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Dr Justin Yeung, Albany Health Campus - NEAT – The Journey of a Regional WA Site
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Dr Justin Yeung, Albany Health Campus - NEAT – The Journey of a Regional WA Site


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Dr Justin Yeung delivered the presentation at the 2014 Emergency Department Management Conference. …

Dr Justin Yeung delivered the presentation at the 2014 Emergency Department Management Conference.

The 2014 Emergency Department Management Conference explored areas such as how to improve access to care, clinical redesign, NEAT compliance, patient flow, point of care testing, geriatric care, and enhance the performance of Emergency Department.

For more information about the event, please visit:

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  • 1. Big  Smoke  to  Sleepy  Hollow   The  NEAT  journey  of  a  small  regional   hospital   Jus=n  Yeung  
  • 2. The  Big  Smoke  
  • 3. The  Australian  Magazine  -­‐  November  17-­‐18  2007  
  • 4. The  Australian  Magazine  -­‐  November  17-­‐18  2007  
  • 5. Expert  Panel  Review  of  Elec=ve  Surgery  and  Emergency  Access  Targets  under  the  Na=onal  Partnership  Agreement  on   Improving  Public  Hospital  Services     Report  to  the  Council  of  Australian  Governments  30  June  2011  
  • 6. RPH  ED  cri=cal  care  corridor  –  1030  am,  April  2010    
  • 7. Coronial  Inquest  into  death  in  August  2008  –  July  16  2012  
  • 8. Coronial  Inquest  into  death  in  August  2008  –  July  16  2012  
  • 9. Coronial  Inquest  into  death  in  July  2009  –  July  16  2012  
  • 10. Overcrowding?   •  A  sense  of  urgency?   •  What  problem?  
  • 11. 50% 60% 70% 80% 90% 100% 04/07/10 25/07/10 15/08/10 05/09/10 26/09/10 17/10/10 07/11/10 28/11/10 19/12/10 09/01/11 30/01/11 20/02/11 13/03/11 03/04/11 24/04/11 15/05/11 05/06/11 26/06/11 Week Ending 10/11 Weekly - % ED FHR Admissions with LOE <= 4 Hours 09/10 10/11 Change  in  Medical  Model  –  VMP  to  salaried  (09/10  vs  10/11)   Admissions  within  4  hours  
  • 12. ED PATIENT JOURNEY : TRIAGE TO DISPOSITION EDPATIENTJOURNEYROLES/TASKS PATIENT IN EMERGENCY DEPARTMENTTRIAGE Pathway 1 Straight into department TN1, CO2 – CO7, Dr2, N1, C5 ADMIT Theatre Ward – direct HITH CO14,NP7,Dr10,N6,C6 DISCHARGE CO15,NP8,Dr11, N6-7, C7, TN7 TRANSFER CO16,NP9,Dr12,N6-7,C8 PATIENT ARRIVES ED Coordinator - CO N1: Commences nursing assessment and care after allocation by CO. C6 ADMIT: complete any unfinished data on MR1, stamp MR55A with “ED” stamp, electronic admission – process sheet, place patient sticker in Admission book, notify CO when admission completed, put patient notes in pt’s pigeon hole correlating to ED bay patient is in. C7 DISCHARGE: appointments. C8 TRANSFER: photocopying etc info required for transfer. C5: Bedside registration: leaves triage desk to complete. Uses C.O.W. Whilst completing b.s reg in ED, TN will alert C to subsequent patients arriving who may also require b.s.registration prior to C returning to triage. C1: completes & checks accuracy of demographics. C2: Retrieves medical records C3: Makes up ID band. C or TN puts ID band on patient (primary nurse ultimately responsible for ensuring ID band worn). C4: Makes up / prints stickers and places with patient’s file. Dr2: Receives handover from CO / TN. Dr1: info collected by Dr / CO & communicated to TN & C TN1: TN obtains demographics of patient at Triage desk: clinical info, name, DOB. Ward Clerk obtains some demographic information. If ED Ward Clerk not present, then TN obtains all information required for Triage. TN2: Allocates to disposition: ie stream and Pathway1 or Pathway2 TN3: Initiates early assessment and treatment ► Analgesia: need to develop criteria around this. ?pain scale within criteria? As guide? What do other sites do? ► Investigations: Imaging. NOT bloods. Need to develop inclusion and exclusion criteria and consultation criteria around this task. ► Nursing Care: hydration, basic dressings, ice/heat packs, collect urine sample, immobilisation (eg bandages/ slings), weights, bsl’s. TN4: Monitors wait room and communicates process/ timeframes to patient, esp in ATS breaches. Responds to enquiries from patients, eg time until entry into ED. TN5: Re-assesses and re-triages as necessary Guide for reassessment time-frames: ►ATS 3 – reassess within 30mins ►ATS 4 – reassess within 60mins > reassessment times monitored by elec. tracking system ►ATS 5 – reassess within 90 mins. TN6: Handover to CO &primary nurse for Pathway1 patients: TN contacts CO on DECT phone or face-to-face that they are bringing patient into ED. TN meets CO at door / in ED and provides patient handover. TN7: Notifies C and CO re patients requiring bedside registration. CO8: Patient called into department by NP, Dr or CO. Dr calls patient into department and liaises with CO re same. CO &NP liaise re patients seen by/allocated to NP. CO4: CO receives clinical h’over from TN&allocates bed. CO5: CO keeps whiteboard up to date (this will change to maintaining electronic tracking system). CO6: CO liaises with family in “complex” situation (otherwise primary nurse in standard situation). CO7: CO allocates nurse & notifies Dr of pt entering ED. CO9: CO allocates nurse with appropriate skills following Dr request for nurse assistance. CO10: CO re-allocates nurse / Dr to higher acuity patients entering ED as clinically indicated. CO may initiate treatment as required (eg ATS 1-3) when Dr/nurse not readily available. CO monitors patients in department and has awareness of patients’ acuity and location in ED, staff allocated to each patient, workload/capacity/whereabouts of staff members (including when staff momentarily out of department). CO1: PRIOR NOTIFICATION * Info collected by Dr / CO & communicated to TN, C & floor staff. Only CO and Dr to take these calls. * SJA, Community Mental Health and Police prior notification calls to be taken by CO. Switch to forward to CO DECT phone. CO to inform TN (slip of paper?). CO answers ambulance phone. Incoming prior notification calls from doctor should be directed to Dr. CO to hand to Dr. ?Dr to carry DECT phone? (to be investigated) CO2: Liaises with Triage Nurse or CO monitors tracking system. CO3: Prioritises patient flow by stream, time of arrival, and ATS. ATS 1&2 – seen immediately (brought straight into department). ATS 3-5 – seen in order of arrival. Streaming: Complex and Non-complex streams. CO11: prioritises order, liaises with departments, informs nurses & Dr. **discussions required with imaging/lab re processes around this. CO14: CO notifies Nurse Manager for ward allocation, allocates admitting Dr, notifies admitting ward coordinator, liaises with primary nurse re patient readiness for transfer to ward, and calls admitting ward to arrange collection of pt. CO or primary nurse notifies NOK re patient admission. CO15: monitors patients discharged from ED. CO16: ensures notes ready for transfer with patient. Dr3: Patient called into department by NP, D or CO. Dr and NP liaise with CO re where pt is allocated. Dr4: informs CO of need for nurse. Dr5: med assessment of pt Dr6: organises investigation and informs CO Dr9: informs CO pt ready for disposition. Dr10 ADMIT: ad.checklist, notify admitting Dr, may notify family/pt. Dr11 DISCHARGE: summary of attendance, letter,scripts, referrals, provide X-rays. Informs N and CO of patient dc from ED. Dr12 TRANSFER: as per D10. Dr to Dr h’over. Triage Nurse - TN Doctor - Dr Nurse - N Nurse Practitioner - NPClerk - C N2: collaborates with Dr in patient care. Completes nursing physical assessment & informs Dr of same. OPI screen. N3: informs CO of investigation requested in liaison with Dr. N6: Nsg documentation complete. Liaison with NOK as appropriate. N7: Provide starter pack, coding, provide with X-rays. Arrange appointments as appropriate (eg wound clinic) NP1: Patient called into department by NP, D or CO. Dr and NP liaise with Coord re where pt is allocated. NP2: NP assessment NP3: organises investigation and informs CO NP6: informs CO pt ready for disposition. NP7: liaise coordinator re arranging admitting Dr, ad.checklist, notify family/pt. NP8: complete summary of attendance, letter, scripts, referrals, provide X-rays. NP9: liaise with coordinator re arranging admitting site/Dr/team. Investigation required? order test test done results reported N4: Involved in collaborative patient care. N5: informs CO of consultation requested in liaison with Dr. NP4: may request additional clinical assistance via CO. NP5: organises consultation and informs CO. Dr7: requests clinical assistance via CO. Dr8: organises consultation and informs CO. CO12: arranges additional staff on request (eg orderly). See escalation plan. CO13: CO aware of referral for consult, time of referral, & can f.up if not acted on within “reasonable” timeframe. yes PROCEDURE