Every good idea has its time

Jill Windle RGN, MSc. FFENLecturer Practitioner in Emergency Nursing

Time to reflect on ….

Demonstrate achievements (spanning 20 years)

Discuss innovations in practiceLearning from mistakes (hindsight is a

wonderful thing)Sharing good practiceFuture challenges

Local pressures

Fast, fair and convenient access to health care

No waiting!The right clinician

to see the right patient at the right time

Sustaining the ED Quality Indicators

Achievement required

This level of activity is proving difficult

Capacity always an issue

If we do not work as a team we cannot succeed!

A brilliant team

Major benefits of collaboration

Support roles

Limited number of Band 3 HCSW Well trained – NVQ Level 3 Clear roles & responsibilities

Triage – venepuncture, cannulation and ECGResus - cubicle preparedness, relatives supportTransfer facilitator role, safe & efficient transfer

and improves time to ward from decision to admit

Developing band 5 role

Competency based orientation programme (FEN)

Strong mentorship and clinical supervision

Structure for achievement – timeframesTriagePGDsNurse requested X Rays

Obstacles to overcome

Radiology resistance to Nurse initiated X Rays

PID / stakeholder involvement

ENP & AP primary interpretation

AP now CT, MRI range of presentations

Making the most of the change

February 2010 target reduction of £7.2m set for Salford Healthcare.

2011 closure of all five Walk-in centresNew build ED and PCC co-located

including GPOOH serviceWhy not use MTS to signpost patients to

right clinician, right place at the right timePresentation Priority Matrix (PPM) offered

creative solutions (2nd Eds)

Stakeholder engagement

ED ConsultantsSenior ED NursesPrimary Care

NursesGPsPrimary Care

PhysicianEmergency Care

Practitioners (ECP)

Identify localstakeholders

Map each p-p complexto a disposition

BGYOR

1 2 3 4 5

Abdominal pain in adults R Ma MaP PC PC

Abscesses and local Infections R Ma Mi PC PC

Allergy R R MaP PC PC

Asthma R R Ma PC PC

Back pain R Ma MiP PC PC

Bites and stings R R MiP PC PC

Chest pain R R Ma Mi PC

Collapsed adult R R Ma Mi PC

Dental problems R Ma Mi Dent Dent

Diabetes R R/Ma Ma PC PC

Diarrhoea and vomiting R R MaP PC SC

Ear problems R Ma MaP PC PC

Eye problems R Ma Mi/Eye Mi PC

The Deflection Process

PPM developed to safely deflect patients from the ED to primary care

Run by key practitioners with additional primary care training (ECP)

Short consultationRecording of observations but no in-depth

physical examPatient education essentialThe discussion is more important

than the action

ENPs: Band 6 & 7

Developing Clinical Skills module

Defined presentations managing ambulatory caseload

Assess, diagnose, treat

Practice guidelines PGDs / NMP Choice for patients

ENP ad hoc practice

2 years limited exposure (2009 – 2011)OSCAs reveal retained competence across

injury skill setLoss of confidence not competence

19.2 18.25 18.6

21.75

17.2 16.618.4

17

0

5

10

15

20

25

ENP 1 ENP 2 ENP 3 ENP 4 ENP 5 ENP 6 ENP 7 ENP 8

Mean mark achieved invidual ENPs across all 5 skill sets

Advanced Practitioners

A hybrid not a traditional nursing role Masters level - Clinical Practice Trained to high standards using a Bio-

Medical model Certainly not a junior doctor substitute Funding? Organisational preparedness Clinical career pathway for Senior nurses

Advanced Practitioners

1999 1st AP post 2013 = 8 NPs in ED, 6 in PANDA

A truly autonomous roleClinical expertiseManaging complex clinical case loadNon-Medical PrescribersRole models & innovators in practice

Trauma Centre status

• Problem• Lack of role clarity• Lack of training

• Structure• Team leader• Team number

• Organisation• Task allocation• Horizontal / vertical

activity

Saving lives

• Experienced team – train together work together

• 65% nursing staff TNCC trained

• Team allocation & organisation

• Inter departmental links

Measuring achievement

Multi skilled workforce delivering right care to right patient at point of entry

Streams of care with designated staffing and expertise

Nursing roles – improving patient journey Time to definitive management Patient choice & experience Staff recruitment & retention benefits

Measuring achievement

Trauma team developments = improved patient outcomes

Improved time to senior clinical decision maker Drs and Aps

Continued collaboration, sharing experiences

National input across the team, shaping the future

The future of the ED team?

Continued political directiveDriven by a changing workforce Emergency Nurses & Medical staff will be

central to changeChallenges from NHS & private sector, to

deliver treatment & care to patientsUltimately the patients right to choose will

shape future healthcare