Improving quality in a national intestinal failure unit: greater efficiency, improved access and reduced mortality

Donaldson, E.; Taylor, Michael; Abraham, Arun; Carlson, Gordon L; Fletcher, Olivia; Varden, Jacqui; Teubner, Antje; Lal, Simon

doi:10.1136/flgastro-2014-100482

Cited by 5 publications

(4 citation statements)

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“…SPC has been applied in other healthcare settings to improve quality outcomes, such as decreased complication rates and improved infection control. 17,23 The therapeutic options for microbiota restoration evolve rapidly, with commercial stakeholders and public stool banks forming to meet the demand for microbiota-based therapies. The use of SPC may guide local clinical decision-making and facilitates comparability between institutions, as it may help standardise the clinic outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…SPC is a valuable tool to monitor the FMT effect, and the varying FMT effect suggests that the use of FMT requires close quality monitoring. SPC has been applied in other healthcare settings to improve quality outcomes, such as decreased complication rates and improved infection control 17,23 . The therapeutic options for microbiota restoration evolve rapidly, with commercial stakeholders and public stool banks forming to meet the demand for microbiota‐based therapies.…”

Section: Discussionmentioning

confidence: 99%

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Donor, patient age and exposure to antibiotics are associated with the outcome of faecal microbiota transplantation for recurrent Clostridioides difficile infection: A prospective cohort study

Baunwall

Hansen

Andreasen

et al. 2023

Aliment Pharmacol Ther

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SummaryBackgroundFaecal microbiota transplantation (FMT) is effective for recurrent Clostridioides difficile infection (rCDI), but its effect varies inexplicably.AimsTo optimise the effectiveness of FMT for rCDI and validate determinants for effectMethodsWe conducted a cohort study, including all patients treated with FMT for rCDI between October 2018 and June 2020. Statistical process control was used to evaluate the impact of prospective quality improvement on the effect of single FMT treatments per 10–11 patients. Targeting an 80% effect, optimisations included changes to processing procedures, preparation and clinical application of FMT. The primary outcome was the resolution of Clostridioides difficile‐associated diarrhoea at week 8. If CDI recurred, FMT was repeated. All patients were followed for 8 weeks after their latest FMT.Results183 patients with rCDI received 290 FMT treatments. A single FMT achieved resolution at week 8 in 127 (69%, 95% CI: 62%–76%), while repeated FMT cumulatively achieved resolution in 167/183 (91%, 95% CI: 86%–95%). The single FMT effect varied between 36% and 100% over time. In a mixed‐effect model, patient age above 65 years, non‐rCDI antibiotics at week 1 post‐FMT, and donor were associated with effect. Neither increasing the dosages of faecal microbes nor standardising the processing improved outcomes.ConclusionFMT has a high cumulative effectiveness in patients with rCDI following multiple administrations, but the single FMT effect is variable and may be optimised using statistical process control. Optimising FMT by considering patient age, post‐FMT antibiotics, donor and multiple administrations may improve the treatment outcomes.ClinicalTrials.gov (Study identifier: NCT03712722).

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Donor, patient age and exposure to antibiotics are associated with the outcome of faecal microbiota transplantation for recurrent Clostridioides difficile infection: A prospective cohort study

Baunwall

Hansen

Andreasen

et al. 2023

Aliment Pharmacol Ther

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“…Due to the complex nature of the patients’ clinical needs, patients’ mean length of stay was relatively long at 44 days,12 such that the anticipated discharge date could move multiple times prior to final discharge, placing excessive burden on the local PN pharmacy compounding unit having to make daily bags rather than preordering PN for a number of days. As patients’ conditions stabilised and discharge was planned, PN prescriptions were proactively changed to standard bags, liberating compounding slots for other patients and providing greater flexibility in discharge planning without compromising patient safety or wastage.…”

