Senior
Assessment and
streaming
From Concept to creation
Dr Matthew Vukasovic
HOD Westmead Emergency
Need for change
ED waiting room…….back then
o Patients physically
segregated from the actual
ED
o Physical and psychological
barrier to pa...
Ambulance corridor
o Waiting room also functions
as a thoroughfare
o Patients feel neglected,
anxious and fearful
o NO add...
• Casualties of a sick system
• Julie Robotham Medical Editor SMH
January 10, 2009
• A WESTMEAD Hospital scheme designed t...
Our journey of innovation and
redesign
oCo-design project
Emergency and Cardiology Services
oIntegrated models of care
ED ...
Co- Design Project 2009
o Involving staff, patients
and carers to identify
current model of care
delivery and process
o De...
Patient and carer experiance
“When I came in, I think it was a little bit
long. I would say about 20 minutes,
anything cou...
Lessons learnt
o Analysis of the ‘Front of House’ processes
o Functionality
o Patient safety
o Performance
o Aesthetics of...
Trauma redesign project
o Improve experience
for trauma patients
o Understand ‘as is’-
current state’ vs ‘to
be’- ideal st...
Process mapping project
• Delays to triage have
been validated in the
Emergency
Department process
mapping exercises
• Var...
Previous scenario’s
• Westmead 2009-2010
• Worsening Access block
• Worsening Triage benchmark performance
• High DNW rate
• High ED LOS
• Wel...
‘AN ED WITHOUT A WAITING ROOM’
Presentation for NSW Health
November 20th 2009
What did we propose?(2009)
• Quick triage
o Redesigning clerical & triage processes
• Senior decision making team at point...
Streaming
TRIAGE FRONT OF HOUSE
TEAM
Early decision making
ACUTE ED
FASTTRACK
MAU UNIT
ESSU/ETZ
Disposition
Early pregnanc...
Our journey of innovation
oInitial SAFE-T pilot (Dec 2010)
1 room
oESSU
6 beds
oSAFE-T and ETZ (Feb. 2011)
1-2 spaces plus...
SAFE-T Phase 1
• Clinical space
SAFE-T zone → 2 bed initial assessment
stream initiate zone (ASI), 5 treatment space
early...
SAFE-T
• Business rules
• Early Assessment (Bloods,Imaging,exam.)
• Early treatment (IV antibiotics,analgesia,fluids)
• 10...
Options from SAFE-T
Zone
Pilot Study Dec 2010Characteristic Control group Intervention group Comments
Eligible patients – ATS categories 3, 4
and 5...
SAFE-T trial data
• Trial period → 24/02/2011 – 08/05/2011
• Comparison period →24/02/2010 –
08/05/2010
• SAFE-T zone hour...
Time to first seen KPI
ATS
category
Category 1 Category 2 Category 3 Category 4 Category 5
Year
2010 100 % 81.4 % 49.5 % 5...
LOS – In SAFE-T hours
In SAFE-T hours Year
2010 2011
Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75...
Conclusions
• 5.2%(6.5%) increase in number of presentations
during the intervention period
• Statistically significant im...
Conclusions
• Most of the LOS reduction were noted during SAFE-T
hours of operation for ATS categories 3 and 4 (17.9%
and ...
• Need to test your MOC in current environment
• Collect data to validate your MOC
• Publish this data if possible
• Provi...
The journey continues
o Building works 2012-2013
o New UCC opens ( 6 treatment spaces +2)
o New Resuscitation rooms open
•...
Models of Emergency Care
Emergency Services, Westmead Hospital
Defining the ideal patient
journey
... Emergency Department Models of Care Redesign
ED Front End processing
... Quick triage
and
registration
ED Front End Processing
... SAFE-T
ETZ Six chairs & two trolleys
Considerations for streaming patients through ASI model of care
• ED capacity including
Workforce (availability of senior ...
ETZ
ED RMO
Works in ASI &
ETZ
Senior Nurse
CIN level
2 hours
Initiate treatment while
awaiting transfer to ED
MoC
Observe ...
