“Drain the Pain” An Innovative Liver Project

Sarah Lawty A/ Quality and Safety Manager LBH

Outline

• Northern NSW has the highest incidence of Hep C per capita

• Decompensated liver disease refers to when over 80% of liver function is lost

• Many patients who commence on the program have a life expectancy of 6 months

• Large volume paracentesis refers to drainage of 4L or more of ascetic fluid from the abdomen

AIM Statement

“By the end of June 2014, 100% of patients presenting to the Medical Assessment Unit (MAU) for large volume paracentesis secondary to decompensated liver disease will be admitted via bed management and discharged within twenty four hours.”

Project Timeline

2013

Phase 1 commenced June 2013 and concluded June 2014.

2014

Phase 2 commenced as part of the LFBPO commencing June 2014- current.

Ongoing

Projections for phase 3 to commence post analysis of phase 2 data.

The team • Sponsors

– Lynn Weir GM (Au) – Narelle Gleeson DON (Rep/Au) – Lyn Hopkinson (Rep/Au)

• Agents – Lea McAllister NUM – Heather Gould Pt Flow

Manager – Gastroeneterologists x 5 – MAU CNS2

• Targets – Nursing – Registrars – RMOs – Patients

GM SA

DMS/ DON

SA

Consultants

Sa, Sr, A, T1

Registrar

T2, A*

RMO T2, A*

DDON

Sa, Sr,

NUM Sr, T3, A

CNS2

T, A* CNS2

T, A*

RN T

RN T

RN T

Phase 1 Themes

Overnight Length of Stay

Patient Initiated Admission Process

End of Life Planning

Clinical Practice Guideline

“DRAIN THE PAIN”

An innovative liver disease project

Overnight LOS

Solutions

Admission Packs

• Paperwork packs developed

• Paperwork to be completed prior to discharge

Admission process via bed

management

• Bed Management is a key link in the process

• Agreed radiology time is 1300hrs on day of arrival

EBP drain insitu time

• Evidence suggests the risk/benefit drain insitu time is four hours

• Medical and nursing staff education provided

• Drain insitu time stipulated in the CPG

Challenges

• How to streamline the admission process?

• Radiology time is precious

• MAU beds aren't always available early in the day

• Drain insitu time can vary from a few hours to 48hrs

Patient Initiated Admission Process

Challenges

• Bed availability

• Gatekeeping

• A change for patients

• Education needs for staff and patients

Solutions

ED

avoidance

• Admission commences in DTU then patient goes to MAU post drain insertion

Target Weights

• Patients allocated target weights

• Documented in education packs, EMR and patient logbook

Education

• Education packs for patients

• In-service education for staff

Clinical Practice Guideline

Challenges

• Patients have complex care requirements

• Recommendations for screening requirements need to be met

• Drain insitu time of four hours

• Varied use of albumin

Solutions

Chronic disease

• Baseline assessment

• Recommended allied health assessments

Preventative screening

• Screening for hepatocellular carcinoma

• Screening for varices

Drainage process

• Four hour drain insitu time

• 100ml of 20% Albumin every 3L drained

End of Life Planning

Challenges

• Patients are all palliative, most are aged 40-50yrs some with varied degrees of support

• Patients may not understand

their prognosis • Families may not be

prepared • No end of life planning in

place

Solutions

Education

packs

• Disease and lifestyle information

• Advanced Care Directive

Communication

•ACD lodged with GP, copy in patient notes and flagged on EMR •Ongoing Support

Palliative care

•Early referral to palliative care

•Preferred place of care

Phase 1 Outcomes

Patient survey results indicate

service satisfaction

Gatekeeping process in place.

ED avoidance.

100% of patients have had in home facilitated deaths

202 Total bed days saved

CPG approved

Average LOS reduced from 3 days to 1.5 days

Patient Participation Patient Story Project streaming interactive pin board made available in public space to allow for patient/ general public interaction and feedback/questioning. Informal qualitative statements received from patients. Patient Survey of service

Consumer participation

Patient Surveys

qualitative feedback

Patient Mapping

Carer Input

Show me the Money $$

$67, 670

Savings in bed days

ED avoidance

Reduced LOS

Where to from here? • Phase 2

» Six hour LOS

» Change in catheter type

» Improved GP communication

» Embedded patient care plan mapping

» Projected savings

$71,661.30

• Phase 3 » Outpatient Clinic

» Hepatology Nurse Practitioner

Thank You

• To the team involved in the Clinical Leadership Program

• To the Gastroenterologists for letting me do what I wanted (!)

• To my Sponsors for their never ending support

• To all the staff who helped me along the way

• To my patients for their patience!