G226(P) It will stick like glue: improving the management of simple lacerations in A&E

Background Lacerations are the 6th most common presentation to A&E in the UK. These vary from complex wounds requiring specialist review to those that can be repaired with steri-strips or glue. Most wounds are simple enough to be repaired by the nurse who first assessed the child. However, local practice in Children’s Emergency Area (CEA) has been for every wound to be reviewed by a doctor. Consequences include long waiting times and crowded waiting rooms. Aim Decrease time spent in CEA by children with ‘simple lacerations’ to 90 minutes by September 2019. Methodology PDSA Cycle 1: A Standard Operating Procedure(SOP), designed by our multi-disciplinary team, was implemented on 18th August 2019. This sets a standard management pathway for children presenting to CEA with lacerations, and allows a nurse-led-discharge for ‘simple lacerations’ which do not meet exclusion criteria. Average encounter times (AET’s) were recorded on a Run Chart for the first six children presenting to CEA with ‘simple lacerations’, each week between March–October 2019. Prior to implementation, only AET’s for lacerations which could have been managed by nurses were included. After implementation, AET’s reflect the first six patients managed by either nurses or doctors. We compared AET’s between 31st March–18th August prior to implementation, to AET’s between 18thAugust–15th October after implementation. PDSA Cycle 2: Senior CEA nursing staff provided teaching to improve confidence and adherence to the SOP. Results The average AET prior to implementation was 192 minutes. After implementation, average AET reduced to 117 minutes. Since implementation, 52% were managed by nurses, with an average AET of 80. In the same time period, average AET for those managed by doctors was 163 Conclusion Using the SOP resulted in significant improvement of overall AET’s in CEA. AET’s for nurse-led-discharges were lower than for doctor-led-discharges. Lower AET’s result in lesser exposure to pathogens in the waiting room and allow doctors more time with acutely unwell children. We hope the pathway could serve as a model for other CEA’s across the UK. With evidence that AET’s are shorter for nurse-led-discharges, our next PDSA cycle will focus on increasing number managed by nurses. We will monitor balancing measures: returning patients, and patient satisfaction.