Trauma and resuscitation
Four resuscitation bays
including 1 dual function
isolation room
249
234
258
228
262 258
276
311 302 306
650 650
672
714 706
752
679
728
767
677
97
84 83
109
128
144
104
124
102 94
34 35
...
24 Beds
Acute care...
1 hours for ED assessment and commence
clinical management plan. ED SMO will review
patient within1 hour and make a decisi...
Four chairs
Two Trolleys
Two Consult Rooms
One Procedure Room
Waiting Room
Urgent Care Centre
UCC: TOTAL PRESENTATIONS WITH LOS < 2 HRS
4494
5386
5515
6789
6586
5962 6009
6786
1665
1790 1814
2109
2549
2176
2611
3364
...
Four beds
Four chairs
Emergency Short Stay Unit
(Discharge stream)
Urgent care
centre
SAFE-T
Acute care
Features of ESSU Model
Special purpose beds.
High turnover.
NOT interchangeable with ...
ESSU: AVG LOS WITH LOS <4HRS
13:23
12:02
10:16
10:55
11:25
10:01
9:10
9:44
8:14
7:45
139
91
275
155
219
252
276
335
435
46...
ESSU: TOTAL PRESENTATIONS WITH LOS <24HRS
608
421
951
810
1010 991
1108
1217
1377
1457
0
200
400
600
800
1000
1200
1400
16...
Acute Admissions Unit
(Admission stream)
SAFE-T
Acute care
Features of the AAU Model of care
Differentiated patient admitted under an
inpatient team but may need ....
Scenario 1
58 year old female presents with increasing back pain
Known metastases to sacral area
Background metastatic bre...
Scenario 2
25 year old female presents with lower abdominal pain
LMP 3 weeks ago
•Temp 36, HR 69, B/P 120/72, RR 14
Scenario 3
65 year old male presents with one episode of PR
bleeding. Nil past history, Family history of Bowel Ca
Otherwi...
Scenario 4
52 year old male, sudden onset Left flank pain
Pain 10/10
Unable to pass urine
Scenario 5
33 year old male currently on chemotherapy for AML
Febrile with temp of 38.5, BP 130/70, HR 130/min
No beds in ...
Lessons learnt
• Any new MOC requires staff collaboration and
engagement
• “Listen” to feedback
• Importance of education ...
Dicussion
• Staffing
• Complex roles(need to be clearly defined)
• Senior decision maker
• Adding value(bloods,imaging,tre...
Discussion
• Role of ETZ
• 10 minute limit
• Rapid triage
• Ambulance offloads
• Access block
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation
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Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation

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Matthew Vukasovic, Director of Emergency Medicine, from Westmead Hospital, NSW delivered this presentation at the 5th annual Emergency Department Management conference. For more information on the annual conference, please visit:
www.healthcareconferences.com.au/edmanagementconference

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Piloting A Senior Assessment And Streaming Model Of Care: From Concept To Creation

  1. 1. Senior Assessment and streaming From Concept to creation Dr Matthew Vukasovic HOD Westmead Emergency
  2. 2. Need for change
  3. 3. ED waiting room…….back then o Patients physically segregated from the actual ED o Physical and psychological barrier to patients o Minimal observation of patients possible o Minimal therapeutic interventions
  4. 4. Ambulance corridor o Waiting room also functions as a thoroughfare o Patients feel neglected, anxious and fearful o NO added value for the patient within the waiting room o Ambulance OST delays
