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Critical Care Division, Lyell McEwin Hospital Emergency Department Model of Care March 2018
Critical Care Division, Lyell McEwin Hospital
Emergency Department Model of Care
March 2018
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TableofContents
Executive Summary ................................................................................................................................ 3
Why change? .......................................................................................................................................... 4
Current model ...................................................................................................................................... 4
Rationale for changing the ED Model of Care ..................................................................................... 5
Anticipated Benefits ............................................................................................................................. 6
Clinical Improvement ........................................................................................................................... 7
ED Senior Assessment and Streaming Model of Care ........................................................................... 8
Patient arrival ....................................................................................................................................... 9
ED Streams ......................................................................................................................................... 9
Resus ............................................................................................................................................. 10
Active Care at Triage (ACT)........................................................................................................... 10
Undifferentiated .............................................................................................................................. 11
See and Treat ................................................................................................................................ 11
Disposition ......................................................................................................................................... 11
Discharge ....................................................................................................................................... 11
Emergency Extended Care Unit (EECU) ....................................................................................... 11
Admission ...................................................................................................................................... 12
Transfer .......................................................................................................................................... 12
Front Loading .................................................................................................................................... 12
Benefits of the future model .................................................................................................................. 12
Implementation of the future model ........................................................ Error! Bookmark not defined.
Bibliography .......................................................................................................................................... 14
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Executive Summary The Lyell McEwin Hospital (LMH) Emergency Department (ED) manages adult and paediatric patients with a range of presentations, including life-threatening conditions as well as a wide variety of other acute and complex problems. The ED has two resuscitation rooms and a total of 27 assessment cubicles organised into three areas:
Area A (12 adult monitored acute care beds)
Area B (11 adult subacute care beds)
Paediatric area (4 subacute paediatric care beds).
There are also a number of special purpose rooms and a 14 bed Emergency Extended Care Unit (EECU) for patients requiring more than 4 hours of emergency assessment or care but less than 24 hours before discharge. On a daily basis, there are currently an average of 208 presentations (although this number can regularly peak to over 225), with 75% of these presentations compressed into a predictable 12 hour period of high activity. This period of activity compression usually commences between 10:00 – 12:00 and is sustained until approximately 22:00 – 24:00. Peaks within this time frame also occur, with up to 20 - 25 presentations arriving within the space of 1 hour almost daily. The average daily occupancy is 95% however 100% occupancy is routinely exceeded for more than 15 hours a day with over-occupancy peaking up to 160%.
The new ED model of care (MoC) will have a focus on Improving the Patient Journey. Everybody Matters. A fundamental driver for revising the ED MoC arises from:
The announcement of a major expansion of the ED environment to meet the current demands, and
to better meet sustained increases in demand for both flow, volume and acuity through the LMH ED in the years ahead.
The new ED MoC is expected to improve the patient journey by reducing unnecessary patient movement and the average length of stay of patients in the ED. Other benefits which will result to the South Australian community include quality outcomes, patient and carer experience, and patient flow and system outcomes.
The ED Senior Assessment and Streaming Model of Care is underpinned by a number of principles related to triage category and time to be seen, assessment within 30 minutes of arrival and an ED disposition plan within two hours of arrival. A senior assessment and streaming model of care provides for an early assessment of patients presenting to the emergency department for treatment who are then streamed to a particular area within the ED that is related to their expected disposition.
Active care at triage; the senior ‘quick look’ approach from the waiting room means senior clinicians can make a prompt initial assessment to determine the likely best stream for the ongoing ED work to occur in and commence some early focussed interventions. An increase in the complex comorbid population has seen an expansion of numbers of priority 3 presentations to the ED and senior clinician review from the waiting room is a way to bring forward this assessment and temporising treatment stage and supports early disposition decision making, hence decreasing the time a given patient may spend in a bedded cubicle.
This new ED MoC moves patients into the facility quickly, decreases bottlenecks at the entrance, reduces patients waiting for treatment/care in the waiting room and ensures timely access to the right care in the right place in the hospital. Improvements will include time to meaningful treatment in the main department, time to radiology and time to admission.
