With DVT-related admissions costing Luton PCT around £1m a year, action was needed. Alison Meynell and colleagues report
Hospital-based diagnosis of deep vein thrombosis linked to the need for many inpatient admissions, costs Luton primary care trust approximately£1m a year. But the PCT has now implemented phase one of the first nurse-led community DVT service.
In addition to costs, the change was prompted by the Our Health, Our Care, Our Say white paper and the former Bedfordshire and Hertfordshire strategic health authority's response.
It was anticipated that siting the service away from the acute hospital, in a walk-in clinic in the town centre, would improve access and reduce hospital visits.
It was also expected that the patient pathway could be accelerated, as patients would avoid the accident and emergency wait needed even if they were referred by their GP.
Patient choice would be improved, as patients could still elect to travel to hospital for assessment. Finally, improved integration of the anticoagulation and radiology services at Luton and Dunstable Hospital trust, with the community anticoagulation service and walk-in centre run by the PCT, was also seen as an incidental of the project.
The new service was set up to allow GPs to refer patients with a suspected DVT to the community service, following agreed criteria. Eligible patients are referred to the walk-in centre instead of A&E. Here clinical scoring and when appropriate a D-dimer blood test and routine blood chemistry are done by walk-in centre staff. Patients with either a high clinical score or a positive D-dimer test are referred by nurses to the hospital radiology department for an ultrasound scan to confirm DVT. This avoids possible inpatient admission and the 60 per cent of patients whose initial screening is negative are referred back to their GP.
From the generation of the initial concept, a business plan was written and presented to the SHA for funding under an Invest to Save initiative. The budget was based on set-up costs for capital equipment only, with staff training and consumables provided as part of equipment contracts and from a budget surplus following competitive tendering of the equipment contract.
The projected saving to the PCT from the reduced number of hospital admissions was to be reflected in the service level agreement with the hospital.
Once funding was granted by the SHA, clinical and IT groups were formed. The main brief of the clinical group. with representatives from the hospital, the PCT and the walk-in centre. was to identify clinically sound processes and develop the protocol for the proposed service. This included:
- criteria for referral - patients with co-morbidity or other risk factors will continue to be referred to hospital for assessment;
- step-by-step instructions for walk-in centre nurses on assessment procedures, documentation, patient information and communication with other professionals;
- a DVT clinical scoring system, adapted by hospital haematology consultants;
- the patient group direction for the tinzaparin sodium injection, allowing eligible nurses to supply and/or administer this prescription-only medicine in specific circumstances without a doctor's prescription;
- standard letters and patient record pro formas.
The clinical group was also responsible for agreeing specifications and producing tenders for equipment, arranging quality assurance processes for the chosen D-dimer machine, agreeing the training needs of walk-in centre and Luton treatment centre staff and developing an appropriate staff training programme.
The IT project group included IT professionals from the hospital, Bedfordshire shared services (the PCT provider), the project manager, community anticoagulant nurse specialist and representatives from Instrumentation Laboratory Ltd, the successful tender applicant. As well as supplying the D-dimer machine, the company also supplied software allowing patient information to be accessed at each of the three sites..
Inappropriate referrals not meeting the suitability criteria led to a revision of the service model after just one month, to allow GPs to refer all patients with suspected DVT to the walk-in centre. The centre's nurses then triage the patient for suitability for community-based screening, with unsuitable patients referred to the hospital.
Uptake of the service by GPs has been inconsistent, leading to lower savings to date for the PCT than was anticipated in the original business plan. To ensure the full potential is realised, ongoing communication is needed to remind some GPs of its availability, safety and efficiency.
An audit of the first six months, including a review of clinical outcomes and patient satisfaction, is under way. Referral criteria will be reviewed in light of the results and a rolling audit programme is planned.
In phase two of the service reconfiguration, scheduled for early 2007, all management of warfarin treatment will be transferred to the community anticoagulation service at the treatment centre. In phase three the whole DVT patient pathway, including definitive diagnosis by ultrasound scan, will take place in the community.
Beyond this we hope communication can be streamlined by the introduction of electronic GP referral to the community DVT service and access by the GPs to the patient-management system. -
Alison Meynell is lead nurse and anticoagulant nurse specialist at Luton treatment centre; Wendy Walker is senior project manager and Ian Winstanley is director of patient services at Luton PCT.