Summary
The Oxford thrombosis service houses an out-patient DVT diagnostic service which has been running since 2000. In 2012, the DVT team led an initiative for a ‘one-stop’ diagnostic DVT service, raising money to secure an intra-departmental ultrasound scanning machine.
With the direct involvement and support of the radiology department, the existing patient pathway for DVT diagnosis was adapted so that all patients undergoing assessment for DVT were offered same day compression ultrasound within the DVT department. The main outcomes that the team has been able to improve are patient satisfaction and diagnostic waiting times.
Challenge
The Oxford DVT clinic is at a significant distance from the main Churchill Hospital building and radiology department. This, combined with poor patient mobility and reliance on portering staff, often made it difficult for patients to get to ultrasound scanning (USS) appointments on time. Furthermore, patients were frequently returned to the DVT clinic by the portering team following a significant delay. This affected their clinical care and led to delays in patient discharge and an accrual of nursing overtime.
The team felt that these difficulties were unacceptable to the patient group and that the development of a ‘one-stop’ DVT clinic, with on-site USS, would improve the patient pathway and experience while reducing the portering team’s work load.
Objectives
The objectives of the initiative were three-fold: to obtain an in-house USS machine; to improve patient experience; and to reduce delays in diagnosis.
The remote location of the USS department meant that an uninterrupted patient pathway, from initial assessment by the nurse within the DVT clinic, rapid diagnosis with USS and then timely relaying of results to patients, was compromised. This sometimes meant that patients could not undergo a full clinical assessment by a thrombosis doctor until the following day, due to late return of the patient to the clinic area, necessitating their return to the clinic.
Solution
The DVT team met with radiology to implement the initiative and discuss the feasibility of having a ‘DVT’ ultrasound machine. Radiology supported the initiative, since it would lead to a more productive USS diagnostic clinic without recurrent delays. The ultrasonographers rearranged their USS lists to match the times of the DVT clinic and it was agreed that an ultrasonographer would be present in the DVT clinic between 1pm and 4pm daily. The DVT nurses arranged their working patterns to accommodate this time frame, ensuring smooth transition of patients from initial nursing assessment to immediate USS. The money for an USS machine came from two sources: the Blood Coagulation Research Fund, and a grateful patient who donated £10,000.
Results
Once the USS had been procured, the initiative aimed to improve the patient experience and to reduce delays in diagnosis, ensuring that all patients completed full DVT assessment within one clinic visit.
A survey was completed after implementation of the machine. This found the average time spent waiting to be seen in the DVT clinic was 12 minutes (± 9min), with most patients being seen within 20 minutes of arrival. This was considered acceptable by 88 per cent of patients surveyed.
Prior to the USS machine being purchased, a patient would routinely spend three to four hours in the hospital undergoing assessment, investigation and diagnostic procedures. Patients now spend, on average, 61 minutes (± 31mins) in the department.
Learnings
Once the concept of a one-stop DVT service had been conceived, the priority was to set up multi-disciplinary team meetings between ultrasonographers, the DVT clinic staff and the porters. These meetings enabled the DVT patient pathway to be revamped and allowed full involvement of the wider team in decision making. They also improved relationships between the departments, making it easier to change practice once the machine was purchased, with all sides being engaged.
The radiology department had to rearrange scan slots – without their cooperation, the initiative would have failed. The DVT team also experienced challenges, such as price increases and additional service contract fees. The team remained focused on their goal and kept the ultrasound machine on the agenda.
Evaluation
The impact of the initiative can be measured through length of patient stay at the out-patient clinic and patient satisfaction. Patients now have their assessment, blood tests, diagnostic USS scan and treatment (if required) within, on average, 61 minutes of arriving in the department.
The patient satisfaction survey demonstrated that most patients were extremely happy with their care and their waiting times and that total time spent in the DVT clinic was short. Patients commented that the DVT clinic provided: ‘an excellent service’ with ‘very friendly and professional staff’ in a ‘quiet, calm, comfortable’ environment.
