Pediatric Nursing and Healthcare

Biography

Biography: Alok Kumar

Abstract

BACKGROUND: Unplanned nature of patient attendance in A&E leads to unnecessary waiting time for children. This process has a clinical and operational part to it. While doing my course, I realized lean strategies could be utilized to reduce waiting time in A&E. AIMS: This project is to identify and reduce the number of non-value added steps along the patients' journey (Children of 0-14 years of age) attending emergency department at Mayo General Hospital. This is aimed to reduce the waiting time, reduce the overall time, and thus, improve the patient experience and render better patient care attending emergency department at Mayo General Hospital. METHODS: I have formed a team, which was duly approved by hospital management. The team has hardworking, experienced, dedicated and committed hospital staff. The team consisted of: - Paediatric Consultant, Registrar, senior house officer (NCHDS) - PROJECT MANAGER: Myself - Clinical Nurse Manager III- Paediatrics, A&E. - Assistant Staff Officer. - Staff nurses-Paediatric, A&E. - Other members will be co-opted as necessary - And last but the most important- the patient; children The team has been established and is already undertaking a number of activities and weekly meetings. The main steps included: - Establish clearly existing waiting times for paediatric patient. - Establish clearly the existing patient journey - Identify stakeholders to involve in the process mapping session. - Identify issues/ solutions/bottlenecks/ decision points. - Identify where value added and non-value added activity exists. - Explore options to improve the position. This should ideally include: 1. Implementation of improvement plans 2. Re-evaluation of the effectiveness of improvement plans. - And last but the most important- the patient, children. To further my lean project I formulated a document to record time taken for children in accident and emergency in the various stages of their waiting period-current visual map. This format mapped the time taken for paediatric patients at various stages that a patient generally has to undergo i.e. in medical terms, history & examination, differential diagnosis, investigation, interpret results, definitive diagnosis, determine care plan, implement and follow up review. RESULTS: Future VSM was formulated taking care of the variations /delays seen. Discussions were made with paediatric consultants, senior staff nurses, senior house officers, registrars and their observations and opinions were taken into account. We have a system already in place. To introduce improvement into it, the following current recommendations were suggested, based on current value stream map analysis. VARIABLES SUGGESTIONS: 1. >3 children waiting to be seen in A&E in Monday mornings, Friday afternoon, Bronchiolites, Gastroenterites season. The Paediatric registrar is called to assist. Team on call to use the 5S principals to organize the work and instilling the discipline. Visual display: On call team takes a look at the board- (e.g. 5 children waiting): and gets into action. 2. Interdepartmental transfer e.g. transfers between surgeons and orthopaedics Better communication and better team play will lessen waiting period. 3. Children may be kept waiting for bed once admitted- thus increasing the total waiting time. Liasion of A&E with Paediatric Ward for quicker transfer to ward. 4. One ED cubicle-causes delay if more than three children need to be seen. There should be provision for second cubicle which if not in use can be used by the Emergency department. 5. Lab, X-ray department should be contacted at appropriate time to avoid unnecessary delay, thus leading to better time management. The main idea is to holistically assess, diagnose, treat, discharge/ refer, and evaluate child care in a safe and co-ordinate way in line with the best practice, incorporating health promotion, education, and risk reduction, in the run. Thus, application of these measures: (a) Registrar led On-call Team (b) Visual display of number of waiting children, (c) Discussion and application of Lean Tools with the NCHD Team (d) Better communication with surgical and orthopaedic teams (e) Constant Consultant supervision (f) Making the new team aware of the issue of reducing waiting time in A&E during the induction meeting itself, LIMITS: Old staff resisting change, some NCHDs non -compliant. CONCLUSIONS: Reducing waiting for children in ED. Lean thinking is about team involvement. Lean thinking is about team involvement. It focuses on the process, not on individuals. This is because teams are superior to individuals at identifying and implementing improvement opportunities. I have had meetings with the medical, the surgical and the obstetric team and have persuaded them to have projects on similar lines, to discuss and be familiarized with Lean Tools (5S, Value Stream Map, Kanbans, Kaizen events, Visual Display), and formulate a Current Value Stream map. Formulating Current Value Stream Map for each individual Team will help them to 'go and see' and give them their 'waste goggles'. This will help the above team doctors to redesign care accordingly and reduce waiting time in accident & emergency for the adult patients as well, thus delivering best possible care. Our aim is to deliver the best for patients, for staff, for our community and for the taxpayer.