026A Plan for Every Patient: Achieving Excellence in Communication and Interdisciplinary Working on a Specialist Geriatric Ward

Le résumé fourni par la source

Beaumont Hospital catchment area has a 20% higher proportion of over 65’s and over 85’s than the national average. The clinical needs of older patients are complex as they frequently present with multiple co-morbidities accompanied by functional decline, cognitive deterioration and complex social care needs. Older patients should have access to Comprehensive Geriatric Assessment and appropriate treatment without unnecessary delay. In 2015 the Beaumont improved performance plan was developed to deliver the objectives of the National Clinical Programme for Older People (2012). To enhance communication processes and reduce potential delays via prompt referral to MDT for Comprehensive Geriatric Assessment and collaborative interdisciplinary decision making regarding patient needs, goals, and predicted dates of discharge. Quality improvement methodology was adopted. Multiple driver-diagrams and plan-do-study-act cycles were completed. Regular data was collected to measure the impact of the implemented changes. Monthly clinical sub-group meetings provided a structured forum, accountability for staff and a formal way to identify gaps in the service. A daily Plan for Every Patient board meeting has been established on Hardwicke ward, led by a Clinical Nurse Manager and lasting approximately 20 minutes. It is attended by the full MDT including Consultants and/or Senior Registrars, and a representative from the hospital’s delayed discharge team. It facilitates prompt identification of new patients, sources of delay and potential discharges that day, as well as immediate referral to the MDT. MDT referral response times have been minimised to within 24 hours during the core working week. Daily board meetings have been embedded into practice. An ethos of daily decision making, communication and planning for discharge from admission has been established on the ward. The emphasis is now on sustaining the improvements to date on Hardwicke ward, as well as sharing the learning with other MDTs.

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