ED Stream WorkshopAcute MOC

August 2013

ED Stream Workshop

John Hunter Hospital

Emergency Department

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List All MOC used in your Facility

NSW Health Models of Care

1. Triage and Registration

2. Clinical Initiatives Nurse

3. Resuscitation & trauma

4. Acute care

5. Early Emergency Department Senior Assessment and Streaming

6. Fast Track

7. Sub-acute

8. 2:1:1

9. Emergency department Short Stay Units

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JHH ED FT Key Principles

1. Patient selection

2. Business rules, guidelines & expectations to patient management

3. Optimising use of beds

4. Medical and Nursing senior clinical decision makers

5. Minimizing wastage

6. Improving equipment

7. Improving utilisation of current resources

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John Hunter ED Fast Track Model

1. Patient selection: new criteria July 2013

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YES NO Pre-empt (in the WR)

Limb injuries Joint Sprains

Limb injury

finger/toe injury

Minor contusion/abrasions

Follow up post #

No neurovascular compromise Not severely deformed/dislocated Not elderly who cannot mobilize or unable to cope at home No acute medical cause for fall Not a septic joint

Organise X-Rays & analgesia (as per NIX and NIA guidelines)

Skin Simple laceration to face, trunk, limb

Scalp laceration

Suture removal

No neurovascular compromise Not septic/ unwell Not immune-compromised Not requiring procedural sedation

Cellulitis No significant co-morbidities Not septic/ unwell Not immune-compromised Not peri-orbital, orbital

Skin or subcutaneous abscess

No significant co-morbidities Not septic, unwell Not immune-compromised

NBM for sedation

Skin burn; <5% TBA superficial/partial thickness

Not face, groin, fingers, toes, or overlying joints

Analgesia Wet dressings

Dressings change Bites/stings Needle stick injury

Pulmonary Cough

Not tachypnoeic Not hypoxic; saturations > 95% Not septic, unwell looking No significant co-morbidities Not immune-compromised

If the patient is febrile or has crepitations on auscultation then ask FT Doctor for a CXR request form

Throat pain No stridor or airway compromise No significant co-morbidities Not unable to swallow

Isolated rib injury Must be < 50yo Not requiring narcotic analgesia Not tachypnoeic Not hypoxic; O2 sats < 95% No significant co-morbidities

Ask the FT Doctor for a CXR request form to exclude a pnuemothorax Analgesia(as per NIA guidelines)

Gastro-intestinal Vomiting and diarrhoea Must be < 50 yo No significant co-morbidities Abnormal vital signs

Anti-emetics Trial of fluids

Gastro-intestinal Vomiting and diarrhoea

Must be < 50 yo No significant co-morbidities Abnormal vital signs Abdominal pain Not septic, unwell looking

Anti-emetics Trial of fluids

Abdominal pain Not requiring narcotic analgesia No exacerbation of pain on movement, walking or coughing Normal vitals including fever Non complicated abdominal or surgical history No recent abdominal surgery

Bloods (as per C-Path matrix) Urine bHCG

Haemorrhoids 1° or 2°

Genito-urinary UTI Not septic Normal vital signs Non complicated urological Hx, No significant co-morbidities No flank pain

Urine

Flank pain + haematuria Must be < 50yo No history of AAA

Urine Analgesia

head Minor head injury Must be < 65yo normal GCS or mentation No meningism No focal neuro abnormalities, No vomiting, LOC > 5mins No amnesia > 30mins Not anti-coagulated No underlying acute medical problem causing the fall

Dental Toothache Not septic Analgesia

Ophthalmology Conjunctivitis

Corneal FB

Corneal abrasions

Hyphema

Peri-orbital cellulitis

Chemical splash

No Major facial trauma

ENT Nasal, ear FB

Isolated nasal #

Rash Urticarial rash Non blanching rash

YES NO Pre-empt (in the WR)

Limb injuries Joint Sprains

Limb injury

finger/toe injury

Minor contusion/abrasions

Follow up post #

No neurovascular compromise Not severely deformed/dislocated Not elderly who cannot mobilize or unable to cope at home No acute medical cause for fall Not a septic joint

Organise X-Rays & analgesia (as per NIX and NIA guidelines)

Skin Simple laceration to face, trunk, limb

Scalp laceration

Suture removal

No neurovascular compromise Not septic/ unwell Not immune-compromised Not requiring procedural sedation

Cellulitis No significant co-morbidities Not septic/ unwell Not immune-compromised Not peri-orbital, orbital

Skin or subcutaneous abscess

No significant co-morbidities Not septic, unwell Not immune-compromised

NBM for sedation

Skin burn; <5% TBA superficial/partial thickness

Not face, groin, fingers, toes, or overlying joints

Analgesia Wet dressings

Dressings change Bites/stings Needle stick injury

Pulmonary Cough

Not tachypnoeic Not hypoxic; saturations > 95% Not septic, unwell looking No significant co-morbidities Not immune-compromised

If the patient is febrile or has crepitations on auscultation then ask FT Doctor for a CXR request form

Throat pain No stridor or airway compromise No significant co-morbidities Not unable to swallow

Isolated rib injury Must be < 50yo Not requiring narcotic analgesia Not tachypnoeic Not hypoxic; O2 sats < 95% No significant co-morbidities

Ask the FT Doctor for a CXR request form to exclude a pnuemothorax Analgesia(as per NIA guidelines)

Gastro-intestinal Vomiting and diarrhoea Must be < 50 yo No significant co-morbidities Abnormal vital signs

Anti-emetics Trial of fluids

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

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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 TrackExpedite the patient journey for less-urgent/non-complex patientsUsing dedicated staff (seconded to FT for 3 month blocks) Working within team based careClearly defined roles with expected performance measuresOperating hours which reflect high demand periods (0800-2400hrs)Uses quarantined space where patients are treated in a dedicated area by dedicated staffCommence treatment earlyStrict inclusion and exclusion criteria supported by business rulesUse of clinical protocols that promote initiation of nursing careRapid access to appropriate imaging and pathologyPatients with a single system problem that can be discharged <2 hoursEasy access to specialty outpatient, GP and community care referral services

Information managementiPM will be used to enter all patient informationUse of standardised communication for medical and nursing staff- ISBARCAP- 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

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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?

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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

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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

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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

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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

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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

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Clinician run model

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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

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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

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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

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Evidence of Success

Review in October

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