Key features and benefits of the ED MoC include:
Multidisciplinary teams in functional areas
Senior ED clinician assessment within thirty minutes of arrival
Patient disposition decision made within two hours of arrival
All ED referrals to inpatients performed by senior clinicians. High quality clinical decisions made early can have a positive effect on the efficient use of resources.
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Why change?
Current model
The Lyell McEwin Hospital (LMH) emergency department (ED) manages adult and paediatric patients with a range of presentations, including life-threatening conditions as well as a wide variety of other acute and complex problems. When patients arrive at the ED, they are triaged by a senior nurse using the Australasian Triage Scale to prioritise the urgency in which patients are seen based on the severity of their condition. More urgent care needs are seen in priority over those predicted as less urgent, with expected time targets guided by this assigned triage category. Following triage, patients are moved into the ED for further assessment and care, the exact location depending on their triage category, the level of monitoring required, specific care needs, age and safety risk profile are all taken into account when determining the level of assessment and care needed. This point of decision making leads to the concept of “patient streams”, which are defined areas within the department with staffing resource to meet specific cohorts of patient care needs. ED has two resuscitation rooms and a total of 27 assessment cubicles organised into three areas:
Area A (12 adult monitored acute care beds)
Area B (11 adult subacute care beds)
Paediatric area (4 subacute paediatric care beds).
There are also a number of special purpose rooms and a 14 bed Emergency Extended Care Unit (EECU) for patients requiring more than 4 hours of emergency assessment or care but less than 24 hours before discharge.
Hourly fluxes of patient arrivals occur not only in number but also in urgency. Due to the large overall number of patients, at any given time, and limited assessment space to deal with these surges in arrivals, EECU is often used as a flow through space for patients awaiting inpatient unit assessment or access to ward beds. This compromise solution has historically served as a means of freeing up assessment spaces for new patient arrivals.
Some patients present with a simple, single system condition not requiring a prolonged episode of care in a bedded environment. These patients have been historically streamed to a number of special purpose rooms around the department without dedicated staff allocation, but more recently, are now streamed to an area in the medical imaging holding bay to the ‘See and Treat Service’ as a temporary solution to expand capacity.
Once in an assessment space, a nurse, nurse practitioner (NP) or doctor sees the patient, and performs an assessment of the presenting concern. A wide range of investigations, symptom control measures and stabilising treatments may then follow. Dependent upon the needs of the individual patient’s presenting concern, three main outcomes may occur. They are:
1. Patient is discharged home with organised follow up in the community or hospital outpatient service.
2. Patient undergoes further assessment and/or short term treatment of their condition/s within the emergency extended care unit (EECU) with the expectation that they will likely be discharged from the hospital. This may include input from allied health or other ancillary services such as Drug & Alcohol, to enable a safe discharge to home or an alternate place of care with the view to acute hospital admission avoidance for those without an ongoing acute medical care need.
3. Patient requires inpatient specialist team referral for admission to hospital, either within the Lyell McEwin Hospital or outside the Local Health Network based on the limitations of NALHN Service Capability Framework (e.g. paediatric surgery to WCH, neurosurgery to RAH).
Currently there are inefficiencies in flow and care delivery. For example patients are frequently moved out of assessment cubicles to make space available for the inflow of new patients requiring time urgent assessment. Frequently gridlock occurs, due to patients awaiting advanced diagnostics from services not available at LMH or across the entire 24 hour cycle, delays in inpatient team decision-
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making and waits for transfer to an inpatient bed.
Rationale for changing the ED Model of Care
The emergency department is under pressure with presentations increasing from just over 40,000 per annum in 2006 to 75,878 in 2017. Analysis of trends in the types of presentation and patient outcomes suggests that the level of acuity and complexity of patient needs has also increased. Figure 1 shows the number of ED presentation by triage category for 2013 and 2017. The data shows increases in the number of presentations for triage category 1, 2 and 3; while a decrease in the number of triage category 4 and 5 presentations over the same time period. The number of triage category 1 presentations has increased by 115%, from 1003 presentations in 2013 to 2157 in 2017; triage category 2 presentations have increased from 9,473 to 13,145 (38.8% increase) and triage category 3 presentations have increased by 6,614 (23.8%).