  5. 5. • Casualties of a sick system • Julie Robotham Medical Editor SMH January 10, 2009 • A WESTMEAD Hospital scheme designed to slash costs and improve performance statistics by getting patients out of ambulances more quickly contributed to the deaths of two patients, who received sub- standard care in the emergency department, internal investigations claim
  6. 6. Our journey of innovation and redesign oCo-design project Emergency and Cardiology Services oIntegrated models of care ED HOPE (MAU) oNew models of emergency care Fast Track oProcess mapping projects oRedesign projects Trauma redesign project oInternal waiting room proposal 2006 2007 20092008
  7. 7. Co- Design Project 2009 o Involving staff, patients and carers to identify current model of care delivery and process o Designing improvement strategies collaboratively
  8. 8. Patient and carer experiance “When I came in, I think it was a little bit long. I would say about 20 minutes, anything could happen in 20 minutes. They should have put me straight in.” (Patient: Co-design project) “After being assessed by the triage nurse & before going into the Emergency ward I was in quite a lot of pain. It would have been good to have had some pain killers and also to have some privacy” (NSW Patient survey) That was very hard because the triage nurse, she is trying to type your name & address and I’m thinking can we just get him in and I can do all of that later. Then she sent me to the other counter to register my husband” (Carer: Co- design “It was scary, a lot of things go through your mind when your husband is sick. I was grateful when we go inside, once on a bed I felt a lot better, more secure” Carer: Co-design Project
  9. 9. Lessons learnt o Analysis of the ‘Front of House’ processes o Functionality o Patient safety o Performance o Aesthetics of the ED experience o Analysis of the whole interaction for the patient/carer o Impact on clerical, nursing and medical staff o Importance of project management o Project plan
  10. 10. Trauma redesign project o Improve experience for trauma patients o Understand ‘as is’- current state’ vs ‘to be’- ideal state’ o 18 process maps o Voice of the patient o 1:1 staff interviews o Focus groups Trauma redesign workshop 5th August 09 1- 5pm
  11. 11. Process mapping project • Delays to triage have been validated in the Emergency Department process mapping exercises • Variable delays can be 10 minutes to > 1 hour to triage
  12. 12. Previous scenario’s
  13. 13. • Westmead 2009-2010 • Worsening Access block • Worsening Triage benchmark performance • High DNW rate • High ED LOS • Well known adverse effects o Adverse clinical incidents o Performance degradation and delays in care o Staff and morale issues o Training and recruitment issues o Patient dignity and privacy issues
  14. 14. ‘AN ED WITHOUT A WAITING ROOM’ Presentation for NSW Health November 20th 2009
  15. 15. What did we propose?(2009) • Quick triage o Redesigning clerical & triage processes • Senior decision making team at point of entry o Senior doctor and nurse (CIN) • Early streaming models • Internal ETZ to replace the waiting room • Separate pathways for streamed patients NO waiting room ED
  16. 16. Streaming TRIAGE FRONT OF HOUSE TEAM Early decision making ACUTE ED FASTTRACK MAU UNIT ESSU/ETZ Disposition Early pregnancy assessment clinic PECC
  17. 17. Our journey of innovation oInitial SAFE-T pilot (Dec 2010) 1 room oESSU 6 beds oSAFE-T and ETZ (Feb. 2011) 1-2 spaces plus 4 in ETZ 2010 2011 20132012
