Optimising triage, waiting times and service delivery in

busy emergency departmentsbusy emergency departments

Suzanne MasonProfessor of Emergency Medicine

University of SheffieldUniversity of SheffieldSheffield Teaching Hospitals NHS Trust

Importance

• ED crowding a majorED crowding a major international problem

• Understanding the organisational challenges g gmay help specialty achieve gains more swiftly g yand less painfully

3

Wh i d i i h ?What is driving change?Policy User behaviourPolicy

• NHS Plan– Reducing ED waiting times

• Reforming Emergency Care

• Increased demand for and use of emergency services

• Users inappropriately accessing f

g g y– 4-hour target; Improve access; new

ways of working• Transforming NHS Ambulance Services

higher level of care than they need(Lowry 1994; Victor 1999)

• High proportion of patients arriving to ED by ambulance are

– mobile health resource; taking healthcare to patient; reducing ED attendances

• NHS Next stage review

to ED by ambulance are discharged without referral

(Pennycook1991; Volans 1998)

• Social mobilityC l it f bl

g– care nearer patient, quality,

changing expectation• European Working Time Directive; GP

contract

• Complexity of problem• Expectations• Time-sensitive care• Ageing populationcontract • Ageing population• GP behaviour

Is crowding bad for patients?

Is crowding bad for patients?• Crowding negatively impacts

– Time to thrombolysis Time to antibiotics– Time to antibiotics

– Meeting quality targets for cardiac care – Treatment of pain

F ti l t t– Functional status – Mortality – Errors – Hospital Length of Stay

• Schull 2004; Fee 2007

A service concept?

• The ED should be the hub of the emergency care system– Deficits in primary care or community services will

increase ED workloadTimely and efficient procedures for admission to– Timely and efficient procedures for admission to hospital are essential to prevent ED overcrowding

– Demands for emergency care are increasing g y gannually and the current emergency care systems are working near the limits of capacity

The Way Ahead 2008 UK College of Emergency MedicineThe Way Ahead, 2008. UK College of Emergency Medicine

Strategies

1. Reduce attendances2. Improve flow3. Avoid admission4. Improve exit

M 2006 H l d 2004• Munro 2006; Holroyd 2004

Reducing attendances• Patterns of accessingPatterns of accessing

emergency care– Increasing numbers via GP etc

Penson 2007; Thompson 2010– Penson 2007; Thompson 2010

• Redirecting patients appropriately and safely to other sources of care?

– Washington, 2002

• WIC, NHSD – no effect onWIC, NHSD no effect on reducing attendances in UK or USWill t t b th• Will urgent care centres be the answer?

Role of ambulance service• Increased role inIncreased role in

assessing, treating and signposting patientsg p g p– Hampered by time targets

• Paramedic practitioners reduced transfer of elderly fallers by 25%M 2007• Mason 2007

• ECPs increased on-scene discharges by 37%discharges by 37%

• http://www.sdo.nihr.ac.uk/sdo982005.html

Improve flowImprove flow• See and Treat

Patient sees only one professional who can– Patient sees only one professional who can make decisions, usually a senior doc or ENP

• Streaming– Separating minors and majors. Effective as p g j

demonstrated by numerous studies• Sanchez 2006; Kilic 1998; Ieraci 2008;

• Senior doctor triage Feel if have someone • Senior doctor triage– All cases: Terris 2004; Choi 2006; Subash 2004.

Majors cases: M 2005

senior up front, 90% of time will make right decisions about tests… (Bus Mgr, ED )– Majors cases: Mason 2005

Admission avoidance

The Clinical Decision Unit‘Patients with a low risk of high risk condition’

• Little evidence of impact on ED flowimpact on ED flow

• No RCTs• Good for some

pathways of care• ?dumping grounds –

th li i l i d i ithe clinical indecisionunit

Clinical fast tracking

• Condition specific– DVT, low risk CP, #NOF, stroke, STEMIDVT, low risk CP, #NOF, stroke, STEMI

• Nurse-led• Impact on admission rates• Impact on admission rates• Increased workload / resources for ED

– Increased referrals from community

front end was sorted, but the back end continued toThe Backdoor the back end continued to be a big, big block (NM)

• Medical/Surgical Assessment Units• Acute PhysiciansAcute Physicians• Admission and Discharge Planning

E l di h ti• Early discharge preparation• Discharge lounge enforcement• Community beds Reach 98% for patients going

home, but can’t get referrals into hospital. .. They haven’t

l d th b k d di hsolved the back door, discharge planning and community services. (LC)

What is happening now?

Monitoring time in ED(N=15 EDs N=774 095 patient episodes)(N 15 EDs, N 774,095 patient episodes)

2003

isod

es

14

16

18

Discharged

Adm itted

2004

odes

14

16

18

D ischarged

Admitted

Perc

enta

ge o

f atte

ndan

ce e

p

2

4

6

8

10

12

Per

cent

age

of a

ttend

ance

epi

so

2

4

6

8

10

12

Total tim e in departm ent (m inutes)

0 60 120 180 240 300 3600

2

Total tim e in departm ent

0 60 120 180 240 300 3600

2

2005

16

18 2006

16

18

ntag

e of

atte

ndan

ce e

piso

des

6

8

10

12

14

DischargedAdmitted

tage

of a

ttend

ance

epi

sode

s

6

8

10

12

14

16Discharged

Adm itted

Total time in department (minutes)

0 60 120 180 240 300 360

Per

ce

0

2

4

Total tim e in departm ent (m inutes)

0 60 120 180 240 300 360

Perc

ent

0

2

4

ED factors influencing waiting times

• 65% (n=137) of type I UK EDs participated• Structured interviews, clinical data, HCC data,

i d th t din-depth study• 14% mean WT relates to size and casemix

35 3% WT l t t i k• 35.3% mean WT relates to nurse sickness, non-pay spend and lead clinician style

• EDs with longer mean WT have higher levels• EDs with longer mean WT have higher levels of psychological strain and greater autonomy and control over workand control over work

http://www.sdo.lshtm.ac.uk/files/project/49-final-report.pdf

SAFETIME studySAFETIME study

• Data from 15 UK EDs in-depth interviews 9Data from 15 UK EDs, in depth interviews 9 EDs

• Streamlining process vs providing less careStreamlining process vs. providing less care• Trust engagement• Leadership from ED• Leadership from ED• Staff costs and benefits

Impact on personnel• Burden of the target falls most heavily on nurses

Feel like my personal responsibility to

• Opportunity for greater nursing power autonomy

Feel like my personal responsibility to make sure patient doesn’t breach. (Senior staff nurse, ED)

Opportunity for greater nursing power, autonomy or skills enhancement Empowered emergency nurses to start patient

work-ups. (Business Manager, ED) Nurses became much more directive (LC, ED)

• Increased patient satisfaction, fewer complaints• Detrimental impact on training and practical

became much more directive (LC, ED)

Detrimental impact on training and practical procedures

• Focus on decision makingUsed to do more teaching on floor…. not much time now, we Focus on decision making much time now, wehave to keep moving. (LC)

The future?• Sustainability• Quality metricsy• Consultant-led

serviceservice• Observation

medicinemedicine