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