  18. 18. SAFE-T Phase 1 • Clinical space SAFE-T zone → 2 bed initial assessment stream initiate zone (ASI), 5 treatment space early treatment zone (ETZ) • Staffing • ED Physician/Registrar • JMO • RN
  19. 19. SAFE-T • Business rules • Early Assessment (Bloods,Imaging,exam.) • Early treatment (IV antibiotics,analgesia,fluids) • 10 minutes per patient • Disposition planning • Early streaming (SSU,MAU,wards) • Acute care bed bypass/quarantining • ETZ • Discharge home or clinics • Early Inpatient team review
  20. 20. Options from SAFE-T Zone
  21. 21. Pilot Study Dec 2010Characteristic Control group Intervention group Comments Eligible patients – ATS categories 3, 4 and 5 67 90 More patients reviewed in same bandwidth during trial period. Length of stay – irrespective of ATS categories 451 minutes (95% CI 371 – 533) 324 minutes (95%CI 276 – 410) Median difference of 136 minutes (95% CI 61 – 211). p=0.0003 Time to medical intervention – ATS category 3 154.5 minutes (95%CI 27 – 251) n=34 patients 18 minutes (95% CI 16 – 29) n=43 patients Median difference of 116 minutes (95% CI 24 – 185) p<0.0001 Time to disposition – ATS category 3 557.5 minutes (95%CI 484 – 914) n=34 patients 410 minutes (95% CI 315 – 456) n=43 patients Median difference of 237.5 minutes (95% CI 107 – 401) p<0.0001 Time to medical intervention – ATS category 4 72 minutes (95% CI 37 – 128) n=25 patients 32 minutes (95%CI 17 – 49) n=35 patients Median difference of 37 minutes (95% CI 12 -79) p=0.0015 Time to disposition – ATS category 4 342 minutes (95%CI 222 – 395) n=25 patients 276 minutes (95%CI 222-403) n=35 patients Median difference of 19 minutes (95%CI -70 – 119) sided p=0.66 Time to medical intervention – ATS category 5 180.5minutes (95%CI 119 – 229) n=8 patients 27 minutes (95%CI 4 – 75) n=12 patients Median difference of 124.5 minutes (95%CI 63 – 185) Two sided p=0.0003 Time to disposition – ATS category 5 413 minutes (95%CI 295 – 547) n=8 patients 124minutes (95%CI 67 – 337) n=12 patients Median difference of 232 minutes (95%CI 64 – 390) Two sided p=0.01
  22. 22. SAFE-T trial data • Trial period → 24/02/2011 – 08/05/2011 • Comparison period →24/02/2010 – 08/05/2010 • SAFE-T zone hours of operation – 1000hrs to 1800hrs Year Total2010 2011 Status Out of SafeT hours 5039 5468 10507 In SafeT hours 5146 5245 10391 Total 10185 10713 (↑ 5.2%) 20898
  23. 23. Time to first seen KPI ATS category Category 1 Category 2 Category 3 Category 4 Category 5 Year 2010 100 % 81.4 % 49.5 % 54.8 % 76.8 % 2011 99.6% 92.3 % 69.1 % 73.4 % 86.3 % p- value p = 1.00 p < 0.001 p < 0.001 p < 0.001 p < 0.001 Year Percentage meeting criteria Time < 30 mins 2010 74.5 % 2011 79.5 % p-value p < 0.001 Off-Stretcher time KPI (OST)
  24. 24. LOS – In SAFE-T hours In SAFE-T hours Year 2010 2011 Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75 LOS (hours) All patients 6.0 3.9 8.8 5.5 3.2 8.2 LOS (hours) Discharged patients 3.8 2.5 5.3 3.5 2.3 5.1 LOS (hours) Admitted patients 7.6 5.6 10.5 6.9 4.8 9.9 In SAFE-T hours Year 2010 2011 Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75 LOS (hours) All patients 6.0 3.9 8.8 5.5 3.2 8.2 LOS (hours) Discharged patients 3.8 2.5 5.3 3.5 2.3 5.1 LOS (hours) Admitted patients 7.6 5.6 10.5 6.9 4.8 9.9 In SAFE-T hours Year 2010 2011 Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75 Category 1 P=0.358 5.1 3.7 7.2 4.9 2.9 7.8 2 P=0.118 6.4 4.4 9.2 6.2 4.1 8.6 3 P<0.001 7.5 5.3 10.5 6.5 4.2 9.4 4 P<0.001 5.7 3.6 8.4 4.9 2.8 7.6 5 P=0.017 3.5 1.9 5.4 3.1 1.7 5.0 In SAFE-T hours Year 2010 2011 Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75 Category 1 P=0.358 5.1 3.7 7.2 4.9 2.9 7.8 2 P=0.118 6.4 4.4 9.2 6.2 4.1 8.6 3 P<0.001 7.5 5.3 10.5 6.5 4.2 9.4 4 P<0.001 5.7 3.6 8.4 4.9 2.8 7.6 5 P=0.017 3.5 1.9 5.4 3.1 1.7 5.0