Dr7, NP4, CO12, N4 noPrior notification Coordinator / Dr CO1, Dr1, C1-C4 PDD INVESTIGATION CO11, TN8 access block INVESTIGATION Medical Imaging, Pathology CO11, NP3, N3, Dr6 Decision on Disposition Dr9, NP6 no NP INVOLVEMENT NP2 MEDICAL INVOLVEMENT Without nurse: Dr5 with nurse: Dr4+5, CO9, N2 Walk ins triaged by Triage Nurse V3 CONSULTATION Medical, Nursing or Other Specialty CO13, NP5, N5, Dr8 Nurse only consultations NURSE N4 SJA arrival triaged by Coordinator TN1 – TN6 Police escort COORDINATOR INVOLVEMENT CO10 V1 V2 V4 V5 Possible decision on disposition PDD TRIAGE TN1-TN7 C1-C4 CO2 – CO3 Patient facilitated into department NP1,CO8,Dr3 WAITING ROOM Pathway 2 "Can waits” TN4, TN5 TN8: TN completes coding for discharged patients OTHER: TN must have achieved Triage Competency to act as TN within ARH ED. TN maintains equipment and stocks in Triage Room at commencement of shift.
  • 13. ED  changes  in  a  nutshell   •  Defined  ED  coordinator  /  flow  posi=on   –  Separate  triage  and  coordinator  role   •  Increased  clerical  cover   •  Refurbishment  of  mental  health  interview  room   •  ED  to  ward  checklist  /  handover  document   •  “streaming”   •  Pa=ent  tracker   •  Guinea  pigs  
  • 14. Increased  ED  capacity   •  2  Resuscita=on  bays  (+  1)   •  8  general  assessment  bays  (+2)   •  1  nega=ve  pressure  room   •  2  procedure  rooms   •  4  fast  track  bays  (+4)   •  Plaster  room  (+1)   •  Observa=on  ward  (+4)  
  • 15. Coronial  Inquest  into  death  in  July  2009  –  July  16  2012  
  • 16. 5400   5900   6400   6900   7400   7900   8400   8900   9400   9900   0   10   20   30   40   50   60   70   80   90   100   2010  Q3   2010  Q4   2011  Q1   2011  Q2   2011  Q3   2011  Q4   2012  Q1   2012  Q2   2012  Q3   2012  Q4   2013  Q1   2013  Q2   2013  Q3   2013  Q4   2014  Q1   NEAT  total  %   NEAT  admission  %   NEAT  discharge  %   NEAT  transfer  %   presenta=ons   Quarterly  NEAT  data  –  2010-­‐2014  
  • 17. 0   50   100   150   200   250   Triage  1   Triage  2   Triage  3   Triage  4   Triage  5   Total   FIN  2010/11   FIN  2011/12   FIN  2012/13   FIN  2013/14   Median  length  of  episode  (minutes)  –  10/11  to  13/14  
  • 18. Have  we  made  things  harder?   •  Doctors  on  site   •  “Deskilled  nurses”   •  Grown  up  hospital   – Changed  medical  model  (fewer  VMPs,  more   salaried  /  specialist  lead  teams)   •  Increased  governance  /  supervision   •  Increased  cri=cal  thinking  /  safety   – More  forms  /  paperwork  /  minimum  standards   – Harder,  beier,  stronger,  faster?  BIGGER    
  • 19. NEAT  total  %  –  FY  12/13,  13/14  
  • 20. Admission  rate  from  ED  –  FY  12/13,  13/14  
  • 21. NEAT  Admissions  <  4  hours  –  FY  12/13,  13/14  
  • 22. NEAT  Discharges  <  4  hours  –  FY  12/13,  13/14  
  • 23. Did  not  wait  –  FY  12/13,  13/14  
  • 24. Access  block  –  FY  12/13,  13/14  
  • 25. What  have  we  done  …  restart     •  ED  breach  comments  and  analysis   – Daily  review  at  Nurse  manager  mee=ng   •  Introduced  “Booking  slip”     •  Audit   – Manual  admissions   – Surgical  admissions   – Radiology   •  Water  cooler  chat  
  • 26. a  Delay  to  seen  in  ED         b  Clinically  appropriate     c  Delay  ED  Management  Decision    
  • 27. a  No  bed  /  appropriate  bed  -­‐       b  Delay  transfer  to  ward  -­‐  why  eg.  staffing,  mul=ple  admits,  aner  hours   c  Orderly  delay      
  • 28. 70%   75%   80%   85%   90%   95%   100%   ED  breach  codes  discussed  at  Daily  nurse  manager  mee=ng   NEAT  %  total  –  2013/14   July  2013   June  2014   ED  booking  slip  
  • 29. Audits   •  30  admission  audit  (Oct  2013)   – Surgery  breaches  62%   – GP  VMP  medical  breach  26%   – SMP  salaried  medical  breach  44%   – 2  cases  /  day  suitable  for  observa=on  ward   •  6  week  surgical  admissions  (June  2014)   – 58%  surgery  breaches   – If  geong  CT,  97%  breached  4  hour  target  
  • 30. What’s  next   •  Determining  what  actually  maiers.   – High  acuity  pa=ents   – Admiied  pa=ent  cohort   – Minimising  =me  in  ED    
  • 31. What’s  next   •  ED  nurse  triage  admission  predic=on.   – 80%  PPV   – 87%  NPV   •  Nurse  ini=ated  treatment  pathways.   – IT  to  support  this  (informa=on  tracking,  CPOE)   •  No  new  deckchairs  =  streaming  /  priori=sa=on   •  No  new  sundecks  =  flexibility  for  short  stay  /   observa=on   •  Tipping  point