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The nurse-led innovation that cuts costs and workload while improving patient outcomes

Video and simulation training in IV self-administration allows faster inpatient discharge

Video and simulation training in IV self-administration allows faster inpatient discharge

  • Hospital nurses’ project achieves increase in self-administration of antibiotics once inpatients return home
  • Team’s work eases workload pressures for community nurses and allows prompt hospital discharge
  • Patient feedback is ‘universally positive’

OPAT team members from left: healthcare assistant Emma Nash, specialist nurses Rob Moule and
Tanya Porter, clinical fellow Christian Holfing and infusion service senior sister Anna Mayhew.

A nurse-led team that made videos and a dummy training ‘arm’ that shows patients how to self-administer intravenous antibiotics has saved its trust £5 million in its first year – as well as improving patient experience.

The outpatient parenteral antimicrobial therapy service (OPAT) nurses’ project at Cambridge University Hospitals NHS Foundation Trust cut the time patients take to learn IV self-administration, enabling earlier discharge home from Addenbrooke's Hospital.

Better for patients

OPAT specialist nurse Tanya Porter, who led the project, says inpatients had been taking an average of five days to become competent in self-administration under the previous protocol, which relied on ward nurses finding time to begin teaching patients. The nurses would demonstrate to the patient or relative, who would then undertake three doses under nurse supervision, before a final assessment by an OPAT specialist nurse.

‘This was adding to ward nurses’ already busy workloads and unsurprisingly led to variation in teaching methods,’ recalls Ms Porter. ‘Standardised training methods provide better outcomes for patients and reduce associated costs. And we wanted to reduce nurses’ workload.’

‘Initially, we faced resistance from the ward nursing staff, as teaching patients using the model plastic arm took up valuable clinical nursing time’

Tanya Porter, OPAT specialist nurse

Under the new approach, the first patient teaching session is delivered by a member of the OPAT nursing team using a specially designed plastic training arm. The patient is also introduced to the standardised teaching documents that Ms Porter produced.


Tanya Porter demonstrates syringe preparation.

It took two days for Ms Porter and her team to film training videos. Senior sister Anna Mayhew provided support and guidance on the clinical information contained in both film and documents and consultant Emma Nickerson organised the recording.

Consistency was crucial. ‘I systemically recorded the individual aspects of the videos while ensuring continuity was maintained,’ explains Ms Porter. ‘And I closely studied the video narrative to guarantee the visual and written information complemented each other.’

Development

The training arm had to be developed with care. OPAT healthcare assistant and ward tissue viability lead Emma Nash liaised with the vascular access team to arrange for a PICC line (peripherally inserted central catheter) to be inserted in the arm. It took her several hours to work out how to ensure medication could be administered via the PICC line without leaking and destroying the plastic arm. 


The training arm, as seen in the videos. 

As with all innovations, there were challenges.

‘Initially, we faced resistance from the ward nursing staff, as teaching patients using the model plastic arm took up valuable clinical nursing time,’ says Ms Porter. ‘However, as the change was implemented it quickly gained momentum and as length of stay was reduced it gained support from ward staff.’

Improving uptake

Although both the teaching videos and documents were available to all wards on the hospital intranet, the team found at first they were not being used – even though access instructions were in the patient’s electronic notes.

‘To overcome this we ensured the patient’s first teaching session on the ward was undertaken by a member of the OPAT nursing staff,’ says Ms Porter. ‘We encourage patients to access the videos on their personal devices to empower them and support their development as expert patients.’

The team made videos specific to individual antibiotics, and made the films widely available on free video-sharing site Vimeo.

Tanya Porter’s tips for how to make a demonstration video

  • Don’t underestimate how long it will take to do the filming. Numerous cuts and takes are required
  • Include team members as much as possible for ideas
  • Try to complete filming in under four weeks to maintain continuity
  • Minimise the effects of breaks in filming, which make continuity difficult, by reviewing the material frequently during filming 
  • Write a script and practise several times before trying to film speech and processes
  • Understand that finding the time from clinical work to undertake the filming will be a challenge
  • Make sure other team members are aware of the long-term goal of the project so that they support the process

 

Step-by-step advice

The videos take the patient through the process step by step. The ‘setting up’ section includes handwashing and infection-control measures and there is a list of equipment the patient needs to have ready.

