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

2. 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

3. 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

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

5. 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 ( hrs)
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

6. 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

7. 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?

8. 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

9. 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

10. 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

11. 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

12. 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

13. Clinician run model

14. 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

15. 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

16. 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

17. Evidence of Success
Review in October