Bren Dorman, FRACS Clinical Director

Otolaryngology Head & Neck Surgery Auckland District Health Board

Auckland

Otolaryngology Head & Neck Surgery

Auckland City Hospital Green Lane Clinical Centre

Challenges:

Increasing FSA referral volumes: population increases

Variable quality of referrals

Primary care interactions: referrals, guidelines, follow-up

What ORL conditions can GPs manage?

System complexities causing inefficiencies

Need for specialised equipment in managing complex patients

Shorter hospital stays: day stay and outpatient procedures

Pressure on specialised and scarce clinical resource.

A. Appropriate and efficient referrals

B. Focused and time-efficient

surgery

C. Effective and efficient

follow-up care

Referral Triage FSA Follow-up Surgery Pre-admit

& book Ward Discharge Diagnostic GP visit

Self mgmt

Referral guidelines

ToC/ Follow-up instructions

Self mgmt information

Checklists Triage

guidelines Follow-up protocol

Treatment guidelines

Clinical leadership – by specialty

GP care instructions

Patient experience

Self mgmt information

Monitoring protocol

Patient information

Referral Improvement project In-clinic local anaesthesia Pathways

Follow-up improvements Sinusitis Pathway

Surgery prioritisation Vertigo Pathway

Patient pathway

Evid

ence

•Incomplete referrals

•Referral formats inconsistent

•Delays to referral triage, missing referrals

•Dizzy audit: 22/84 audited appointments were for patients with BPPV

Act

ion

Im

pac

t

•Implemented standard referral templates for ORL across region

•Defined criteria and minimum requirements for referral acceptance

•Published and communicated to primary care

•Quality and completeness of referrals

•Vertigo referral pathway and eReferral template design

•CT Head for Sinusitis – Virtual FSA

Referral improvement project

eReferral site - Otology

Criteria

Vertigo pathway & video

• Access to Diagnostics – primary care direct referral for CT scan for Sinusitis

• Includes minimum criteria

• Virtual FSA for all patients, about 15 per month done

• Referral triage to now include (positive) scan, resulting in decreased virtuals

CT Sinusitis – virtual FSA

Evid

ence

A

ctio

n

Imp

act

Local Anaesthesia procedures

•Best practice evidence

•In-house experience

•Reviewed inpatient procedures:

•Current time taken for GA procedures

•Developed protocols for scoping and laser procedures

•Set up procedure rooms in-clinic

•Trained staff

•650 procedures done since end of 2010

• Currently 30 - 35 per month

•Time saved

•Cost impact

Evid

ence

A

ctio

n

Follow-up improvement project Im

pac

t

•Audit: 40 - 60% of follow-ups in ENT not deemed necessary in its current format

•Audit: GP follow-up is an alternative for about 20-40% of follow-ups

•Ratio of follow-up to FSA varies between clinicians

•Follow-up routines after surgery (e.g. FESS) vary between clinicians

•Defined follow-up protocols for common conditions

•Established nurse phone clinic for Head & Neck monitoring

•Repatriated non ADHB patients for follow-up in own DHB

•Redesigned clinic outcome form

•Established scheduling policy to reduce priority for follow-up

•Nurse clinic

•Outcome form

•Protocols

• Long term, stable patients

• Enrolment process

• Escalation policy

• Evidence based phone questionnaire

Results:

• Saving clinician and patient time

Head + Neck nurse phone clinic

New ORL clinic outcome form

More prominent placement of ‘Discharge’ options, including patient directed, home DHB repatriation and transfer to GP

Include purpose for follow up (reason) and alternative methods for follow up delivery (phone or virtual)

Nurse follow ups

• SCRUM – how we manage our capacity to meet production and waiting time targets with minimal waste

• MOS – how we manage the service

Other ORL improvements

• Importance of engaged clinical leaders

• Challenge of allocating time to change initiatives

• Role of data collection and management

• Making sure patient is kept central

• Overcoming funding challenges

Conclusions