LAUSR

Background The Complex Need Clinic (CNC) in Tallaght University Hospital Dublin, provides a multidisciplinary service to 50 children with exceptional healthcare needs. It is held twice monthly. These children are often non-ambulant, and require enteral feeding. Attending the hospital is often logistically challenging; parents having to organise time off work, transport to and from the hospital, find parking and care for other children, which can lead to stress and anxiety for care givers. In addition, European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) 2017 states children receiving enteral nutrition should be reviewed regularly by dietitian and have nutritional bloods annually, and non-ambulant children are recommended to have annual hip surveillance as per the Cerebral Palsy Integrated Pathway Scotland (CPIPS) 2013 guidelines. Aim Increase the number of children attending the CNC receiving co-ordinated care of non-urgent investigations and synchronised appointments from 48% to 100% and improving time efficiency for the patient whilst they attend clinic, by January 2019 Methods Retrospective review of children attending the Complex Needs Clinic revealed only 48% of children who required hip x-ray monitoring, annual nutritional bloods or dietetic review did not have these completed on the same day. A process map and root cause analysis were completed, involving all stake holders including the parents of children attending the clinic. Opportunities for improvement were identified. Time in motion studies were preformed post intervention. Results The root analysis and process map identified two areas for improvement; a pre-clinic chart review to highlight patients requiring investigations and pre-ordering of bloods and radiological investigations would stream line the patient journey. Initial time in motion study revealed patients would spend up to greater than 60% of their time in clinic waiting to be seen. Post implementation of pre-clinic review, co-ordination of same day appointments rose to 100%, and waiting times were reduced to less than 25% of total time spent in clinic. Conclusion The implementation of a preclinic chart review clearly identified patients requiring investigations allowing for improvement in adherence to guidelines and improved handover of clinical information. By mapping the process and discussion with families have identified further opportunities for change, better access to disability parking spaces and obtaining a hoist for weighing and changing non ambulant children. A clinical proforma has been developed to assist parents and clinicians increase the efficiency of medical reviews. Ideally, the presence or access to pharmacy support would further enhance the patient journey.