suzanne mason: optimising triage, waiting times and service delivery in busy emergency departments
TRANSCRIPT
Optimising triage, waiting times and service delivery in
busy emergency departmentsbusy emergency departments
Suzanne MasonProfessor of Emergency Medicine
University of SheffieldUniversity of SheffieldSheffield Teaching Hospitals NHS Trust
Importance
• ED crowding a majorED crowding a major international problem
• Understanding the organisational challenges g gmay help specialty achieve gains more swiftly g yand less painfully
3
Wh i d i i h ?What is driving change?Policy User behaviourPolicy
• NHS Plan– Reducing ED waiting times
• Reforming Emergency Care
• Increased demand for and use of emergency services
• Users inappropriately accessing f
g g y– 4-hour target; Improve access; new
ways of working• Transforming NHS Ambulance Services
higher level of care than they need(Lowry 1994; Victor 1999)
• High proportion of patients arriving to ED by ambulance are
– mobile health resource; taking healthcare to patient; reducing ED attendances
• NHS Next stage review
to ED by ambulance are discharged without referral
(Pennycook1991; Volans 1998)
• Social mobilityC l it f bl
g– care nearer patient, quality,
changing expectation• European Working Time Directive; GP
contract
• Complexity of problem• Expectations• Time-sensitive care• Ageing populationcontract • Ageing population• GP behaviour
Is crowding bad for patients?
Is crowding bad for patients?• Crowding negatively impacts
– Time to thrombolysis Time to antibiotics– Time to antibiotics
– Meeting quality targets for cardiac care – Treatment of pain
F ti l t t– Functional status – Mortality – Errors – Hospital Length of Stay
• Schull 2004; Fee 2007
A service concept?
• The ED should be the hub of the emergency care system– Deficits in primary care or community services will
increase ED workloadTimely and efficient procedures for admission to– Timely and efficient procedures for admission to hospital are essential to prevent ED overcrowding
– Demands for emergency care are increasing g y gannually and the current emergency care systems are working near the limits of capacity
The Way Ahead 2008 UK College of Emergency MedicineThe Way Ahead, 2008. UK College of Emergency Medicine
Strategies
1. Reduce attendances2. Improve flow3. Avoid admission4. Improve exit
M 2006 H l d 2004• Munro 2006; Holroyd 2004
Reducing attendances• Patterns of accessingPatterns of accessing
emergency care– Increasing numbers via GP etc
Penson 2007; Thompson 2010– Penson 2007; Thompson 2010
• Redirecting patients appropriately and safely to other sources of care?
– Washington, 2002
• WIC, NHSD – no effect onWIC, NHSD no effect on reducing attendances in UK or USWill t t b th• Will urgent care centres be the answer?
Role of ambulance service• Increased role inIncreased role in
assessing, treating and signposting patientsg p g p– Hampered by time targets
• Paramedic practitioners reduced transfer of elderly fallers by 25%M 2007• Mason 2007
• ECPs increased on-scene discharges by 37%discharges by 37%
• http://www.sdo.nihr.ac.uk/sdo982005.html
Improve flowImprove flow• See and Treat
Patient sees only one professional who can– 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;
• Senior doctor triage Feel if have someone • Senior doctor triage– All cases: Terris 2004; Choi 2006; Subash 2004.
Majors cases: M 2005
senior up front, 90% of time will make right decisions about tests… (Bus Mgr, ED )– Majors cases: Mason 2005
Admission avoidance
The Clinical Decision Unit‘Patients with a low risk of high risk condition’
• Little evidence of impact on ED flowimpact on ED flow
• No RCTs• Good for some
pathways of care• ?dumping grounds –
th li i l i d i ithe clinical indecisionunit
Clinical fast tracking
• Condition specific– DVT, low risk CP, #NOF, stroke, STEMIDVT, low risk CP, #NOF, stroke, STEMI
• Nurse-led• Impact on admission rates• Impact on admission rates• Increased workload / resources for ED
– Increased referrals from community
front end was sorted, but the back end continued toThe Backdoor the back end continued to be a big, big block (NM)
• Medical/Surgical Assessment Units• Acute PhysiciansAcute Physicians• Admission and Discharge Planning
E l di h ti• Early discharge preparation• Discharge lounge enforcement• Community beds Reach 98% for patients going
home, but can’t get referrals into hospital. .. They haven’t
l d th b k d di hsolved the back door, discharge planning and community services. (LC)
What is happening now?
Monitoring time in ED(N=15 EDs N=774 095 patient episodes)(N 15 EDs, N 774,095 patient episodes)
2003
isod
es
14
16
18
Discharged
Adm itted
2004
odes
14
16
18
D ischarged
Admitted
Perc
enta
ge o
f atte
ndan
ce e
p
2
4
6
8
10
12
Per
cent
age
of a
ttend
ance
epi
so
2
4
6
8
10
12
Total tim e in departm ent (m inutes)
0 60 120 180 240 300 3600
2
Total tim e in departm ent
0 60 120 180 240 300 3600
2
2005
16
18 2006
16
18
ntag
e of
atte
ndan
ce e
piso
des
6
8
10
12
14
DischargedAdmitted
tage
of a
ttend
ance
epi
sode
s
6
8
10
12
14
16Discharged
Adm itted
Total time in department (minutes)
0 60 120 180 240 300 360
Per
ce
0
2
4
Total tim e in departm ent (m inutes)
0 60 120 180 240 300 360
Perc
ent
0
2
4
ED factors influencing waiting times
• 65% (n=137) of type I UK EDs participated• Structured interviews, clinical data, HCC data,
i d th t din-depth study• 14% mean WT relates to size and casemix
35 3% WT l t t i k• 35.3% mean WT relates to nurse sickness, non-pay spend and lead clinician style
• EDs with longer mean WT have higher levels• EDs with longer mean WT have higher levels of psychological strain and greater autonomy and control over workand control over work
http://www.sdo.lshtm.ac.uk/files/project/49-final-report.pdf
SAFETIME studySAFETIME study
• Data from 15 UK EDs in-depth interviews 9Data from 15 UK EDs, in depth interviews 9 EDs
• Streamlining process vs providing less careStreamlining process vs. providing less care• Trust engagement• Leadership from ED• Leadership from ED• Staff costs and benefits
Impact on personnel• Burden of the target falls most heavily on nurses
Feel like my personal responsibility to
• Opportunity for greater nursing power autonomy
Feel like my personal responsibility to make sure patient doesn’t breach. (Senior staff nurse, ED)
Opportunity for greater nursing power, autonomy 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
became much more directive (LC, ED)
Detrimental impact on training and practical procedures
• Focus on decision makingUsed to do more teaching on floor…. not much time now, we Focus on decision making much time now, wehave to keep moving. (LC)
The future?• Sustainability• Quality metricsy• Consultant-led
serviceservice• Observation
medicinemedicine