Section: Discussionmentioning

confidence: 99%

Application of quality improvement techniques to reduce parenteral nutrition wastage in a national intestinal failure unit

et al. 2017

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ObjectivesParenteral nutrition (PN) costs approximately £80 per day per bag. Unpredictable changes in patients’ clinical condition, venous access loss or reasons related to the processes involved in administering PN can lead to PN wastage. Cost efficiencies are imperative to optimise limited resource utilisation in all current healthcare economies. We undertook a quality improvement (QI) project to reduce PN wastage in an adult acute hospital setting. The project SMART’s (specific, measurable, achievable, realistic, time-based) objective was reducing in-patient PN wastage by 10% in 9 months using QI methodology on a national intestinal failure unit (IFU).MethodWastage reasons were evaluated through pareto charts to target waste reduction using ‘Plan, Do, Study, Act’ (PDSA) cycles. Variation was mapped using c-charts.Results12-week baseline wastage data predicted 1000 bags wasted per annum (p.a.). PDSA cycles actioned included: regular enhanced clinical team awareness of wastage; unused PN bags redistributed within expiry date; stock bag rotation; critical path analysis of PN bag journey; enhanced discharge planning/coordination; reorganisation of fridge PN storage according to weekday; changing ordering frequency and bag type (from tailored to standard) to increase flexibility around discharge date and PN weaning. Implementation of PDSA cycles led to a 34% reduction in PN wastage in 9 months.ConclusionIn a high-use IFU, PN wastage is common and costly. Using a QI approach with concurrent PDSA cycles and a motivated multidisciplinary team, high levels of wastage reduction are possible with associated significant cost savings and from this study a predicted cost saving of approximately £30 000 p.a.

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“…Quality Improvement (QI) methodology was used to modify and adapt the remote discharge pathway. Team members were able to identify areas in which to conduct plan–do–study–act cycles to test ideas for change . The study formed part of service evaluation required as part of developing a new patient pathway/process and therefore formal ethical approval was not required because it was registered with the relevant trust bodies.…”

Section: Methodsmentioning

confidence: 99%

A novel discharge pathway for patients with advanced cancer requiring home parenteral nutrition

Bond

Teubner

Taylor

et al. 2019

J Human Nutrition Diet

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Background The use of home parenteral nutrition (HPN) for palliative indications is increasing internationally and is the leading indication in some countries. Discharge on HPN can be complex in metabolically unstable patients and requires intestinal failure expertise. Methods Between 2012 and 2018, we performed a retrospective analysis aiming to assess the impact of a novel remote discharge pathway for palliative HPN patients. This was evaluated using a quality improvement approach. Results One hundred and twenty‐five patients with active malignancy [mean (range) age 58 (25–80) years] were referred to the intestinal failure unit (IFU) for remote discharge. Of 82 patients were discharged from the oncology Centre on HPN using the pathway. The remaining 43 patients either declined HPN or the Oncology team felt that the patient became too unwell for HPN or died prior to discharge. There was an increase in patients referred for remote discharge from 13 in 2012 to 43 in 2017. The mean number of days between receipt of referral by the IFU to discharge on HPN from the oncology centre reduced from 29.4 days to 10.1 days. Following remote discharge, the mean number of days on HPN was 215.9 days. Catheter‐related blood stream infection rates in this cohort were very low at 0.169 per 1000 catheter days. Conclusions This is the first study to demonstrate the remote safe, effective and rapid discharge of patients requiring palliative HPN between two hospital sites. This allows patients with a short prognosis more time in their desired location.

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Improving quality in a national intestinal failure unit: greater efficiency, improved access and reduced mortality

Cited by 5 publications

References 1 publication

Donor, patient age and exposure to antibiotics are associated with the outcome of faecal microbiota transplantation for recurrent Clostridioides difficile infection: A prospective cohort study

Donor, patient age and exposure to antibiotics are associated with the outcome of faecal microbiota transplantation for recurrent Clostridioides difficile infection: A prospective cohort study

Application of quality improvement techniques to reduce parenteral nutrition wastage in a national intestinal failure unit

A novel discharge pathway for patients with advanced cancer requiring home parenteral nutrition

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