Figure 1 – LMH ED presentations by triage category 2013 and 2017
Figure 2 provides information about the disposition of patients seen in the ED, by admission or discharge. The number of people discharged has increased by 5% (36,371 to 38,381), with a 21.1% (15,033 to 18,209) increase in the number of people admitted from the ED, over the same time period.
Figure 2: Disposition from ED for discharge or admission 2013 and2017.
Other dispositions described in Figure 3 show an increase in Emergency Extended Care Unit and mental health admissions, with a decrease in the number of transfers out of the ED.
Figure 3: Disposition from ED for EECU, mental health and transfers
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Presentations of more than 75,000 per annum means around 200 presentations per day, on average (range 170-240). Around 75% of people presenting to ED do so in a 12 hour period (1000-2200).
A fundamental driver for revising the ED model of care (MoC) arises from:
The announcement of a major expansion of the ED environment to meet the current demands, and
to better meet sustained increases in demand for both flow, volume and acuity through the LMH ED in the years ahead.
The success of the MoC hinges on a range of reforms including:
Minimising both the number of steps and length of queues experienced for patients by reducing duplication of clinical and administrative services
reducing waiting times
ensuring senior early decision making to prompt the next step of care required in the patient journey
optimising, wherever possible, an appropriate, smooth and ‘direct admission’ process.
The ED should only be used for patients with an undifferentiated diagnosis or for those that need specialist skills and care that is provided in an ED. The key to the ED flow model is timely movement of patients to and through the appropriate streams.
As the profile of clinical services provided at the LMH changes and the population of the greater northern suburbs of Adelaide expands, it is anticipated that there will be at least a 20% increase in attendances to the ED by 2031, with an overall increase in the rate of admission from 30% to approximately 36%
The new ED MoC will have a focus on Improving the Patient Journey. Everybody Matters. Staff will be supported through the MoC to enable them to provide care according to the five elements:
Patient and family centred care
Accessible, integrated and coordinated care
Working as a team
Acting on feedback
Safe and reliable care
Effective and efficient staff and resource allocation is needed to continue to provide good patient care as this demand and service activity rises, as well as enable staff to work in a supportive environment that enhances both quality of patient care as well as staff wellbeing and ensuring staff learning needs are met. The transition from novice to an experienced clinician takes both time and education
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investment. This drives a positive culture and leads to ongoing workforce sustainability. Ultimately then, future service provision is not only maintained, but also enhanced, as a skilled, resilient workforce are better able to adapt to future innovative practice changes, increase in demand and ensure quality patient centred care.
Anticipated Benefits
The new ED MoC is expected to improve the patient journey by reducing unnecessary patient movement and the average length of stay (ALOS) of patients in the ED. Other benefits which will result to the South Australian community include the following
Quality outcomes:
Less time to symptom management and/or pain relief
Early risk stratification
Patient and carer experience:
Increased patient satisfaction
Minimisation of patient wait times
Increased communication with patients about their management plan
Patient flow and system outcomes:
Early identification of patient disposition to care outside of the ED
Decreased length of stay of stay in the ED
Less ‘did not wait’ episodes
Clinical Improvement
Fundamental process changes that will result in clinical improvement are:
Front loading in the ED with early senior clinician decision making
Ensuring each patient has a management and disposition plan within 2 hours from ‘time seen’
ED making admission decisions allowing ‘Direct Admissions’ to the wards
Improved patient transition to the wards
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ED Senior Assessment and Streaming Model of Care The ED Senior Assessment and Streaming Model of Care is underpinned by the following principles:
Triage category 1 patients will be seen immediately upon arrival through the resuscitation stream
Triage category 2 patients will be seen within 10 minutes of arrival through any of the 3 streams based on clinical need
Triage category 3, 4 & 5 will be streamed based on complexity of care needs with all patients having an assessment commenced within 30 minutes of arrival. Assessment may include the following activities:
o Nursing observations / assessment
o Assessment by a senior emergency clinician – emergency medicine consultant or registrar, a nurse practitioner (NP) or a senior emergency nurse
o Commencement of an investigation pathway
o Commencement of symptom focussed or stabilising treatment
All assessments by junior ED medical staff will be discussed with a senior ED clinician within 30 minutes of commencement of assessment
ED disposition plan will be decided within 2 hours of arrival
90% of patients will be physically either discharged, transferred, moved to EECU or admitted to an inpatient service ward within 4 hours of arrival within the bounds of clinical safety and appropriateness
A senior assessment and streaming model of care provides for an early assessment of patients presenting to the emergency department for treatment who are then streamed to a particular area within the ED that is related to their expected disposition. High quality clinical decisions made early can have a positive effect on the efficient use of resources. The workflow and the inter-relationships of the elements of the senior assessment and streaming model are set out below in figure 1.
