Improving Plastic Dressing Clinic Burden by Reducing Punch Biopsy Referrals Using a Patient Information Leaflet: A Quality Improvement Project

Background Although being a safe intervention with low complication rates, a significant proportion of patients undergoing punch biopsies were referred to the local plastic dressing clinic (PDC) despite providing minimal utility and adding to an already heavily burdened clinic. The aim of this quality improvement (QI) project was to reduce the number of patients who had undergone a punch biopsy who were referred to PDC. The steering group included a plastic surgeon consultant, a senior outpatient department (OPD) and a PDC nurse, and a junior trainee. Process mapping and driver diagrams were used to identify a patient information leaflet as the intervention. Methods A patient information leaflet was created by the clinical lead, which included advice for postoperative wound care and when to seek medical attention. This leaflet was provided to every patient who underwent a minor operation for a skin lesion from September 2021. Operative notes of patients who underwent a punch biopsy were reviewed from October to November 2021 and from August to September 2022 to identify the number of patients who were referred to PDC. Concurrently informal feedback from patients and the process manager guided any necessary changes. Results There was a small improvement in the number of PDC referrals during October-November 2021 (46%) compared to the baseline measurements (54%). This corresponded with an absolute risk reduction (ARR) of 7%, risk ratio (RR) of 0.86, and relative risk reduction (RRR) of 14%. No changes were made at this stage. There was a much greater improvement in August-September 2022 (20%) compared to the baseline measurements with 34% ARR, 0.37 RR, and 63% RRR. Informal feedback from the process manager confirmed that every patient received a leaflet and that the patients found the leaflet very helpful. Conclusions The implementation of the patient information leaflet has led to a reduction in referrals of patients with punch biopsies to PDC. While this is a small and narrow project, it demonstrates the values of QI methodology to select a successful intervention. Furthermore, it corroborates with other studies that have shown that patient information leaflets empower patients and can help reduce the National Health Service (NHS) outpatient burden. Considering its simplicity, trialing a similar approach in other specialties is strongly encouraged.