Administration

Quality

• Quality indicators• Risk management• Consumer participation• Complaint analysis and resolution• Clinical audit and review• Occupational health and safety• Human resource development

Quality indicators and their measurement

• Access– Waiting times, access block

• Safety– Lost time to work related injuries, body fluid exposures, patient falls

• Acceptability– Patient satisfaction surveys, written complaint rate

• Effectiveness– Admission rate by triage category, time to thrombolysis/PCI,

unexplained representation within 48 hours

• Continuity– Provision written health info for sentinel conditions –asthma, wound

• Efficiency– Waiting time by Australasian triage scale

Quality cycle

Quality cycle

• Monitoring – collecting appropriate data (quality indicators) that help identify aspects of a problem or establish a baseline

• Assessment – analyse the data and use to assess the current situation and determine actions to be taken to improve quality

• Action – implement actions – practical solutions for system improvement that come from assessment decision

• Evaluation – closing the loop – determine whether desired outcome has been achieved

Complaints

• Classification– Interpersonal, medical, environmental, financial

• Response– Acknowledge <24 hrs phone / written

• Information gathering– Staff involved, Other colleagues, PHx – previous complaints, staff, pt file,

GP

• Documentation• Response

– <72hrs without judgement, +/- meet with pt advocate and support person, apologise without admitting liability

• Thank• Contact

– Medical defence, medical administrator, hospital lawyer (only go as high as necessary

• Continued Quality Improvement

Continued Quality Improvement

• Audit– Complaints – identify recurrent themes

• Identify systems failure not individual• Education• CISD

– Critical incident stress debrief

Policy

• Identify problem• Information gather

– Colleagues – your ED, other EDs, other interested parties– My college– Web, journals, texts

• Delineate– Aims– Resources – financial, staff, equipment

• Education of staff– Medical and nursing

• Implementation of plan• Continued quality improvement

The Violent Patient

• Safety– Self, staff, other patients, violent patient

• Strategies approach– Recognition – PHx, current Hx, drugs / EtOH– Prevention of escalation – see early, set limits, show of force, up

triage, area

• Restraint– Verbal, show of force, physical x6 arrow, chemical (PO, IM, IV)

• Safe disposition– Inpatient (medical, pysch), outpatient

• Continued Quality Improvement– Critical Incident Stress Debrief, future prevention of violence – ED

design, control access, education, undress all patient

• Exclude organic cause

Protocol

• It’s important to read the question and make sure you are answering what they ask – a question on protocol development is different to outlining the protocol itself

• ANSWER THE QUESTION!!

Protocol development

• Topic choice (common, costly, current high variation in practice, opportunity for improvement in practice, doctors interested)

• Delineate aims and resources (financial, staff, equipment)

• Literature search (previous guidelines, critical literature reviews, randomized controlled trials) – remember ACEM college guidelines

• Consultation with experts / other interested parties

Protocol development cont…

• Guideline drafts • External review (random sample of practitioners,

random sample of relevant specialists, experts in the field, professional organizations)

• Re-write and further consultation with experts • Approvals • Review date set – usually 1-2 years• Education of staff involved• Implementation• Guideline evaluation / audit

Written Protocol

• Title• Authors

– include other interested parties

• Date Reviewed• Scope• Condition

– clearly defined

• People involved (patients, staff) – inclusions, exclusions– (eg, age, qualifications)

• Recommendations– the medical bit – what happens when where how who– include disposition if appropriate

Written protocol cont…

• Rationale– why this protocol is important and what your aims are: improved patient outcome,

cost, patient flow, uniformity of approach, medicolegal– also include rationale as supported by the literature for your recommendations

• References– including ACEM policies, literature review

• Date of next review– include planned audits and how it fits into the quality cycle

• Rachel Hoyle, Alastair Meyer, July 2006

Procedure

• Indications• Contraindications• Complications• Explanation and Consent• Staff• Equipment• Analgesia, anaesthesia, sedation• Procedure – including patient positioning and sterile

technique• Post procedure care

SAQ 1

• You are the Director of the emergency department with the following problem. The hospital’s access block is 47% and its bed occupancy is 92%.