  25. 25. Conclusions • 5.2%(6.5%) increase in number of presentations during the intervention period • Statistically significant improvement in time to first seen and Off-stretcher time KPI across all categories • Statistically significant decrease in DNW rate • Median, 25th and 75th percentiles length of stay was reduced for all patients in 2011 compared to 2010 • Statistically significant LOS changes were noted in ATS categories 3 and 4 (14.3% and 11.8%)
  26. 26. Conclusions • Most of the LOS reduction were noted during SAFE-T hours of operation for ATS categories 3 and 4 (17.9% and 17.0%) • Increasing SAFE-T hours of operation to 12 hours will lead to statistically significant improvements in LOS for categories 3 and 4 ( 16.5% and 17.3%) • Positive effects despite significant worsening in Access block and hospital bed occupancy rates • Multiple ED throughput measures bundled in a model of care have significant positive impact on LOS
  27. 27. • Need to test your MOC in current environment • Collect data to validate your MOC • Publish this data if possible • Provides necessary impetus to drive change • Provides necessary evidence for your staff and executive
  28. 28. The journey continues o Building works 2012-2013 o New UCC opens ( 6 treatment spaces +2) o New Resuscitation rooms open • SAFE-T /ETZ opens (2 +8 treatment spaces) o Trial AAU( planning for new AAU) 2013 2014 20162015
  29. 29. Models of Emergency Care Emergency Services, Westmead Hospital
  30. 30. Defining the ideal patient journey ... Emergency Department Models of Care Redesign
  31. 31. ED Front End processing ... Quick triage and registration
  32. 32. ED Front End Processing ... SAFE-T ETZ Six chairs & two trolleys
  33. 33. Considerations for streaming patients through ASI model of care • ED capacity including Workforce (availability of senior decision maker) Vertical v Horizontal patient Bed availability in acute care ASI Front of House Cordinator Front of House Cordinator 10 minutes Admission stream • Acute (undifferentiated/complex) • AAU (Differentiated , allocated in pt team) Senior Doctor Junior Nurse Senior Nurse Triage level Discharge stream • ETZ 2 hours • UCC 2 hours • ESSU 2-23 hours • Waiting Room Blocked stream If appropriate MoC is access blocked send to ETZ
  34. 34. ETZ ED RMO Works in ASI & ETZ Senior Nurse CIN level 2 hours Initiate treatment while awaiting transfer to ED MoC Observe /treat patient for up to 2 hours prior to discharge Speciality team review Observe patient who symptoms are not well defined access block Provides increased ED Capacity when there is access block
  35. 35. Trauma and resuscitation Four resuscitation bays including 1 dual function isolation room
  36. 36. 249 234 258 228 262 258 276 311 302 306 650 650 672 714 706 752 679 728 767 677 97 84 83 109 128 144 104 124 102 94 34 35 46 49 43 35 35 50 51 31 8 5 9 11 11 5 11 12 6 10 0 100 200 300 400 500 600 700 800 900 SPRING 2010 SUMMER 2010/2011 AUTUMN 2011 WINTER 2011 SPRING 2011 SUMMER 2011/2012 AUTUMN 2012 WINTER 2012 SPRING 2012 SUMMER 2012/2013 RESUS PRESENTATIONS BY TRIAGE CATEGORY 1 2 3 4 5
  37. 37. 24 Beds Acute care...
