Redesigning  the  ED  

Dr  Paul  Jarvis  Consultant  in  Emergency  Medicine  

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The results shown here are specific to one health care facility and may differ from those

achieved by other institutions.

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Disclaimer

Old System

Tradi;onal  ED  System  

Treatment

Disposal Triage

Dr Review Investigations

Nurse

Assessment

Dr Review Walking

Ambulance Consultant

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What is the problem?

•  System  designed  to  make  pa;ents  wait    (Triage  is  a  step  to  decide  how  long  you  should  wait)  

•  Two  access  points  to  the  service    

•  Inves;ga;ons  requested  late  

•  Poten;al  for  inexperienced  staff  to  order  unnecessary  inves;ga;ons  

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EDIT ED Dr Treatment Disposal

Ambulance

Walking

Consultant Consultant

EDIT  System  

Redesign ED Process

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•  Introduc;on  of  Point  of  Care  Tes;ng  (POCT)    •     

•  i-‐STAT®  System    –  CHEM8+  –  CG4+  

Introduced Point of Care Testing

31778  Rev A 1/14 For In Vitro Diagnostic i-STAT is a registered trademark of the Abbott Group of Companies in various jurisdictions For Intended Use Information – See Intended Use Section

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Phase  1  –  Evaluate  the  performance  of  the  tradi;onal  ED  model    -‐    1st  April  to  24th  May  2013  (3835  pa;ents)    

Phase  2  –  Evaluate  introducing  POCT  into  tradi;onal  ED  model    -‐  28th  May  to  29th  September  2013  (7033  pa;ents)    

Phase  3  –  Evaluate  POCT  and  EDIT  model  together  –  30th  September  to  18th  October  2013  (1200  pa;ents)  

3 Phase Trial

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Before  Trial      Median  Blood  Results  being  available:  63  minutes  

   Trial  Results      Median:  3  minutes        Able  to  do  60%  of  ED  bloods  using  i-‐STAT  

Point of Care Testing

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Effect of the 3 Different Working Models on the Median ED Times

68% Overall

Reduction

40% Overall

Reduction

60% Overall

Reduction

Tim

e hh

:mm

Results

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Non-EDIT EDIT

Breach Performance Monday to Friday 9-5

Consistently meeting 4 hour target Much less variation with EDIT based model

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Results

* - only 1 consultant

When only 1 consultant causes special cause variation in performance r = -0.8

UCL

*

*

*Two consultants on duty, except during the days noted 031778 Rev A 1/14 For In Vitro Diagnostic

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Dates 30 Sep – 18 Oct 2013

 With  tradi;onal  model  9  pa;ents  are  undergoing  ED  Care  in  the  ED  central  area  at  any  one  ;me  (Monday  to  Friday  9-‐5)    EDIT  &  i-‐STAT  reduces  this  to  5  due  to  quicker  processing  of  pa;ents          

       

Results

Reduces Overcrowding

Frees up time to Care

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With  Tradi;onal  Model  3%  of  pa;ents  seen  in  ED  Central  Area  Monday  to  Friday  9-‐5  are  discharged  with  30  minutes  of  arriving.    With  EDIT  &  i-‐STAT  this  is  increased  to  10%  with  the  addi;onal  benefit  of  being  seen  by  a  consultant.  

Results

Reduces Overcrowding

Frees up time to Care

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With  Tradi;onal  Model  11.4%  of  pa;ents  seen  in  ED  Central  Area  Monday  to  Friday  9-‐5  return  within  7  days  of  their  ini;al  presenta;on    With  EDIT  &  i-‐STAT  this  is  9.1%    Shorter  pa;ent  journey  ;mes  do  not  equate  to  more  pa;ents  having  to  return  to  the  ED  within  7  days  

Results

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 360  ED  a_endances  per  day  cross  site  

 2.5%  reduc;on  =  9  few  admissions  per  day  

 

       

Rates of Admission

Old System 21.5%

Old System & i-STAT 21.7%

EDIT & i-STAT 19.0%

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Introduc;on  of  a  consultant-‐led  assessment  process  (EDIT)  and  POCT  provides:  

 • 40%  reduc;on  in  the  median  ;me  from  pa;ent  arrival  to  being  declared  ‘ED  Ready’    • 2.5%  reduc;on  in  the  median  number  of  pa;ents  admi_ed  

Conclusion

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(CG4+)  Lactate  The  test  for  lactate,  as  part  of  the  i-‐STAT  System,  is  intended  for  use  in  the  in  vitro  quan;fica;on  of  lactate  in  arterial,  venous,  or  capillary  whole  blood.    The  i-‐STAT  lactate  test  is  useful  for  (1)  the  diagnosis  and  treatment  of  lac;c  acidosis  in  conjunc;on  with  measurements  of  blood  acid/base  status,  (2)  monitoring  ;ssue  hypoxia  and  strenuous  physical  exer;on,  and  (3)  diagnosis  of  hyperlactatemia.  

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Intended Use Information