1. Optimising triage, waiting
times and service delivery in
busy emergency departments
Suzanne Mason
Professor of Emergency Medicine
University of Sheffield
Sheffield Teaching Hospitals NHS Trust

2. 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. 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

4. Is crowding bad for patients?

5. 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

6. 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 capacity
The Way Ahead, 2008. UK College of Emergency Medicine
Ahead 2008

7. Strategies
1. Reduce attendances
2. Improve flow
3. Avoid admission
4. Improve exit
• Munro 2006 H l d 2004
M 2006; Holroyd

8. 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?

9. 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%
• http://www.sdo.nihr.ac.uk/sdo982005.ht
ml

10. 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

11. Admission avoidance

12. 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

13. 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

14. 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)

15. What is happening now?

16. 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)

17. 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
http://www.sdo.lshtm.ac.uk/files/project/49-final-report.pdf

18. 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

19. 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)

20. The future?
• Sustainability
• Quality metrics
y
• Consultant-led
service
• Observation
medicine