ED Stream Workshop Acute MOC August 2013 ED Stream Workshop John Hunter Hospital Emergency Department

List All MOC used in your Facility NSW Health Models of Care Triage and Registration Clinical Initiatives Nurse Resuscitation & trauma Acute care Early Emergency Department Senior Assessment and Streaming Fast Track Sub-acute 2:1:1 Emergency department Short Stay Units FOH redevelopment; streamlined triaging at WR and 5 bed ambulance bay. Without creating a barrier to definite care. Co-located with clerical staff (bedside). Extensive post-grad Emergency Cert and competency framework. CIN; between hours……., review and management within benchmarks……..,communication……..(patient feedback studies) Number of triage cat 1& 2 per day………,Coordinated team approach requiring access to a large pool of senior medical and nursing staff, trauma team activations (busiest trauma centre in NSW with highest injury severity scores) Senior ED supervision, clinical pathways, timely access to specialist consultants and transfer of patients Early assessment thus direction in clinical management and efficient use of resources, streaming assessment zone built, SAS trailed, pathway developed, no staff. Streaming areas…ESSU(not staffed)&MAU(no beds) Important part of ED, busy, utilized by many specialists units using it as a rapid access area, patient complexity creep, trial in 2012, recent enhancements in staff/pathways/equipment Low acuity but complex patients managed in team B Policy directive for 2:1:1 challenges of flow over effect from lack of ward beds and delays in inpatient reviews resulting in ED bed block . Not all specialties on board with 2:1:1 (only division of medicine) 8 bed ESSU. Occupancy rate….. Without dedicated medical staff

JHH ED FT Key Principles Patient selection Business rules, guidelines & expectations to patient management Optimising use of beds Medical and Nursing senior clinical decision makers Minimizing wastage Improving equipment Improving utilisation of current resources

John Hunter ED Fast Track Model Patient selection: new criteria July 2013 Avoid patients that will block FT

John Hunter ED Fast Track Model Business Rules and Expectations Fast Track Trial 2012, staff survey 2013 New Business rules JHH ED July 2013 30-60 minutes in assessment cubicles Staff roles Process mapping of top 10 DRGs Improving patient flow in FT utilising waiting room, patient recliners, ESSU Minimizing wastage Improving equipment &utilisation of current resources John Hunter Hospital Emergency Department Fast Track Fast track (FT) is a dedicated area in the Emergency Department for the treatment of Ambulant, non-complex, single problem patients who can be discharged within <2 hours. Senior Staffing, revised processes and pathways, room equipment and layout are designed for rapid turnaround of patients. The Key Performance Indicators (KPI’s) for the Fast Track area is for 90% of patients to be discharged within 4 hours. Triage allocates patients into the FT area using a pre-determined inclusion/exclusion criterion (see below). FT provides an alternative option to treat non-complex patients in a timely manner, reducing long waiting times for minor problems. The Fast Track Model of Care has been aligned to the NSW Emergency Department Model of Care Guidelines. Key Principles of Fast Track Expedite the patient journey for less-urgent/non-complex patients Using dedicated staff (seconded to FT for 3 month blocks) Working within team based care Clearly defined roles with expected performance measures Operating hours which reflect high demand periods (0800-2400hrs) Uses quarantined space where patients are treated in a dedicated area by dedicated staff Commence treatment early Strict inclusion and exclusion criteria supported by business rules Use of clinical protocols that promote initiation of nursing care Rapid access to appropriate imaging and pathology Patients with a single system problem that can be discharged <2 hours Easy access to specialty outpatient, GP and community care referral services Information management iPM will be used to enter all patient information Use of standardised communication for medical and nursing staff- ISBAR CAP- system to be used for reviewing pathology and imaging results, as well as formulating discharge paperwork

John Hunter ED Fast Track Model Optimising use of limited bed space Competing need for beds orthopaedics/subspecialist vs. ED Minimising time wasted waiting in a bed 4 ED assessment beds 1 specialty assessment/treatment bed 7 recliner beds 8 waiting room beds New operational rules for patient flow, bed use Senior Nurse as flow coordinator and protector of bed space

John Hunter ED Fast Track Model Senior Decision Makers 2012 JHH ED Fast Track Trial Senior staff work over twice as fast as junior staff “dedicated senior medical and nursing staff working to optimise the performance of Fast Track systems as they have the ability to make timely treatment and disposition decisions with minimal consultation” Considine et al 2010 2 teams consisting of 1 senior Doctor and 1 senior Nurse each promoting team work Feasibility study in utilising Nurse Practitioners?

John Hunter ED Fast Track Model Minimising wastage Senior staff order less pathology and imaging tests Reduce time wastage Protecting assessment & treatment beds for patients receiving active management Improved collaboration between doctors and nurses; eliminating time wasted by the nurse waiting for the doctor to finish their assessment before nursing duties are completed

John Hunter ED Fast Track Model Equipment to improve efficiency Desk, computer, phone, Otoscope/Opthalmoscope in each ED assessment room 1 dressing-suture trolley each team Assessment-treatment bed for orthopaedics IT screen displaying time stamps of FT patients Fact sheets/handouts incorporated in D/C summaries Portable Tonopen DECT phone to improve communication between triage/ED coordinator/ESSU/SAS

John Hunter ED Fast Track Model Improved utilisation of current resources Enhanced Physiotherapy role uses existing resources to manage minor limb injuries New Guidelines July 2013 Significant improvements in patient care and flow will lead to a submission for weekend cover

Improved waiting times Benefits of the Model 2012 Fast Track trial Improved patient flow Improved waiting times Improved 4 hour National Emergency Access Targets Optimising use of FT bed space

Challenges Implementation and training of staff in new business rules and guidelines Sustainability when Doctors constantly rotate through FT Large number of subspecialty reviews and transfers to JHH ED FT Orthopaedics: 8.7 patients a day, ⅓ transfers, ⅓ GP referrals, 39% meet NEAT Uncontrolled variables: delayed registrar reviews, admissions and transfers to ward ED has no control over patient flow of the patients requiring subspecialty review Solution is to open ‘rapid access clinics’ Limited space Does not operate during the night 2400-0800

Clinician run model

Designated and segregated treatment area Differences between your Model and the definition in the “Emergency Department Models of Care July 2012” Consistencies Staffing Dedicated senior medical & nursing staff Physiotherapy Designated and segregated treatment area Pathways and process mapping; need to develop standing order protocols for early nursing care Strict inclusion/exclusion criteria

Identify the Resource Required for your Fast Track Model Staffing: model of 2 doctors and 2 nurses implemented July Training & implementation of new business rules and guidelines Development of new guidelines and standing orders for nurses Physical space and procedure room Clinical operation plans

Monitoring and Evaluation Daily statistics Number of patients through FT Number discharged within 2hrs & 4hrs Waiting time Admissions Did not waits Patient incidences and complaints Weekly staff feedback Number of Orthopaedic patients, admission rate, NEAT Number of Opthalmology, admission rate, NEAT

Evidence of Success Review in October