Junior doctor-led QI – developing an online dynamic triage system

The FMLM Cambridge QI Conference 2015 took place late November 2015 and I was given the great opportunity to present a junior doctor-led project to develop a new referral system from A&E to medicine.

At our busy teaching hospital we had identified major issues with the system of bleeping the medical middle grade for every A&E referral, or direct GP referral on arrival. Often medical middle grades were caring for unstable patients, or having sensitive discussions. They were not always able to respond swiftly, or delegate jobs to other team members, resulting in mutual frustration and concern from medical and A&E teams.

We gathered feedback from nurses, doctors, health informatics personnel and managers, forming a multidisciplinary guiding team. We jointly developed and delivered a smartboard referral system that resulted in increased clinician satisfaction scores (from 3.8 to 7.3 on a 10 point scale), reductions in referral time (to under five minutes, previously 10-20 minutes) and waiting time for A&E doctors (by five minutes), with a reduction in four-hour breaches from late A&E referral, despite increased attendance. Clinical details are now entered on the computer by the referring clinician, reserving bleeps for the most unwell patients. The password-protected smartboard can be accessed by any member of the team, displaying patients in order of clinical priority, grouped into red, amber or green risk categories, calculated from latest Modified Early Warning Score (MEWS) and other causes for concern.

The whole project was a steep learning curve. Doing something because you are genuinely passionate about it and can clearly see the need for change is an enormous motivator, particularly as we had to be quite persistent at the beginning to get things off the ground. After a great team effort, we now have an online referral system that allows both the A&E and acute medicine doctors to spend more time seeing patients and less time trying to get hold of each other.

There are definitely things we would do differently next time. One standout point for me at the Cambridge QI conference was the emphasis on understanding why people do the things they do (human factors), understanding the unexpected impact change may have on other systems or people (balancing measures), and seeking and valuing the viewpoints of people you might not have considered within the system you want to change. One really helpful way to do this, highlighted at the conference, was through shadowing.

Having had my appetite whetted by our referral project, and refreshed by the fantastic work showcased by junior doctors and medical students at the conference, I am genuinely excited for our next team project: facilitating timely discharge summary writing. In the coming weeks we will be shadowing pharmacists, ward clerks and A&E coordinators to see the system from their point of view and understand the impact of our proposed improvements. The FMLM Cambridge QI Conference was a great opportunity to learn and network and has impacted the way I am embarking on my next QI project. I look forward to next year!