Figure 1. LMH ED proposed model of care
Emergency Department
Patient arrival ED Streams ED StreamsDisposition:
Any can occur from any stream
Patient arrives
UndifferentiatedAdult or
Paediatric
Admission
Transfer
EECU>4/24<24/24
Likely discharge
Triage
ResusP1
P2 traumaP2 behaviour
See and TreatSimple, single
systemAmbulatory
Immediate
Single SystemAmbulatory
ACTPre-assessment
process
Discharge
NEAT CLOCK
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Patient arrival
Patients arrive at the hospital ED and present to triage, where they are assigned to a triage category, according to urgency; based on the Australasian Triage Scale. At this point in the patient journey, an accurate administrative registration process also occurs. It is important to note that 70% of ED presentations to the LMH do not come by ambulance and hence have not had a pre-hospital assessment. Many have undifferentiated health problems and the risk to their health may range from minor through to severe or life-threatening. The majority (70%) of ED presentations do not come by ambulance and hence have not had a pre-hospital assessment. Subsequently the waiting room and the area around the triage desk may include clinical active care such as, blood pressure measurement and provision of pain relief. Triage may also refer patients directly to other assessment units in the hospital including Women’s Assessment Unit, Birthing Assessment Unit and (in the future) the Psychiatric Emergency Care Unit, bypassing the ED altogether.
ED Streams
There are three streams that patients can be sent to:
Resuscitation: those patients who require an immediate time-critical team based response, according to their clinical need.
See and Treat: those patients who have simple, single system conditions, and are ambulatory, not requiring prolonged time within a bedded assessment space.
Undifferentiated; adult and paediatric: those patients who require a bedded assessment space because of complex and/or urgent needs requiring multi-disciplinary approach to assessment, treatment and disposition determination. This stream is where the vast majority of ED work occurs. Active Care at Triage (ACT) is a front-loaded pre-emptive step in the care of these patients, designed to commence early investigation and focussed treatment prior to a full assessment, that helps to compress the time patients then spend in a bedded assessment space.
Figure 2 shows the physical space where the streams will be located; and includes the staff hub and the emergency extended care unit (EECU).
Figure 2: New physical environment for LMH ED: phase 1.
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Resus
Increased demand and acuity over the last 12-24 months has seen the need for immediate senior medical staff response to patients arriving as triage category 1 and trauma and behaviourally disturbed category 2 patients.
The increase can be linked to:
Increasing age and complexity of population with significant chronic health issues
Increasing populations of patients for whom immediate care may make a significant positive health impact
Increased urgent respiratory illness during influenza epidemic
Increased ambulance patients being brought to LMH ED as a consequence of intra-NALHN Transforming health changes as well as CALHN flow issues following on from the transition to nRAH
Expansion of LMH becoming a Stroke hospital for 12 hours a day, 7 days a week
Increased trauma presentations from SAAS
Increased severe behavioural presentations associated with increased methamphetamine use in the community
Currently the resus team is pulled from their allocated area of work to attend immediately to the patient. This means that the senior workforce is frequently diverted away from the provision of care and supervision for the remainder of the ED presentation – leading to decreased flow. The new model flips this and allocates a supernumerary resus team that, when not attending resuscitations, can assist with ACT, or in other areas of need to assist with flow through the ED.