There are sections on preparing the flush, preparing the medication and administering it and tips on removing air from the syringe.

‘Universally, patient feedback has been positive. Patients say the service is excellent and the instructions clear’

Tanya Porter

Key safety points, such as checking expiry dates, appear in subtitles, and advice on when to contact the OPAT team is outlined.

The team’s evaluation shows the significant difference its project has made, with a 70% increase in the number of patients self-administering their intravenous antibiotics, and a saving of just over £5 million in the first year.

‘Universally, patient feedback has been positive,’ says Ms Porter. ‘Patients have commented that the service is excellent and the instructions are very clear.’


The videos are tailored to each antibiotic.

Patient feedback – ‘I don’t have to go to hospital or wait for a nurse to come’

‘I feel fine about administering my own Ceftriaxone. It saves me and the NHS so much time. I don’t have to wait at home for a nurse to come and administer it or go to a hospital but can do it in my own time and when it is convenient to me.

‘I do it in my bedroom where there’s no distraction. I set up the timings on my phone or tablet. I make sure there are no bubbles in the syringe.

‘One problem I did have was getting the drugs out of the vial – I pulled the needle down too far and it came out of the vial. When that happens you lose the pressure in the vial and you have to reinsert the needle and manually extract the drug but it wasn’t too much of a problem.

‘You just need to be in a room with no distractions – no phone, no TV, no radio. All you need to do is take your time and do not rush.’

Source: OPAT patient training video

 

Fewer bed days and reduced community nurse workload

In the year before the intervention, 125 patients were taught self-administration, whereas in the year after the intervention, 212 patients were taught the technique.

‘Whether patients are able to self-administer is a mutual decision’

Tanya Porter

‘These 212 patients were with the OPAT service for a total of 4,859 days, and therefore not in hospital,’ says Ms Porter. ‘Our hospital values one bed day at £864, which equates to a bed-day saving of £4,198,176. There are also significant savings in community nurse time.’

She adds: ‘Of the 212 patients, 36 were respiratory outpatients who avoided admission entirely by being trained through day case attendance.

‘Whether patients are able to self-administer is a mutual decision,’ stresses Ms Porter. ‘We have patients in their 70s and 80s who administer their antibiotics at home.’

Patient feedback – ‘Patients don’t need to be frightened to do this at home’

‘When the OPAT nurses suggested I self-administer my Daptomycin I was very apprehensive. I had never been involved in anything like this and wanted someone with me for the first time, but I was trained very well by the OPAT nurses.

‘My wife had planned to be with me the first time but we had an emergency at home so I got a friend to be there. 

‘It was very easy. Yes there were a few problems at first when I made mistakes. I dropped the syringe on the floor when I did not have a spare so after that I made sure I had a back up.

‘Patients don’t need to be frightened to do this at home. You need to use your common sense, make your own decisions and if you have a real problem, the OPAT team is there to help.’

Source: OPAT patient training video

                                                                                                              

Patient-centred and evidence-based

Infection rates have improved too. ‘We keep a database and we have a lower rate of line infections when patients self-administer than when community nurses administer the antibiotics,’ says Ms Porter.

Senior sister Anna Mayhew adds that the videos have been embraced by patients.

‘They want to be at home as early as possible and the initiative is helping the hospital both in terms of capacity and finances,’ she says. ‘Patients and their relatives have different learning styles so it is great to have additional resources available.

‘To see the difference is phenomenal,’ says Ms Porter. ‘I didn’t expect to get this far. We have put our patients at the centre of decision-making and this is evidence-based and safe.

‘We have broken that paternalistic barrier – let the patients do it. We have proved that patients do it better.’


Elaine Cole is RCNi special projects editor

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