Background

Local audit data identified that inpatients wait up to 2 days for diagnostic echocardiography (echo) at Guy’s and St Thomas’ NHS Foundation Trust (GSTT). This did not meet the clinical needs of a busy acute care department, including A&E, same day emergency care, and an acute admissions ward. Without access to a same day echo service, GSTT saw delayed patient discharges and increased outpatient echo waiting lists due to patients being discharged before their scan.

The echo team engaged in a quality improvement project to pilot a same day echo service for patients in acute care, aiming to facilitate quicker patient discharge or treatment pathways. This guide shares their learning, allowing others to adopt a similar approach to address the high demand for inpatient echo in busy acute care departments.

Benefits observed

• the percentage of acute care inpatients receiving an echo within 24 hours doubled from 46% before the pilot, to 92% when the new service was running
• same day echo facilitated a same day discharge for 40% of acute care inpatients, and an onward referral to cardiology inpatient services for 17% of patients
• improved relationships between acute care medical staff and the echo department were observed in terms of communication, appropriateness of the echo request, echo result interpretation and onward referral to cardiology services if indicated
• training opportunities have arisen for acute care medical staff to gain British Society of Echocardiography (BSE) L1 accreditation, facilitated by having a regular member of the echo team present on acute care wards to provide echo training

The steps to improve access to echo

1. Stakeholder mapping

• identify stakeholders who will be affected by your quality improvement project. This will likely include patients, acute care medical staff, echo clinical scientists, cardiac physiologists, directorate management teams, IT services and medical physics ultrasound equipment engineers
• involve an acute care senior medic who can act as a point of contact within the acute care department and help champion the implementation of the new service into the acute care workflows

2. Review the current service

• use data to understand how your service currently runs and establish a baseline to measure improvement. Some measures you may wish to include:
  • number of inpatient echo referrals made from acute care
  • time from echo referral to scan
  • number of patients discharged with an outpatient echo referral
• engage stakeholders to discover their views on the current inpatient echo service and where they think improvements can be made
• Utilise NHS England resources such as First steps towards quality improvement: a simple guide to improving services. NHS Improving quality

3. Establish logistics and infrastructure

• echo machine – is there a portable echo machine that could be used in acute care? Do you need to submit a business case to purchase an additional machine?
• connectivity – do you need to be able to download echo studies in the acute care department? do you have the correct equipment to facilitate this (ie ethernet cables, active download ports, sufficient Wi-Fi)?
• reporting – do you have the necessary facilities to report echo studies in acute care in a timely manner?

4. Develop a standard operating procedure

• a standard operating procedure should outline the day-to-day running of the same day echo service to standardise practice across all staff groups involved
• the standard operating procedure should include the appropriate echo indications for referral to the service, the expectations expected of staff working within the service, as well as the appropriate escalation pathways for abnormal echo findings

5. Create a role for an acute care clinical scientist

• within working hours, rota a clinical scientist within the echo team to cover the same day echo service. Ensure the staff member is inducted into the acute care department and is familiar with the standard operating procedure
• the clinical scientist filling this role should:
  • have clinical skills training
  • be able to interpret blood test results, chest x-rays, and other diagnostic imaging to help triage referrals
  • communicate effectively with the acute care medical teams

6. Raise the profile of the new service

• inform stakeholders of the new service and the role of the acute care clinical scientist
• ensure the acute care department is aware of the appropriate referral pathways into the service, when echo is appropriate, how to get echo results, and how to contact the acute care clinical scientist (eg bleep, phone extension)

7. Continue to monitor service performance

• formulate a data management plan to measure whether your changes are leading to improvements. Use daily or weekly statistical process control charts to visually demonstrate and monitor service performance. Data should be reviewed regularly and used to direct your changes
• meet with stakeholders to gauge their opinions on the service and harvest ideas for further improvement

Figure 1: the average number of days from referral to echo, comparing before and after the introduction of the acute care service

Figure 1 above shows that the percentage of patients receiving an echo within 24 hours has increased from 46% before the start of the service, to 92% when the service is running.

Overcoming challenges at Guy’s and St Thomas’ NHS Foundation Trust

Figure 2: driver diagram: access to diagnostic inpatient echocardiography in acute care

Links and resources

• How to implement a quality improvement project: First steps towards quality improvement: A simple guide to improving services.   
• To speak to someone at Guys & St Thomas’ NHS Foundation Trust about this project, please contact jenna.smith@gstt.nhs.uk or camelia.demetrescu@gstt.nhs.uk.
• Further resources on diagnostics can be found on the National Diagnostics Transformation FutureNHS page. An NHS email address will be required to access the page.

Publication reference: PRN01007