ED Stream WorkshopAcute MOC

August 2013

ED Stream Workshop

1

List All MOC used in your Facility

NSW MOH Model Of Care (2012) Hours of Operation

3.1 Triage + Registration 24 hrs

3.2 Clinical Initiatives Nurse 0700-2300 hrs

3.3 Resuscitation (including trauma) 24 hrs

3.4 Acute Care 24 hrs

3.5 Early Emergency Department Senior Assessment and Streaming Nil

3.6 Early Treatment Zone Nil

3.7 Fast Track 1030-1900hrs

3.8 Sub Acute 24 hrs

3.9 Emergency Department Short Stay Units Nil

4.1 Medical Assessment Unit Nil

4.2 Surgical Assessment Unit Nil

4.3 Hospital In The Home 0700-2200hrs

4.4 Psychiatric Emergency Care Centre Services Nil

5.1 Urgent Care Centre Nil

5.2 Health Direct advice line 24 hours

5.3 Connecting Care 0800-1630

5.4 After Hours GP Clinic Nil

2

Describe your Fast Track Model

Key principles Benefits of the Model Challenges Clinician run model (attach model guideline)

• Inclusion and exclusion criteria .

• Identified by Triage Nurse or FAST TRACK staff.

• Separate physical space and model to the rest of the ED.

• Must be recognised as a crucial role, rather than a complimentary role to the ED.

• Operational Plan to stipulate space, processes and staffing.

• Requires flexibility for a contingency plan for those who become evident that are not Fast Track.

• Requires escalation triggers to allocate appropriate resources.

• Capacity to manage high volume, low acuity patients in a reasonable timeframe.

• Gives structure and support to achieving NEAT for those discharged patients.

• Framework for Advanced clinical Nurses.

• Consumer satisfaction

• Staff Satisfaction

• Decreased Departmental overcrowding/ settled waiting room.

• Staffing profile

• Appropriate streaming from triage.

• Allocation of medical staffing

• Space

• Handing over patients into the sub acute stream if deemed necessary (Dr to Dr).

• Community awareness (initial phase)

• Sustainability and consistency (initial phase)

3

Microsoft Word Document

Differences between your Model and the definition in the “Emergency Department Models of Care July 2012”

FAST TRACK (MoH MoC 3.7 - 2012) FAST TRACK (TRRH ED – 2013)

Definition / Key Principles

• Pre Determined Inclusion/ Exclusion criteria

• Ambulant• Non Complex (Single System)• Seen Time – Discharge Time <2hrs• Expedites Care• Diverts patients into a particular stream• Dedicated Senior Medical and Nursing staff working to

optimise performance of Fast Track systems and the ability to make timely treatment and disposition decisions with minimal consultation

• Provides Care that is Standardised and targeted to specific conditions and injuries.

• Operating Hours reflect high demand periods

• Dedicated space and staff• Commences treatment early• Strict inclusion/ exclusion supported by business rules• Clinical Protocols that promote early initiation of nursing

care

• Rapid access to imaging and pathology• Easy access to specialty outpatient, GP and community

referrals

Inclusion criteria included in Operations Plan (2011), meets these specifications.√√√√√Ongoing - Work to be done -Consistent Medical coverage (Nurse Practitioner can lead model)and-Framework in developing Advanced Clinical Nurse role.

Requires auditing process

Medical availability 0800-2200hrs (inconsistent) Nursing coverage 1030-1900hrs (consistent) specifically for Fast Track, Nursing availability 0845-0300 for cubicle area (extension from FT area) √Reliant on CIN, but uses a “pull” ideology from the WRRequires R/V, updating and “polishing”Currently CIN protocol (ACN phase 1) requires ACN Phase 2 to be developed to incorporate Wound management/ fracture management

Imaging yes, Pathology discouraged√

4

Identify the Resource Required for your Fast Track Model

5

What do you need to set it up? Tamworth ED

Staffing (FTEs, Designation) 1x Nursing – 1030-1900hrs 7 days per week1x Medical – Variable, but aim 1030-1900 between both M and E shifts.1x Nurse Practitioner – Variable, although aim 1030 or 1230 starts

Training In-servicesAlthough aim at developing Advanced Clinical Nurses accreditation

implementation requirements Commitment PlanSustainability(had NUM 1’s undertake QAP methodology in evaluating model)

Guidelines, policies, Needs to be developed

Physical space Yes and needs governing

Clinical operation plans Yes (see slide 3)

Monitoring and Evaluation

Monitor Evaluation

Arrival - Time Seen Benchmark Australian Literature illustrates minimal contribution to timely intervention of care.Focus must be on accreditation of Nurses to meet ACEM definition in initiating early intervention as per a Local guidelines approved by the director Emergency Medicine.

Length of Stay Benchmark Australian Literature illustrates moderate benefit in overall LOS in the ED, adding benefit to NEAT.Processes of Fast Track the patients journey through ED, benefit majority ATS cat 4’s and 5’s.

48hr Representation Benchmark NP monitors 48hr representations (if seen by NP)

Ambulance- Transfer of Care Does not promote ambulance offloading into this area

Over census patients in ED, Patients staying in this are overnight.

Problematic as no nurse allocated to this area.

6

Evidence of Success

Improvement in KPIs since implementation

Triage Benchmarks LOS 48hr representation DNW

Impact on overall service

Sustainability Required post implementation review and recommendations Requires ongoing discussion and commitment – ward meetings/ excellence rounding

Transferability Model to be reviewed prior to moving into redevelopment, aiming to promote Advanced clinical roles for nurses (in procedures, under the supervision of NP or MO)

Aim to increase number of staff to suit the volume of daily through put (i.e. 2 x ACN : 1 x NP/ MO), similar to “RITZ” Model (rapid intervention treatment zone in the UK) different to “PIT” Physician in Triage Model.

Attach supporting evidence

7

Evidence Trends/ Impact on Service

8

LAOR%

DNW%

Represent <48hrs %

Admit < 4hours

Admit < 6hours

Admit < 8hours

Discharge< 4hoursNon admit

Discharge< 6hoursNon admit

Discharge< 8hoursNon admit

Total Presentation

Feb 10 0.84 9.63 8 22 - - 75 - - 3320

Feb 11 0.9%(1)

6.9 (6.4)

6.7(6.2)

20.2 44.4 66.2 76.4 91.4 96.2 3000

Feb 12 1.7(1.8)

8.1(5.8)

7.2(5.7)

19.2 42.4 60.8 63.1 83.9 93.2 3211

Oct 12 2.6(1.5)

4.3(4.3)

5.4(5.0)

26.6 52.1 70.6 74.6 89.1 95.4 3405

Dec 12 1.82 3.25 6 27 - - 80 - - 3682

May 13 1.7(1.4)

4.5(3.8)

5.3(5.1)

28.5 56 72.9 76.9 92.3 96.8 3405

July 13 1.27* 3.83* 6* 31* - - 82* - - 3350*