2.  Thames hospital and it’s emergency department  The quality framework team – what it’s been like  3 audit topics

3.  Waikato DHB - 4 rural hospitals – Thames, Taumaraunui, Te Kuiti, Tokoroa – the 4Ts  Variable skill base, resources and facilities

4. Neale Thornton January 2008

5. Neale Thornton February 2007 Coromandel Peninsula from Waihi north and Hauraki Plains Drive Time: 90 minutes to base Population: 26000 year round Summer population 120900 Presentations to ED: 15000 pa Seasonal fluctuations, same infrastructure Retrieval for severe trauma Catchment Thames Hospital

7. 48 bed IPU - Medical, Surgical, AT&R High Acuity Room (3 beds) Operating Theatres Emergency Department 15 beds Midwife-led Birthing Unit Radiology 08.00-18.00 then on call Laboratory 07.00-22.00 then on call Outpatients Facilities/Services-Thames Hospital

8.  ED mix MO and rural hospitalists – extended role outside ED  Physicians and surgeons based Thames  Daylight SHOs, rural registrar training  Visiting AT&R  Many transfers – complexity, speciality, destination, weekends and PH,

9. Developed a PTS service enabling a scheduled transfer of patients between Thames and Waikato hospitals. St John’s with skilled transfer nurse Treatment en route Two way Neale Thornton January 2008

10. Quality Framework Team: Clinical Lead (0.3FTE), CNM, 2IC (0.2FTE) Monthly meetings of team Feedback of results via M&M, ED business meetings, and heads of departments Some support by request from IS and CASU. Application of the Quality Framework Neale Thornton January 2008

11.  Use what already is available – eg LOS data, time to be seen by decision making clinician

12.  What goes in must come out – eg requesting reports by specific discharge codes.

13.  Getting into hot water – analysing complaints, incidents and sentinel events  Themes

14.  Actively gathering feedback from patients and staff

15.  Number 8 wire – develop our own audit tools from scratch  Eg left before being seen – recoded, data collected daily, patient contacted next day, themes, safety.

16. Unplanned representation rates within 48 hours of ED attendance  55 pages of raw data for 1 month  After 3 hours sifting - 20 patients  Several alternative reports available  Filtering data to give useful reports.

17. Reasons for breach: July 2014 – 21 breaches Cause of BreachNumber Bed access block7 Department in Overload0 Awaiting Transfer3 Awaiting Results (CT)1 Lack of resource – telemetry, watch2 Uncertain destination5 Administration – patient not placed in SSU/computer issue 2 Ongoing care – patient acuity1

18.  Transfers  CT  Departmental overload, summer, inadequate staffing  Actions taken January 2015, re audit coming

19. July 2013 – June 2014  38 patients presented to Thames with fractured neck of femur.  8/38 subsequently died within 30 days. 30 day mortality = 21% (expected rate = 10%)  11/38 died within 4 months. 4 month mortality = 29% (expected rate = 20%)  12/38 died within one year. One year mortality = 31.5% (expected rate = 30%)

20.  Time from injury to surgery – longer for rural patients  Multiple delays in patient’s journey  Must be in base hospital to be put on surgical list What can be done?  Use of NoF clinical pathway  Discussion with CD orthopaedics  Discussion with St John re priority transfer  Dissertation topic

21. July 2013 - June 2014  Total: 19 patients; 17 met criteria at triage, 2 had received IV antibiotic prior to ED  Average time to first antibiotics: 2 hours 47 minutes  Deaths: 2/17 (11.7%)  Total no patients received 1 st antibiotic dose within 60 min (Sepsis 6 goal) 3/15 - 20%

22.  After the initial audit, a sepsis treatment pathway was implemented in Thames ED. This pathway is based on the Waikato sepsis pathway and follows international guidelines for sepsis treatment in ED.

23.  Re-audit: Oct 2014 to Feb 2015 (5/12 period)  10 patients presented to Thames ED with “sepsis” diagnosis  9 patients met sepsis criteria  Average time to first antibiotics: 108 minutes (1 hour and 48 minutes)  Deaths: 1/9 = 11.1% mortality  Use of Sepsis Pathway: 2/9 = 22.2% use  Total no patients received 1 st antibiotic dose within 60 minutes (Sepsis 6 goal) 1/9 = 11.1%

24.  Average time to antibiotic – 2h 47m prior to pathway -1h 48m after pathway.  Antibiotic within 60 min - 20% to 11%  Use of sepsis pathway 22.2%

25.  Promotion of use of sepsis pathway and assessment tool  Audit nursing documentation - use of assessment tool  Place pathway at triage to ensure that paperwork is accessible  Re-audit Sept 2015  Better awareness among medical staff. Locums too.

27.  Sometimes difficult to compare statistics directly- due to transport and available services.  No IS service on site so getting specific data can be delayed.  Small team, time constraints  Small team, ability to bring about change

28.  How to define ED overcrowding measures?  Time to analgesia tool?

29.  Quality is not geographical – it applies to rural hospitals as much as metropolitan hospitals  Unsuspected areas for improvement have been unearthed (Thames is a goldmining town!)  It is encouraging to align ourselves with national framework and see how we compare

30. Patient journey time stamp ED LOS Waiting time from triage until time seen by decision making clinician ED overcrowdingED occupancy >100% ED demographic measures UPRA ED quality processesM&M Sentinel events Complaint review and response Staff experience evaluations Patient experience measures Patient experience evaluations Left before seeing doctor or decision making clinician

31. Clinical quality auditsMortality rates for #NOF and STEMI Time to thrombolysis Time to adequate analgesia Time to antibiotics in sepsis Procedural sedation Others – DVT, cellulitis, pneumonia, transfers outside scheduled PTS Documentation and communication Nursing notes, medical notes, medication Performance of SSU Education and training profile Appropriate orientation with feedback Departmental education programme Administration profileDesignated quality team