Centre Projects

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Discharge Summary Timeliness

The discharge summary timeliness project is a high priority corporate project designed to optimize patient transitions and decrease readmission rates. Sponsored by the London Health Sciences Centre (LHSC) Medical Advisory Board, the project is driven by the CPSO mandate to make inpatient discharge summaries available within 48 hours of discharge. After multiple improvement cycles using audit and feedback score cards and education, LHSC had only 50% of summaries distributed within 48 hours in September 2020, with an average distribution time of 89 hours.

The Centre for Quality, Innovation, and Safety (CQUINS), Schulich Medicine, Western University is engaged with multiple stakeholders and implemented a series of Plan-Do-Study-Act cycles to test interventions:

    1. 1. Resident authentication of the discharge summary
    1. 2. Dictation code to auto distribute the summary, prior to physician review
    1. 3. 24 h email notification of deficient summaries
    1. 4. Monthly data to Department Chairs

As of April 2021 we are tracking to reach the target of 65% by June 30th 2021 with a reduction of mean time to distribution of 51 hours. The use of a multi- intervention approach, with multi-sectorial collaboration resulted in significant improvement in a short time period. Ongoing improvement strategies will be implemented to further improve this outcome to meet the CPSO standards.

This overall improvement wouldn’t have been possible without work going on locally within the Departments and Divisions. One example has been in Hematology where they started a project to understand the root causes of their poor performance with completing discharge summaries. Discharge summary sign off was 36% during the baseline collection period from September to December 2020. Root cause analysis highlighted some key areas for improvement and after 2 PDSA improvement cycles discharge summary signoff has increased to 52% by the end of April 2021. This work is ongoing and there continues to be new PDSA cycles completed during the implementation of their planned improvements.

London Health Sciences Centre (LHSC) Urgent COVID Care Clinic (LUC3)

In April 2020, facing emerging issues relating to the care needs for people with a diagnosis of COVID-19, Drs. Erin Spicer, Megan Devlin, Marko Mrkobrada and Michael Nicholson developed a new model of care for an accessible virtual clinic, intended to support those in the community who had a COVID-19 diagnosis. The clinic also aimed to support those discharged home, following a COVID-19 related inpatient admission. Within these groups of people, many were at risk of deterioration and needing rapid medical attention. Patients were referred from the Middlesex London Health Unit, local family physicians, discharging LHSC hospital physicians or emergency department physicians. Drs. Inderdeep Dhaliwal and Jaclyn Ernst initially joined the team for expanded support and since have been joined by other physicians, nurses and other key support staff.

The LHSC Urgent COVID-19 Care Clinic (LUC3) was founded with support from The Centre for Quality, Innovation and Safety and a provincial grant. It has become a central component of the local COVID-19 care pathway, providing a powerful example of rapidly initiated and effective quality improvement implementation, conceived and delivered in the face of an escalating and unknown threat with the potential to cause widespread collapse of the healthcare system.

The program provides daily weekday virtual clinics, with follow up over the weekend. Within two days of a referral being received, patients have their first virtual appointment. Each patient is assessed to see if they require a pulse-oximeter to monitor their blood oxygen levels at home, using an easy-to-use algorithm. For patients requiring a pulse-oximeter, this is delivered directly to the patient’s home, at no cost to the patient. Given the rapidly progressive nature of this disease in some patients, the clinic-based component is augmented with access to a dedicated on-call physician if needed. This is further supported by a novel direct admission pathway to a COVID-19 in-patient bed, allowing patients to by-pass the emergency department.

The clinic provides a comprehensive package of care for both escalation and de-escalation of therapy. This integrated pathway increases patient safety, reduces patient anxiety, and mitigates the risk of exposure for other patients and care providers within the hospital setting. This accrues additional benefits such as minimizing the number of in-person encounters, even if requiring direct admission, and significantly reducing personal protective equipment consumption.

The initial plan was for patients to receive a single, virtual appointment. However, the model evolved as there was greater understanding about the wide-ranging needs of this group of patients. This included on-going medical follow-up by LUC3 and supplementation with additional interdisciplinary support pathways. This has grown to include pathways with clinical and neuropsychology, otolaryngology, cardiology, neurology, and physiotherapy.

As LUC3 activity levels surged during the early months of 2021, a three-pronged approach, in partnership with the Centre for Quality, Innovation and Safety (CQuInS) emerged. The goals were to formally investigate the clinical and fiscal benefits of LUC3 and the overall care package which was so much more than a simple telemedicine consultation service. The imperative to learn more about the patient experience at different timepoints of their journey was also recognized early. Data has been collected and analyzed at regular intervals and constant ‘course corrections’ or improvement cycles completed. Ongoing iterative patient-centred changes have provided a direct organic response to real time data collection and analysis.

In its first 12 months, the clinic has seen over 1600 patients with active disease, a large proportion of the local positive cases, with 65% of those being seen in the first 4 months of 2021. Early findings suggest that the clinic is supporting a diverse and often isolated population with limited access to other forms of healthcare. Further outreach by our physician members was initiated to support vulnerable populations including individuals who identified as Indigenous and unhoused individuals residing at special isolation spaces. The virtual care provided has been particularly well received by patients and their care givers. Patient feedback has been extremely positive, with patients feeling well supported, less anxious and grateful not to feel alone in the course of their illness. A large proportion of patients seen, had disease severe enough to warrant home pulse-oximeter monitoring.

The service provided even more support during the second and third wave of the pandemic. The clinic provided key support to other parts of the healthcare system, facilitating earlier discharge from hospital, for patients who were still on oxygen or needed closer monitoring when back at home. Patients requiring closer monitoring are called by a nurse or physician at least once a day to assess their needs and manage their care as appropriate, until transition to normal follow-up. The clinic also plays a key role in preventing admissions, being able to manage patients’ care virtually and avoiding many from presenting to the emergency department or allowing attendees to be discharged from the emergency department to be followed up by LUC3.

As well as improving the safety, quality of care, and experience for these patients, within the first months of the clinic’s existence, it had also demonstrated significant cost savings.

LUC3 now provides equitable and accessible care to those who need it across the whole of the London Middlesex region and has also supported patients from the GTA who were transferred to LHSC during wave 3, in their transition back home. This patient-centred clinic started as an acute care model but has evolved to develop an additional chronic care element as the needs of this group of patients and COVID-19 are better understood. Through internal monitoring systems, it has had the ability to be responsive and implement change rapidly.