Purpose
– The purpose of this paper is to demonstrate that nurse led discharge (NLD) could improve the efficiency of simple discharges from a short stay surgical ward without compromising patient safety.
Design/methodology/approach
– A protocol for NLD was designed and implemented. Introduction of the protocol was audited and re-audited prospectively.
Findings
– Introduction of the nurse led discharge protocol significantly reduced the rate of delayed discharge (p>0.001). The protocol successfully identified all patients for whom a NLD would be inappropriate and no patients discharged by the nursing team were re-admitted.
Research limitations/implications
– No formal measure of staff and patient satisfaction with the new protocol was performed.
Practical implications
– The nursing team are now able to more effectively manage patient flow through the short stay surgical ward. Mismatch between demand for beds and capacity has reduced.
Social implications
– Patient experience has been improved by the release of time to care for our nurses and the elimination of unnecessary delay in discharge.
Originality/value
– Formal protocol driven NLD can be a safe way of improving efficiency in patient flow. This pattern of discharge could be applied in many hospital systems.
The conservative, surveillance-driven approach recommended by the American Thyroid Association is appropriate for stage I-III disease. However, the more aggressive approach advocated by the British Thyroid Association might provide stage IVa disease patients a greater chance of achieving a biochemical cure.
Aim
Fine Needle Aspiration Cytology (FNAC) remains the primary determinant of management options for a patient with a U3-5 thyroid nodule. There is significant variation in risk of malignancy (ROM) between different centres, possibly reflecting the degree of specialist reporting and interpretation of RCPath guidance. The aims of this study is to report on ROM of FNAC categories in a specialist cytopathology centre.
Methods
Consecutive thyroid FNAC results were analysed over 2 years (2017/18), all reported by dedicated cytopathologists and suspicious samples were peer reviewed. Cases suspicious for NIFTP/FVPTC were classified as Thy4. U-grade was recorded if classified during ultrasonography. Results were analysed with regard to histology available on thyroid surgery and/or clinical follow up.
Results
There were 695 samples from 567 patients. The ROM in each category was: Thy1(6%); Thy2(1%), Thy3a(13%); Thy3f(11%); Thy4(27%); Thy 5(100%). In addition, 34/86 Thy3a nodules were subject to repeat FNAC, with 19 reported as Thy2, 7 as Thy3a again, 1 as Thy3f and 2 as Thy4 on second FNAC. We found that stratification of Thy3a-3f-4 by U grade did not help with risk stratification.
Conclusions
Compared to the recent meta-analysis (Poller et al), we found a greatly reduced ROM in the Thy4 group (27% vs 79%), with smaller reductions in both Thy 3 groups in our specialised cytopathology centre. The reasons for this will be discussed. The descriptor of Thy 4 as “suspicious for malignancy” is inaccurate in our experience. Each centre should use their own figures when advising patients. Repeat FNAC for Thy3a lesions leads to >20% potentially avoiding surgery.
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