• Examining factors contributing to physical ED design • Implementing hospital wide policies to support improved flow • Managing safety and quality in a high flow environment Speaker: Yusuf Nagree Emergency Consultant Fiona Stanley Hospital, WA

1. DESIGN FOR
FLOW
DR YUSUF NAGREE
EMERGENCY PHYSICIAN
FIONA STANLEY HOSPITAL

2. Joondalup
Swan District/Midland
Fremantle
SCGH
RPH
Armadale
Rockingham
Perth 2007
Three tertiary
hospitals – Royal
Perth (adult), Sir
Charles Gairdner
(adult), Fremantle
(mixed)
Four outer
metropolitan –
Armadale,
Rockingham,
Swan Districts,
Joondalup
One paediatric –
Princess
Margaret
One O/G – King
Edward

3. Joondalup
Swan District/Midland
Fremantle
SCGH
RPH
Armadale
Rockingham
Reid Review
Closure of Royal
Perth
Reconfigure
Fremantle to non-
acute hospital
Construction of new
tertiary in the fast
growing South
suburbs: this was to
be a ‘merging’ of
Royal Perth &
Fremantle
‘Upgrade’ to
Joondalup in the
Northern Suburbs
Political pressure –
Royal Perth to
remain open
Fiona Stanley
Hospital

4. DESIGNING FIONA
STANLEY
Mammoth task
Designing a hospital from ground up
Merging of two hospital cultures – RPH & FH
Rarely undertaken before
Also, non clinical services contracted out

5. 0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
Adults
Children
Total
Fiona Stanley Hospital
Patient Attendances

6. 4 Hour Performance

7. DESIGNING FIONA
STANLEY
Design phase
• Consortium of architects
• Multiple clinical user reference groups
• Consumer input
• Changes in scope – 80% single rooms, cardiothoracics,
trauma, phased construction

8. DESIGNING FIONA
STANLEY
$2 billion Fiona Stanley Hospital – largest building project ever undertaken by the State Government
Equivalent of four city blocks
150,000sqm of floor space over five main buildings
6300 rooms in the main building
783 beds, including 140 rehabilitation beds
83% single patient rooms in main hospital
More than five hectares of natural bushland, landscaped parks, internal gardens, courtyards and
plazas
3600 basement, ground level and multi-storey car parking bays

9. DESIGNING FIONA
STANLEY
Public/Private partnership – non clinical services contracted
out to Serco:
Porters
Catering
Cleaning
Communications
Linen
Building maintenance
IT / Telephony / Switchboard
Medical Records*

10. DESIGNING FIONA
STANLEY
IT
Fully wireless
Paperless Hospital
Multi-function bedside computers:
Patients – internet, meal ordering
Clinicians – log on to clinical systems
Sophisticated handheld paging / telephone units
BYOD integration

11. DESIGNING FIONA
STANLEY
IT Issues
Ultimately led to delay in hospital opening
WA Health:
• multiple different systems interfaced together
• some ‘home grown’, others off-shelf
• Most systems integrated across metro
• IT run as partnership with Fujitsu (Health Information
Network)

12. DESIGNING FIONA
STANLEY
IT Issues
Massive task in configuration of all existing systems
Difficulties because clinical services not finalised – trauma, obstetrics, CDTH
Interfacing of new systems required:
• eg. E-diet which was the electronic meal ordering system which
interfaced with Serco’s system but also required interfacing with the
clinical systems so allergies came across
• Three IT players involved
• WA health
• Fujitsu
• Serco / BT
• Other major WA health projects underway – Windows 7, PAS system

13. DESIGNING FIONA
STANLEY
Paperless System
Realisation that current hybrid of systems couldn’t support a fully
paperless system – eg. Medications management
Hardware requirements also made fully paperless difficult – eg.
Recording of observations
BYOD functionality would not be ready in time
“Off-shelf” products to support fully paperless could not interface with
other WA health systems: risk that FSH would be ‘electronically isolated’
from the rest of the State
Dilemma – couldn’t go to paper system as medical records infrastructure
not there

14. DESIGNING FIONA
STANLEY
Paper-lite
Bossnet eventually selected
Medication charts and observation charts paper
Progress notes and discharge summaries electronic
Paper based forms scanned at end of patient episode

15. DESIGNING FIONA
STANLEY
Clinical Design
4 Hour/NEAT big focus
Lot of planning around flow
4 hour rule since 2008– excellent results compared to rest of
Australian
Aim to design FSH to ensure 4-hour performance

16. DESIGNING FIONA
STANLEY
Service Stream Model
Service 1: Cardiovascular, thoracic, renal, endocrine, haem/onc,
aged care
Service 2: allied health, imaging, physics, immunology, ID, pathology,
theatres, pharmacy
Service 3: mental health, womens, children, newborns, state rehab
Service 4: ED, general surgery, acute medical, gastro, trauma,
head/neck, orthopaedics, neurosciences, neurology
Aim to be autonomous, self managing with medical & nursing co-
directors. Heads of Services & Nurse Unit Managers to lead
individual departments

17. DESIGNING FIONA
STANLEY
Clinical Service Plans
About 18 months prior to opening,
HoS and NuMs appointed
Development of department clinical
service plans
Detailed plans – over 50
Numerous clinical guidelines where
appropriate
Cross department / service interfaces
articulated – eg. # NOF
ED plan – 147 pages

18. DESIGNING FIONA
STANLEY
Unplanned / Acute Services
Concentrated around three units:
Emergency Department + Short Stay (ESSU)
Acute Medical Unit (AMU)
Acute Surgical Unit (ASU)
Other:
Orthopaedics, Intensive Care, Cardiology

