The Four-Hour Rule- Lesson's Learnt from the WA Experience


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Presentation given at ICEN2012 on The Four Rule Experience in WA Tertiary Public Hospitals.

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  • Taken from NHS model of care Endorsed by WA cabinet January 2008 after study tour to UK in November 2007. Aimed at all WA public hospitals Targets to be introduced across WA health over a 2 ½ year time frame.
  • In October 2010, the MfH announced a revised target for Royal Perth, Sir Charles Gairdner and Fremantle hospitals of 85% of presentations meeting the four hour goal by April 2011. Princess Margaret Hospital kept its target of 98% by April 2011. The National Emergency Access Target (NEAT) is part of the new National Partnership Agreement (NPA) on Improving Public Hospital Services. The NPA requires all state health services have to achieve 90% of unplanned patients seen, treated and admitted, discharged or transferred in under four hours by 2015, as an average across the calendar year14.
  • Extensive interviews of across all hospital staff from medical to cleaning staff
  • Decrease in DNW
  • Significant changes to improve targets. PMH childrens hospital, hence high stat. FH mixed adult and pead. RPH and SCGH adult.
  • Recent paper discussing the benefits of 4 hour rule, including fall in mortality, decrease in access block
  • RPH - Team based care – team nurses also keeping an eye on the time line, working with nurses in charge of area. Better use of Emergency Medicine ward. Target patients discharged between 4 -8 hours plus patients needing <24 hr admission. (approx 8% presentations) Aim these patients nursed in ward and not corridor therefore decreasing overcrowding. Discharge Streaming Area Identified at triage See’s approx 30% presentations Seen in time order Nurse Practitioners work in area Consultant cover Simple, non complex discharges (only 4 beds) First 2 hours belongs to ED, hen plan and 2 nd 2hours belongs to bed managers. ED right to admit
  • Limited single rooms Nursing staff spend lots of time chasing up paperwork before patients can go to the ward, medical staff not always the best at ensuring everything complete. If not seen by admitting team need MEWS, 6/24 plan etc and senior sign off. Constant reminders to speciality teams that patients can go to the ward prior to review if clinically stable, need to at times remind registrars of policies such as ED right to admit and 60 min rule (once referred speciality teams have 1 hour to review patient before they go to the ward) Most metro hospitals have set safe limits for inside ED – causes ambulance ramping in times of overcrowding. This sets the timeline back – if they wait to get inside, everything is delayed Ramping continues, work is being done to look at distribution of ambulances, efficiencies within ED Preparing for the 10 am surge
  • Hospital wide issue – a lot of work has been done around ward leaders and whole of hospital engagement – as ED staff find this works well in the day when senior staff are on, but this is more challenging out of hours, more of a ‘push’ rather than ‘pull’ mentality
  • We are projected to continue to have an increase in presentations, new hospital opening in 2014. This is projected to help with demand to some extent, but it is expected that we will be as busy as ever in coming years Continually need to re-engage staff
  • It seems at times that we have achieved all the efficiencies that we can – culture must continue to change Staff are constantly expected to maintain or improve Still feels as though we have a us versus them (ward versus ED) mentality Timley ness versus qulaity care Need to change focus toward quality, but it hard to measure quality
  • The Four-Hour Rule- Lesson's Learnt from the WA Experience

    1. 1. The Four-Hour Rule-Lesson’s Learnt from the WA ExperienceKane GuthrieSarah-Louise MoyesLisa GrayKelly-Ann Hahn
    2. 2. Objectives Overview of the 4-hour rule in WA Provide tertiary emergency departmentexperience What we have learnt What the future holds
    3. 3. Why we needed the change Access block & overcrowding Increase in urgency & acuity Aging population & growth Decreasing inpatient beds ED staff providing 50% of time to inpatientcare Increasing adverse events, morbidity &mortality
    4. 4. Increase in presentations across all sites
    5. 5. The Four-Hour RuleAll patients will be admitted,discharged or transferred within 4hours of presenting to an emergencydepartment Endorsed by WA cabinet January 2008 after studytour to UK in November 2007 Introduced April 2009 to Western Australiantertiary public hospitalsAim/focus to: Improve quality of care & patient flow within ED Program of clinical service redesign
    6. 6. The TargetInitial targets set at 85% by April 2010 95% by October 2010 98% by April 2011Re-evaluated target: 85% by April 2011 90% by April 2015
    7. 7. The Review
    8. 8. The Major Findings from the ReviewIncreased demand in presentations. 2010 - 7.1% increase 2011 - 8.8% increase 2012 – presentations still on the rise (?10%)With no increase in actual hospital beds!
    9. 9. The 4-hour to discharge/admissionachievement so far Percentage of ED attendances with a length of episode lessthan or equal to four hours
    10. 10. Access block improvements
    11. 11. The Research
    12. 12. Lesson’s Learnt “Life can only be understood backwards,but it has to be lived forwards.” Stuart Connelly
    13. 13. What’s worked Patient flow/navigators based in ED Over census patients on wards Emergency decision units, better utilisationof emergency medicine wards Discharge streaming areas More investigations done once admitted Surgical & acute medical assessment units
    14. 14. Factors that impede patient flow Single room/isolation requirements Delays with ward cleaning/orderly transfers Paperwork requirements Speciality teams wanting to see patients inED prior to ward transfer Ramping – the 10am bus arriving Clinical acuity- not every patient is sorted in4/24
    15. 15. Some difficultiesFocus on “ED four-hour rule” Assumption issue lies with ED – this isslowly changing Hospital wide issueDirective all patients to be seen Dr within30mins ATS 3,4 & 5- seen in time order ?Achievability
    16. 16. Ongoing challenges Increasing presentations & acuity Change fatigue The winter epidemic Mental health epidemic Lack of acute medical/mental health beds
    17. 17. The FutureThe challenges we face: Sustainability Staff enthusiasm & engagement Staff recruitment & retention Finding new & innovative ways to improvepatient care & flow in the ED
    18. 18. Take Home PointsReducing overcrowding/access block: Decreases pt morbidity/mortality Improves staff satisfaction The four rule was a temporary fixNEAT will need to: Be safe, effective & sustainable Patient focused, without compromisingpatient care Value its workforce
    19. 19. Thank youBe a yardstick of quality.Some people arent used to anenvironment where excellence isexpected. Steve Jobs
    20. 20. Questions