NHS Willows Health, 184 Coleman Road, Leicester, LE5 9LJ, UK.
School of Science and Technology, Clifton Campus, Nottingham Trent University, Nottingham, NG11 8NS, UK.
BMC Nephrol. 2024 Aug 8;25(1):255. doi: 10.1186/s12882-024-03668-x.
The optimisation of patients in primary care is a prime opportunity to manage patient care within the community and reduce the burden of referrals on secondary care. This paper presents a quality improvement clinical programme taking place within an NHS Primary Care Network as part of the wider Leicester Leicestershire Rutland integrated chronic kidney disease programme.
Patients are optimised to guidelines from the National Institute for Health and Care Excellence, by a primary care clinical team who are supported by nephrology consultants and nephrology pharmacists. Multidisciplinary team meetings take place with secondary care specialists and primary care staff. Learning is passed to the community clinicians for better patient treatment locally.
A total of 526 patients were reviewed under this project.The total number of referrals to secondary care which were discharged following first outpatient appointment, reduced from 42.9% to 10%. This reduction of 32.9% represents the optimisation of patient cases through this quality improvement project. Patients can be optimised and managed within the community, reducing the number of unnecessary referrals to secondary care.
This programme has the potential to offer significant improvement in patient outcomes when expanded to a larger patient base. Medicine management and the use of clinical staff are optimised in both primary and secondary care.
优化初级保健患者是管理社区内患者护理并减轻二级保健转介负担的主要机会。本文介绍了 NHS 初级保健网络内正在进行的一项质量改进临床计划，作为莱斯特莱斯特郡拉特兰综合慢性肾病计划的一部分。
初级保健临床团队根据国家卫生与保健卓越研究所的指南对患者进行优化，该团队得到肾病学顾问和肾病药剂师的支持。多学科团队会议在二级保健专家和初级保健人员之间举行。学习成果传递给社区临床医生，以便在当地更好地治疗患者。
该项目共审查了 526 名患者。首次门诊就诊后出院的二级保健转介总数从 42.9%降至 10%。这 32.9%的减少代表了通过这个质量改进项目对患者病例的优化。可以在社区内对患者进行优化和管理，减少不必要的二级保健转介。
当扩展到更大的患者基础时，该计划有可能为患者的治疗结果带来显著改善。初级和二级保健都优化了药物管理和临床人员的使用。