Active Care at Triage (ACT)
The senior ‘quick look’ approach used in the ACT has been translated to the LMH ED from the nRAH ED MoC and elsewhere around the country. Here, senior clinicians make a prompt initial assessment to determine the likely best stream for the ongoing ED work to occur in and commence some early focussed interventions.
For patients arriving via ambulance, SAAS officers will escort the patient into the ED to the ACT area or one of the adjacent Resuscitation Rooms, assist with patient transfer onto an ED barouche and handover care to an ED clinician in that space. Currently, the Draft SAAS Distribution Document has SAAS presentations to LMH ED capped at 7 per hour. SAAS presentations make up 30% of the current total LMH ED presentations.
Patients who walk in will enter close to the ‘Ambulatory Care Area’. If it is not immediately clear at triage, a senior clinician will determine, and stream the patient to the most appropriate team within ED who can meet the patient’s care needs. These senior clinicians can quickly anticipate and commence early interventions during this step.
An increase in the complex comorbid population has seen an expansion of numbers of priority 3 presentations to the ED. Many of these patients require care in a bedded cubicle environment but space and occupancy limitations precludes this from occurring in all instances. Many also may have significant health concerns and are at risk of deteriorating while awaiting access to a more appropriate assessment space. Once seen in a bedded cubicle the process of investigation and temporising treatment often requires the passage of time which can further block the limited resource of the bedded cubicles
Senior clinician review from the waiting room (ACT) is a way to bring forward this assessment and temporising treatment stage and supports early disposition decision making, hence decreasing the time a given patient may spend in a bedded cubicle. Evidence shows that for this to have an impact it needs to be a senior medical decision maker rather than a junior one or if not possible, then a senior emergency nurse following a defined care pathway.
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Apart from streaming to the appropriate undifferentiated area, the senior clinician may also determine that the patient will require more than 4hours of ED care and potentially directly admit the patient to the emergency extended care unit.
Undifferentiated
The undifferentiated stream accounts for the vast proportion of emergency care mostly made up of priority 2 and 3 patients. Priority 3 patients are the largest group of ED presentations, making up approximately 45 % of presentations and account for the longest delays to be seen as well as the longest ED length of stay. Patients in this stream are usually complex, requiring a multi-disciplinary approach with early senior decision making to focus investigation, treatment and disposition decision. Best models support a small pod approach within this stream, consisting of defined groups of geographical bed numbers, managed by a defined assigned clinical team made up of a medical senior decision maker working with a junior medical workforce, nursing and access to allied health to provide efficient and effective patient care. Some patients will be streamed directly from triage and some will go through ACT. There will be three pods in the undifferentiated area, based on current geographical building constraints, with one including the purpose specific safe paediatric area.
See and Treat
The See and Treat service is designed around the needs and care of patients who do not require bedded assessment or treatment and have simple single-system presentations. This is particularly useful at times of surges in presentation demand and also serves as a crucial ‘flex’ capacity in times of crisis or mass disaster management. This area includes a dedicated team including NPs, ED Medical Officers and nurses who focus on rapid through-put of patients with non-complex, single system issues in a geographically focussed purpose built area. The See and Treat area also serves as the initial quarantine area in response to any pandemic, and will require negative pressure capacity.
Disposition
The departure of patients from all ED Streams (Resus, Undifferentiated and See and Treat) can occur in any one of the following four dispositions:
Discharge
Admission to the Emergency Extended Care Unit (EECU)
Admission to an inpatient unit
Transfer out to another hospital
Discharge
Patients are discharged from the department most usually to their own home. While the overall number of patients presenting to LMH is expected to rise, the proportion of those who are discharged directly from the ED back to the community will reduce to 64% based on projected population models.
Emergency Extended Care Unit (EECU)
Patients who are likely to be discharged within 24 hours but require further ED investigations observation of treatment response, or engagement of Allied Health or Mental Health Services to ensure safe discharge can be admitted to the EECU. 10% of ED presentations flow through this area and often include those patients who have special needs such as monitoring for a defined period of time as a consequence of an overdose before being discharged or those who need time to allow the effects of drugs and alcohol to wear off before safe discharge.
