ÃÛÌÒAPP

ÃÛÌÒAPP’s Liver Transplant Co-ordinators at the Freeman Hospital have vastly reduced the length of assessment process for their patients from three days to just one following an in depth quality improvement review.

The new approach has led to a much improved patient experience, more effective MDT meetings and greatly reduced the length of time the patient needs to be in hospital.

In fact, they have seen a phenomenal reduction in bed days from 200 during 2019-2020 to just 7 in 2020-21.

The driver for change

A liver transplant assessment reviews people with chronic liver disease who are on the pathway towards a potential liver transplant.

The assessment involves a range of investigations which aim to identify whether or not a transplant is the most suitable course of treatment for the patient at that time, as getting the timing right is critical.

If left too late the patient could become too unwell to undergo a transplant. If too early, they would not gain any real benefit from such a major, lifechanging procedure.

Historically the assessment process for liver transplant patients at the Freeman Hospital took three days. This involved numerous tests spanning from Wednesday until Friday afternoon during which time the patient would stay in hospital. The tests include:

• a cardio pulmonary exercise test (CPEX)
• a CT scan of the liver
• echo
• ECG
• reviews with an anaesthetist, hepatologist, dietitians and social worker

The team sought to explore improvement techniques to reduce the assessment period with all investigations taking place over one day, negating the need for an overnight stay.

They began the process by visiting other liver transplant centres in the UK based in Leeds and Birmingham to study their assessment processes and see what they could learn from their colleagues.

Teamwork makes the Dream Work!

The next step focused on the importance of introducing improvement through teamwork – working closely with both colleagues and patients.

“We believed that we could vastly improve the entire assessment process from start to finish and began speaking to consultants in Hepatology and Anaesthesia to see how we could work together in a more streamlined way,” explains Peter Robinson Smith, Liver Transplant Co-ordinator.

“As we looked closely at the assessment period we realised that our workflows could be so much smarter as there were no set times for the tests. By working with colleagues in various departments we were able to fundamentally change the approach so that each patients received allocated time slots for each of their tests. As a result, the process has become so much quicker and slicker.”

Peter adds “Most importantly, we knew we needed to speak to our patients and be prepared for all feedback, even if it was difficult to hear. It is only by listening, refining and working together that improvements can be made.”

The team carried out a patient survey and the feedback was very much in favour of reducing the assessment period time, it included:

“I live far away so for convenience it would be better to complete in a day”

“Would prefer not to stay overnight”

“Waste of a bed if all tests can be carried out in one day”

“Would like more coordinated care”

Improvements made

The assessment process for liver transplant patients now one day. Patients arrive at the Day Treatment Centre at 8.15am then go home by 5:00pm with no overnight stays unless they meet specific exclusion criteria such as the need for additional investigations.

All test slots are now at fixed times which has made it quicker for patients and much easier for staff to manage the assessment process.

The referral pathway has also improved. Traditionally, referrals lasted for 10 weeks which was problematic if new issues arose that were not identified.

Now a referral goes directly to a Hepatologist within 4 weeks. The Transplant Co-ordinator then meets the patient to decide whether or not an assessment is required, and then confirms their appointment date.

Additionally, the team has moved to weekly rather than fortnightly transplant MDTs to discuss assessments. This leads to quicker responses and outcomes for patients.

Continual improvement

The liver transplant team is keen to continually improve the assessment process and have gone on to make a number of additional improvements, these have included:

• Reviewing ways to reduce time pressures when a patient first arrives
• Introducing a weekly pre-assessment clinic for patients to help educate them and their family about liver transplants.

The team is keen to keep up the momentum of improvement and will be looking to survey patients again in the near future as well as reviewing the rehabilitation process for patients.

Peter added: “Whilst the improvements we have made so far have had a huge impact, we knew that they would not be perfect straight away so we are always reviewing and refining how we do things.

“I particularly like using the PDSA (Plan – Do – Study – Act) cycle to think about how we can do things better – to keep going back to review what we are doing and how we could make a number of improvements.

“We are always learning, evolving and improving – this doesn’t stop here.”