A Specific Criteria-Based Guideline Improves Compliance With General Surgery Ambulatory Care Standards and Reduces Overcrowding in “Hot Clinic”: A Quality Improvement Study

Background A general surgery hot clinic is designed for the assessment and management of acute general surgical patients in ambulatory settings to avoid unnecessary hospital admissions. Overcrowding in the hot clinic is a major issue in many general surgical settings, and it is thought to be due to a lack of specific criteria-based guideline for identifying eligible patients for ambulatory care. We aimed to perform a prospective audit to assess what proportion of hot clinic patients meets the criteria for ambulatory care. Our second objective was to implement a specific criteria-based guideline and monitoring program to improve compliance with the ambulatory care criteria. Methods The audit included three cycles: baseline audit (30 days in September 2018), first re-audit (30 days in January 2019), and second re-audit (30 days in May 2019). During each cycle, all consecutive patients who attended the general surgery hot clinic were included. Compliance with the hot clinic standards was considered as the outcome measure. We considered compliance of 100% as a target for each standard. A specific criteria-based guideline for the hot clinic was implemented after the baseline audit. A monitoring program was designed to monitor and maintain compliance with the hot clinic guideline. Results During the baseline audit, 224 patients were seen in the general surgery hot clinic. After the implementation of the guideline, this was reduced to 40 patients during the first re-audit and 42 patients during the second re-audit. There was a significant difference in the median number of patients seen per day between the baseline audit and the first re-audit [(7 (6-8) vs 1 (1-2), P < 0.0001] and between the baseline audit and the second re-audit [(7 (6-8) vs 1 (1-2), P < 0.0001]. During the baseline audit, only 19% of patients were seen by the on-call general surgery team prior to a hot clinic; this improved to 100% in the first re-audit (P < 0.0001) and remained 100% in the second re-audit (P < 0.0001). During the baseline audit, only 19% of patients met the eligibility criteria for review in a hot clinic; this improved to 100% in the first re-audit (P < 0.0001) and remained 100% in the second re-audit (P < 0.0001). Conclusions A criteria-based hot clinic guideline suggested in this study improved compliance with general surgery ambulatory care standards, the efficiency of general surgery hot clinic, and overcrowding in general surgery hot clinic. A continuous monitoring program led by an on-call junior general surgery doctor helped to maintain the aforementioned improvements.