  38. 38. 1 hours for ED assessment and commence clinical management plan. ED SMO will review patient within1 hour and make a decision (admit/discharge/AAU/ESSU) . The E-form will be completed and reflect this decision Up to 2 hour for speciality team review and/or allocation to inpatient bed Up to 1 hour to transfer care to admission stream or discharge stream 1 hour 2 hour 1 hour
  39. 39. Four chairs Two Trolleys Two Consult Rooms One Procedure Room Waiting Room Urgent Care Centre
  40. 40. UCC: TOTAL PRESENTATIONS WITH LOS < 2 HRS 4494 5386 5515 6789 6586 5962 6009 6786 1665 1790 1814 2109 2549 2176 2611 3364 0 1000 2000 3000 4000 5000 6000 7000 8000 AUTUMN 2011 WINTER 2011 SPRING 2011 SUMMER 2011/2012 AUTUMN 2012 WINTER 2012 SPRING 2012 SUMMER 2012/2013 UCC Total Presentations LOS < 2 hrs Linear (LOS < 2 hrs)
  41. 41. Four beds Four chairs Emergency Short Stay Unit (Discharge stream)
  42. 42. Urgent care centre SAFE-T Acute care Features of ESSU Model Special purpose beds. High turnover. NOT interchangeable with ward beds. ED Consultant-led: Patient selection Review Decision to discharge
  43. 43. ESSU: AVG LOS WITH LOS <4HRS 13:23 12:02 10:16 10:55 11:25 10:01 9:10 9:44 8:14 7:45 139 91 275 155 219 252 276 335 435 469 0:00 2:24 4:48 7:12 9:36 12:00 14:24 SPRING 2010 SUMMER 2010/2011 AUTUMN 2011 WINTER 2011 SPRING 2011 SUMMER 2011/2012 AUTUMN 2012 WINTER 2012 SPRING 2012 SUMMER 2012/2013 HRS:MINS 0 50 100 150 200 250 300 350 400 450 500 NOOFPTS AVG LOS LOS <4hrs Linear (LOS <4hrs) Linear (AVG LOS)
  44. 44. ESSU: TOTAL PRESENTATIONS WITH LOS <24HRS 608 421 951 810 1010 991 1108 1217 1377 1457 0 200 400 600 800 1000 1200 1400 1600 SPRING 2010 SUMMER 2010/2011 AUTUMN 2011 WINTER 2011 SPRING 2011 SUMMER 2011/2012 AUTUMN 2012 WINTER 2012 SPRING 2012 SUMMER 2012/2013 ESSU Total Presentations LOS <24hrS Linear (ESSU Total Presentations) Linear (LOS <24hrS)
  45. 45. Acute Admissions Unit (Admission stream)
  46. 46. SAFE-T Acute care Features of the AAU Model of care Differentiated patient admitted under an inpatient team but may need .... - team review prior to ward transfer - complex investigations to determine disposition - further observation prior to transfer to the ward Urgent care centre To be admitted to the AAU the following is required: Management and disposition plan Time indicator of when the patient is likely to be transferred to the inpatient ward Trigger point when the transfer would be appropriate(eg when CT report is available)
  47. 47. Scenario 1 58 year old female presents with increasing back pain Known metastases to sacral area Background metastatic breast cancer Last admission under Med ONC last week
  48. 48. Scenario 2 25 year old female presents with lower abdominal pain LMP 3 weeks ago •Temp 36, HR 69, B/P 120/72, RR 14
  49. 49. Scenario 3 65 year old male presents with one episode of PR bleeding. Nil past history, Family history of Bowel Ca Otherwise well • HR 78, BP 110/78, TEMP 36, SpO 98, No postural drop
  50. 50. Scenario 4 52 year old male, sudden onset Left flank pain Pain 10/10 Unable to pass urine
  51. 51. Scenario 5 33 year old male currently on chemotherapy for AML Febrile with temp of 38.5, BP 130/70, HR 130/min No beds in acute
  52. 52. Lessons learnt • Any new MOC requires staff collaboration and engagement • “Listen” to feedback • Importance of education esp. ongoing • Staff In-services over 3 weeks • Clinical scenarios to illustrate ideal patient journeys/pathways
  53. 53. Dicussion • Staffing • Complex roles(need to be clearly defined) • Senior decision maker • Adding value(bloods,imaging,treatment) • Streaming options(more difficult concept to grasp)
  54. 54. Discussion • Role of ETZ • 10 minute limit • Rapid triage • Ambulance offloads • Access block

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