192 Quality improvement project to improve the rate of cancellations of stress echocardiograms in a tertiary cardiac centre

Introduction Stress echocardiography is an important tool in the diagnostic arsenal of cardiologist. However, like most procedure based diagnostic tools there are frequent cancellations on the day for many reasons leading to longer waiting lists and ultimately later diagnosis and intervention for those who need it. We have undertaken a quality improvement project (QIP) to reduce the cancellation rates for stress echocardiography as part of an overall project to improving the inpatient mortality of heart failure patients. Methods and Results Patients- 830 patients who had appointment for stress echocardiography Baseline data was analysed by identifying 307 consecutive patients who were booked for stress echocardiography between 1st November 2022 and 2nd March 2023. A Pareto chart (figure 1) was created to help identify the main reasons for cancellation of the test on the day or with too short notice for a replacement patient to be booked for the list. Interventions were put in place to address the some of the common causes for cancellation (rate-limiting drugs not stopped for >48 hours, patients who did not attend (DNA), Blood Pressure (BP)>180/110. PDSA cycle 1(6/3/2023–20/3/2023) involved a research nurse calling patients intermittently at least 3 days prior to the appointment to remind them to stop their rate-limiting drugs such as beta-blockers (BB). The research nurse would have called patients anyway because of the EVAREST and PROTEUS studies. PDSA cycle 2 (23/3/2023–19/5/2023) involved research nurses ringing all patients 3 days prior to the appointment. A second set of baseline data was collected from 22/5/2023–11/08/2023, during which time the patient received only standard care. That involved only being contacted by admin staff either via phone call/text message to confirm attendance at appointment and to remind them to stop beta blockers (after the EVAREST and PROTEUS studies ended). Patient also received an appointment letter with the same advice. PDSA cycle 3 (17/08/2023–15/9/2023) involved a doctor calling some patients at least 3 days prior to their appointment to confirm attendance, remind patients to stop beta blockers and also to address blood pressure control. PDSA cycle 4 (22/9/23–29/11/23) involved all patients being called by a doctor to address the same points as cycle 3. The baseline data studied 307 consecutive patients booked for stress echocardiography. Of these, 107 were cancelled on the day for different reasons with the main reasons being unknown despite reviewing patient record. The main known causes identified are patients did not attend appointment (DNA), BP >180/110 and failure to stop beta-blocker 48 hours before the appointment. The run chart (figure 2) showed changes in the weekly cancellation rate over time. There was significant improvement in the overall rate of cancellation by the interventions. The median showed a shift at several points in the analysis in the data from an initial valve of 35% to a median of 13% in the final cycles where changes have been implemented to address the main causes of cancellations. We recorded the time it takes to call patients to inform a business case with the aim to make the significant improvement sustainable [median 5 mins, first quartile 3.8 mins, third quartile 5 mins]. The next QI PDSA cycle may assess the impact of an education intervention advising colleagues to address blood pressure at the point of referral. Conclusion Significant reduction in the cancellation rates for stress echocardiography can be achieved with simple interventions. Conflict of Interest None