Pandemic Pandemonium in Paediatrics Postdischarge: Refining a Novel Trainee-Led Initiative during the Covid-19 Pandemic

ABSTRACT

Aims Established in response to the COVID-19 pandemic, a trainee-led outpatient clinic aimed to provide children with continuation of care following discharge from hospital. The service was created as a safe alternative to the long-standing practice of ward attenders, while reducing mounting pressures on appointments at consultant-led clinics. Several issues arose in its implementation with insights from service users identifying the breakdown in written communication as the single most detrimental factor in its success. With wasted journeys, missed appointments and opportunities lost - children, young people and consultant teams found themselves left in the dark. Initial analysis found significant issues at various stages in referral, booking and follow-up management. The project aimed to improve communication to ensure all clinic attendees underwent timely referral and outpatient review with decisions effectively communicated to all parties. Methods Process maps, fishbone and pareto diagrams allowed our problem to be understood and defined. Four domains were recognised as key components in improving communication among service users to include the inclusion of an indication for review, a lead consultant, the successful clinic attendance, and the provision of an outcome letter. The project aimed to improve compliance across the four criteria by February 2022. Using the clinic diary and the electronic care records system (NIECR), outcomes concerning the four domains were ascertained for patients attending the clinic during a six-month period. A baseline measure derived from 20 patients was established and measurements were collected for a further 44 patients whilst changes were initiated. Five interventions were tested in PDSA cycles to include the phased development and distribution of a clinic guideline, referral proforma, trainee troubleshooting sessions and appointment cards. Improvement could be detected and visualised in run charts illustrating the number of criteria met following introduction of an intervention. Results A baseline measure of 20 patients found only 2 patients met the compliance standard of 100% (mean criteria 1.4;SD 1.2). The inclusion of a lead consultant and clinic letter provision were met in 25% and 10% of patients respectively. Following initiation of interventions, the run chart illustrated improvement leading to meaningful change at patient and service level. Interventions resulted in an 80% increase in clinic letter provision and a 50% reduction in the clinic's Did Not Attend (DNA) rate. The median number of criteria met increased from 1 out of 4 to 3 out of 4. 100% compliance across all four criteria was achieved for 13% of patients attending the clinic from our baseline measure of 10%. Conclusion Introducing frequent, small change ideas through PDSA cycles allowed us quickly to identify our most successful interventions to address the frustration surrounding communication breakdown shared by all service users. This process will also be useful in the induction of new trainees managing the clinic. Targeted interventions resulted in a safer, more efficient service. Ongoing feedback continues to guide strategies for change as we strive towards improving the quality of post-discharge care for children and young people. Future work will focus on capturing patient experience and improving patientcentred outcomes.