referral information twice daily. This generates a referral card with basic information relating to the patient’s reason for admission and general current health, which is submitted to a referral folder within the department. The qualified staff members use these referral cards to prioritise referrals.

Inappropriate referrals to the acute Service are unfortunately a common occurrence. Patients’ are referred for assessment, which becomes a requirement prior to discharge. Any referral requires staff time, which has financial implications. A non-complex referral can take an average of 2 -4 hours to fully assess, complete the required paperwork and implement required recommendations. A complex referral can take a couple of days.

An inappropriate referral can cause an unnecessary delayed discharge not only for the patient referred inappropriately, but also for other patients appropriately referred as often they must wait for the qualified to work with the inappropriate referral before they can be seen. This may result in a hospital bed being blocked; occupied by someone that could have been discharged rather than made to wait for an assessment. The rough average costing of a night’s stay in a NHS hospital bed is £500.

Analysis of the problem
Consistent feedback from all therapists within the acute medical team indicated a flaw in the current referral system. Team members highlighted large numbers of referrals that did not meet the criteria for acute medical assessment and similarly large numbers of referrals made at inappropriate times. Following lengthy discussion at a team meeting, it was agreed that the current system was failing. The demand for assessment and interventions to plan for safe discharge from hospital is high. The indication of knowledge and understanding of the purpose of the assessment and intervention within the context of discharge planning is not so high. This was the consensus after reviewing the numbers of, reasons for and timing of referrals.

Generally a referral is made by a qualified nurse sticking a patient information label onto a referral card and selecting a tick box option to indicate reason for referral. An estimation of the time this would take is 10 minutes. Based on an annual salary of a newly qualified staff nurse, this would equate to £1.80. An Assistant visits each ward twice daily, collecting the referral cards and completing information from the patient’s medical notes including reason for...
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