19. DESIGNING FIONA
STANLEY
Emergency Department Design
Huge department – over 3000 sqm
Five discrete areas:
• Resuscitation – 15 cubicles: chest pain, trauma, ATS ½
• Assessment – 16 cubicles: non ambulant, less acute
• Green / Ambulant – 10 spaces
• Short Stay – 15 beds
• Paediatrics – 14 beds: autonomous – separate entrance,
triage, waiting room (4 bed ESSU)

20. DESIGNING FIONA
STANLEY
Emergency Department Staffing
Each area separately staffed:
• Nursing area lead and Consultant (no consultant in
Ambulant)
• Nursing Staff
• Medical Staff
• Ward Clerk (not in Ambulant)
No choice due to distances involved

21. DESIGNING FIONA
STANLEY
Emergency Department Staffing
Assistant Nursing Unit Managers (ANUM)
Mental health team – Psych liaison nurse + registrar
Drug / Alcohol CNS (business hours)
Allied health team (physio / OT / social worker)
Nurse practitioners & Advanced Scope physiotherapists

22. DESIGNING FIONA
STANLEY
Flow
Flow was paramount from the ED
Patients triaged as usual – triage nurse made determination as to
which area patient was – Resus, assess, green…
Area co-ordinator monitor EDIS screen and would ‘pull’ patient
into their area as soon as possible. Aim was to have minimal
number of people in the waiting room
No corridor patients other than front door off-load area

28. FLOW AT FIONA
STANLEY
“Rules”
• ED to make a decision by 2 hours – JMOs to discuss
with senior with 30 min
• Inpatient teams to review patients within 30 min of
referral
• One way referral system
• Patients to leave ED within 60 min of bed request even
if not reviewed by inpatient team and clinically stable
Escalation process when above time points breached

29. FLOW AT FIONA
STANLEY
Wards to ‘pull’ patients from ED when bed available
Patients go to ward when bed available
Safety:
• Not certain wards – eg. ICU, CCU, MH
• ADDS 0-3
• Sign off by senior ED clinician
• Ward registrar informed

30. FLOW AT FIONA
STANLEY
High visibility of Flow
Enterprise Bed Management
(EBM) system – high visibility of
hospital / ED throughout the
campus
Daily bed status reports
Pop up messages on computers
Paging when Code Red/Code
Black

32. FLOW AT FIONA
STANLEY
Emergency Short Stay
24 hour admissions – under ED consultant
ED consultant rostered morning & evening with junior support
Cases
• Overdoses
• Situational crisis
• Alcohol intoxication / withdrawal
• Pyelonephritis
• Cellulitis
• Vertigo
• Gastro-enteritis
• Head injury
• Snake bite

33. FLOW AT FIONA
STANLEY
Chest Pain Assessment Unit
Joint cardiology / ED unit in the short stay ward
TIMI 0-1 – managed solely by ED
TIMI 2-4 – CPAU
Under ED bed card
2 x daily cardiology reg ward rounds – organise tests /
follow-up
ED JMOs to do paperwork

34. FLOW AT FIONA
STANLEY
Acute Medical Unit
50 bed unit with 8 high acuity beds (ionotropes, NIV)
Staffed by consultant physicians (0800-2200)
3 x daily MDT ward rounds (0800, 1115, 1500)
All patients referred from ED seen within 4 hours by consultant 0800-
2000 (14 hours overnight)
Extended hours pharmacy and allied health
Didn’t opt for “all patient” model – specialty teams would admit – eg.
Respiratory. After-hours, AMU registrar may do the admission
paperwork
Aim for 48 hours in AMU then decant to appropriate unit – AMU
consultants have admitting rights to other units

35. FLOW AT FIONA
STANLEY
Acute Surgical Unit
Operated in a similar model to the AMU but 3 x daily ward
rounds not mandated
Senior surgical registrars
Undifferentiated abdominal pain would go to the ASU whilst
waiting CT scans, ultrasounds

36. FLOW AT FIONA
STANLEY
Other
# NOF page
Code Stroke, Code STEMI
ICU service
• Must respond
• Provide management advice
• Facilitate beds

37. FLOW AT FIONA
STANLEY
Ward over-census
Ward over-census used
Wards required to go over-census when ED ramping
Can use other areas of the hospital to go over-census
eg. Hospital gym area, State Rehab centre
Detailed over-census plan including safety issues
Advantages
1 extra patient/ward is safer than 20 extra patients in ED
Provides visibility to ward about bed situation
Avoids delaying discharges on ward

38. LESSONS
Under-estimate demand
Under-estimate Portering requirements
• When flow is paramount, you need high availability of portering to
enable patient movement
Under-estimate senior staffing requirements
• Acute surgical unit. Senior staff in theatre leaving junior surgical
registrars to see consults
Require central bed co-ordination / escalation
IT interfacing / configuration
Under-estimate computer hardware requirements & clinician behaviour
Look after junior staff – shift times

39. LESSONS
Worked Well
• Hospital wide engagement, especially Heads of Department, to drive culture
• Set of “rules” adhered to by everyone (eg. Patients must be seen in ED
within 30 minutes)
• Early, frequent senior decision making
• Develop a “pull culture” and ownership of areas though with central co-
ordination
• Over census can be a useful tool

40. LESSONS
Emergency Department Design
Seriously think about staffing & flow considerations if embarking down pod
structure

41. FLOW AT FIONA
STANLEY
Finely Tuned System

42. ?