• Describe your strategies to reduce access block in this situation. (100%) (2005/2)

 

Examiner’s report

• The overall pass rate for this question was 41/56 (73.2%). • Examiners expected that a good answer to this question would

include a definition of the terms used, a recognition that this high level of access block will impair a whole range of departmental functions and a recognition that this is a whole of hospital problem.

• It was expected that strategies for dealing with the problem would include pre-hospital, ED and whole of hospital approaches.

• In particular a strong understanding of ED approaches such as senior staffing, allied health input and use of short stay/hospital in the home programs was expected.

• Failing answers did not describe enough strategies, especially those centered in the ED. They also tended not to define the problem and show an appreciation that this is a whole of health issue.

SAQ 2

• You are the Director of an emergency department. You have received allegations from the Head of the Division of Medicine that an emergency physician in your department has been consistently rude and condescending to its medical registrars.

• Describe the actions you would take in response to these allegations. (100%)

• (2010.1)

 

Examiner’s report

• The overall pass rate for this question was 68/70 (97.1%) • Pass criteria • Obtain facts / information concerning events. Interview, whilst maintaining

discretion, colleagues to obtain witness accounts if possible. Will involve meeting or phone call with Medical Director to ascertain more details. Apologise for situation.

• Interview the Emergency Physician. Private location, away from distractions. Show genuine empathy for a colleague. Inquire about physical or mental health issues. Is there self harm risk? Listen to his / her story. Document. Explain that behaviour cannot continue.

• Provide feedback to Medical Director in timely fashion.Treat health issues. Refer to GP or employee assistance programme. Requirement for Leave? Be flexible about leave etc. Follow up health issues

• Provide support for behavioural issues or anger management. Counselling. Understanding own behaviour and effect on others. Consider 360o assessment as means of independent feedback.

• If behaviour continues- discuss with EP again. Outline possible disciplinary action but reluctance to use this. Engage human resource department.

• Document.

SAQ3

• A 45 year old man with chronic pancreatitis has presented to your emergency department on multiple occasions in the last two months requesting analgesia for abdominal pain. His behaviour has become increasingly demanding and belligerent. A personalised management plan is now required.

• Describe the process for the development of this management plan (50%)

• Outline the important features to be included in this plan (50%)

• (2009.2)

Examiner’s report

• The overall pass rate for this question was 41/67 (61.2%).

• Pass criteria

• Part (a): Expected that the following process is undertaken: Investigate / determine circumstances / details of the case; Recruit contributors / stakeholders to provide input into the plan; Write plan; Circulate, revise and approve; Disseminate / launch plan; Audit and review.

• Part (b): Features of the plan to include: Patient identification; Clinical problems addressed; Behavioural problems addressed; Immediate / short term strategies (relevant to each ED visit); Medium / long term strategies (relevant to maintenance in community); Relevant contacts / referrals and triggers for this; Documentation of authors of the plan; Authorised by and date; Review mechanism.

• Fail criteria

• Nil stated by examiners

SAQ 4

• After a recent significant adverse event following the insertion of a central venous line you have been asked to investigate emergency department central line insertion.

• a. List the factors that may contribute to such adverse events during central venous line placement (30%)

• b. Describe the measures that may be used to prevent or minimise these events occurring. (70%) (2011.2)

Examiner’s report

• The overall pass rate for this question was 55/81 (67.9%) • Pass Criteria • a) Structured list that included patient/ environment / equipment and operator factors.

Better answers included factors in each of these sections and ranked them in order of prevalence or importance.

• b) Examiners expected description of measures that demonstrated application of quality improvement principles to this clinical adverse event scenario. This required sections relating to information gathering, review of existing guidelines with involvement of relevant ED and non-ED stakeholders, and creation and implementation of a documented departmental process that emphasised safe, competent line placement with emphasis on infection prevention at all times. Additionally there would be education and accreditation processes for line placement techniques highlighting importance of ultrasound guidance, and regular audit and revision of process to maximise patient safety and clinical effectiveness.

• Features of Unsuccessful Answers • No inclusion of proven role of vascular ultrasound in reducing complications of CVL

placement. Failure to include measures that prevent or minimise CVL associated sepsis.No description of quality improvement processes in measures to reduce adverse events.