Suzanne Mason: Optimising triage, waiting times and service delivery in busy emergency departments
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Suzanne Mason: Optimising triage, waiting times and service delivery in busy emergency departments






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Suzanne Mason: Optimising triage, waiting times and service delivery in busy emergency departments Suzanne Mason: Optimising triage, waiting times and service delivery in busy emergency departments Presentation Transcript

  • Optimising triage, waiting times and service delivery inbusy emergency departments Suzanne Mason Professor of Emergency Medicine University of Sheffield Sheffield Teaching Hospitals NHS Trust
  • Importance• ED crowding a major international problem• Understanding the organisational challenges g g may help specialty achieve gains more swiftly g y and less painfully
  • 3 What is driving h Wh i d i i change?? Policy User behaviour• NHS Plan • Increased demand for and use of – Reducing ED waiting times emergency services• Reforming Emergency Care g g y • Users inappropriately accessing higher level of care than they need f – 4-hour target; Improve access; new (Lowry 1994; Victor 1999) ways of working• Transforming NHS Ambulance Services • High proportion of patients arriving to ED by ambulance are – mobile health resource; discharged without referral taking healthcare to patient; (Pennycook1991; Volans 1998) reducing ED attendances • Social mobility• NHS Next stage review g • Complexity of problem C l it f bl – care nearer patient, quality, changing expectation • Expectations• European Working Time Directive; GP • Time-sensitive care contract • Ageing population • GP behaviour
  • Is crowding bad for patients?
  • Is crowding bad for patients?• Crowding negatively impacts – Time to thrombolysis – Time to antibiotics – Meeting quality targets for cardiac care – Treatment of pain – Functional status F ti l t t – 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 workload – Timely and efficient procedures for admission to hospital are essential to prevent ED overcrowding – Demands for emergency care are increasing g y g annually and the current emergency care systems are working near the limits of capacityThe Way Ahead, 2008. UK College of Emergency Medicine Ahead 2008
  • Strategies1. Reduce attendances2. Improve flow3. Avoid admission4. Improve exit• Munro 2006 H l d 2004 M 2006; Holroyd
  • Reducing attendances• Patterns of accessing emergency care – Increasing numbers via GP etc – Penson 2007; Thompson 2010• Redirecting patients appropriately and safely to other sources of care? – Washington, 2002• WIC, NHSD – no effect on reducing attendances in UK or US• Will urgent care centres b th t t be the answer?
  • Role of ambulance service• Increased role in assessing, treating and signposting p g p g patients – Hampered by time targets• Paramedic practitioners reduced transfer of elderly fallers by 25%• Mason 2007 M• ECPs increased on-scene discharges by 37%• ml
  • Improve flow• See and Treat – 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; Feel if have someone• Senior doctor triage senior up front, 90% of time will make right – All cases: Terris 2004; Choi 2006; Subash 2004. decisions about tests… (Bus Mgr, ED ) – Majors cases: M 2005 Mason
  • Admission avoidance
  • The Clinical Decision Unit‘Patients with a low risk of high risk condition’ • Little evidence of impact on ED flow • No RCTs • Good for some pathways of care • ?dumping grounds – the li i l indecision th clinical i d i i unit
  • Clinical fast tracking• Condition specific – DVT, low risk CP, #NOF, stroke, STEMI• Nurse-led• Impact on admission rates• Increased workload / resources for ED – Increased referrals from community
  • front end was sorted, but the back end continued to The Backdoor be a big, big block (NM)• Medical/Surgical Assessment Units• Acute Physicians• Admission and Discharge Planning• Early discharge preparation E l di h ti• Discharge lounge enforcement• Community beds Reach 98% for patients going home, but can’t get referrals into hospital. .. They haven’t solved the back door, discharge l d th b k d di h planning and community services. (LC)
  • What is happening now?
  • Monitoring time in ED (N 15 EDs, N 774,095 (N=15 EDs N=774 095 patient episodes) 2003 200 4 18 18 16 Discharged 16 Percentage of attendance episodes D is c harged odes A dm itted 14 14 A dm itted Percentage of attendance episo 12 12 10 10 8 8 6 6 4 4 2 2 0 0 0 60 120 180 240 300 360 0 60 120 180 240 300 360 T otal tim e in departm ent (m inutes) Total tim e in departm ent 2005 18 18 2006 16 16 Discharged tage of attendance episodes Percentage of attendance episodes Discharged A dm itted 14 14 Adm itted 12 12 10 10 8 8 6 6 Percent 4 4 2 2 0 0 0 60 120 180 240 300 360 0 60 120 180 240 300 360 Total tim e in departm ent (m inutes) Total tim e in departm ent (m inutes)
  • ED factors influencing waiting times • 65% (n=137) of type I UK EDs participated • Structured interviews, clinical data, HCC data, in-depth t d i d th study • 14% mean WT relates to size and casemix • 35 3% mean WT relates to nurse sickness, 35.3% l t t i k non-pay spend and lead clinician style • EDs with longer mean WT have higher levels of psychological strain and greater autonomy and control over work
  • SAFETIME study• Data from 15 UK EDs in depth interviews 9 EDs, in-depth EDs• Streamlining process vs. providing less care vs• Trust engagement• 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 make sure patient doesn’t breach. (Senior staff nurse, ED)• Opportunity for greater nursing power autonomy power, 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 procedures Used to do more teaching on floor…. not• Focus on decision making much time now, we have to keep moving. (LC)
  • The future?• Sustainability• Quality metrics y• Consultant-led service• Observation medicine