There is capacity to expand this number from 10% as other ED short stay admissions are identified within the department but are unable to access EECU beds. From 1st July 2018 NALHN will not be reimbursed for the patients requiring short stay admissions unless they have physically admitted to an EECU bed therefore the EECU beds will be exclusively used for EECU patients.
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Currently, other than a Consultant and Intern on a day shift, there is no dedicated medical workforce to follow-up patients in this area, staff attending from other areas of the Emergency Department. This area requires dedicated medical workforce throughout the 24 hour cycle to allow it to function with improved efficiency.
Admission
Patients are admitted to an inpatient unit at the LMH.
Transfer
To date, the full spectrum of specialist services usually located in a tertiary level hospital has not yet been accommodated at the LMH campus. As a consequence, some patients presenting to LMH ED who require admission under a number of specialist clinical services are routinely transferred to hospitals outside the Northern LHN such as the RAH.
Front Loading
In all streams ‘front loading’ will aim occur in the first thirty minutes of patient arrival. Front loading includes:
A nursing assessment and observations
An assessment by a senior emergency clinician (emergency medicine consultant/registrar/NP/advanced Clinical Initiatives Nurse (CIN))
Start of investigations
Commencement of symptom focussed or stabilising treatment
Within 2 hours of arrival, an ED disposition plan will be ready and in 90% of instances, the patient will have been referred for admission or transfer, discharged or moved into the EECU for further management.
Patients needing inpatient admission will follow, where appropriate, Direct Admission Pathways to inpatient units allowing a full and detailed inpatient assessment to occur in the wards after the patient has left ED. Referrals to inpatient units will be made by an ED consultant, registrar or nurse practitioner.
Benefits of the future model This new ED MoC moves patients into the facility quickly, decreases bottlenecks at the entrance, reduces patients waiting for treatment/care in the waiting room and ensures timely access to the right care in the right place in the hospital.
Improvements will include time to meaningful treatment in the main department, time to radiology and time to admission.
The new ED MoC will support significant progress toward achieving the 90% NEAT target.
Key features and benefits of the ED MoC include:
Multidisciplinary teams in functional areas
Senior ED clinician (ED consultant, registrar, NP, advanced NC, CIN) assessment within thirty minutes of arrival
Patient disposition decision made within two hours of arrival
All ED referrals to inpatients performed by senior clinicians (ED consultant, registrar, NP).
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Next Steps Elements of the revised ED MoC are being piloted in the current ED configuration. Lessons from the nRAH, publications on contemporary ED models of care nationally and internationally have been reviewed and considered. These are essential steps; enabling the testing of the assumptions, prompting refinement of the MoC and increasing staff engagement. The revised LMH ED MoC will undergo continuous improvement through the build transition period and beyond.
A gap analysis has been undertaken to understand how the ED can move from current to new MoC. A number of workshops are in the process of occurring to further test the new MoC with other inpatient areas, consumers and Aboriginal Health. This will assist with the continuous improvement process.
There is also an opportunity to work with the Patient Flow Project that is supported by SA Health through the engagement of Deloitte. Some of this work may include enablers to flow such as transfer times, investigations and imaging.
The sustainability and success of any given model of care hinges on the availability of highly skilled, well supported and resilient staff that can consistently provide high quality, time responsive care to the community. It is important to note that there is a workforce recruitment and retention crisis across Australia in relation to senior emergency department clinicians.
To meet the established requirements of an approved teaching site the ED must provide consultant supervision and teaching particularly to the non-consultant workforce to ensure junior medical staff meet their training requirements as well as AHPRA supervision requirements based on their level of registration.
Contemporary emergency care also requires skilled nurses and allied health professional that can provide advanced and specialised care at all points of the patients emergency journey. This includes assessment skills and the application of critical thinking skills, initiation of early and meaningful specific interventions, the ability to rapidly recognise and respond to clinical deterioration and provide compassionate care to all patients especially our most vulnerable and their family / caregivers.
Underpinning clinical care across the span of a patient’s journey through ED is the support of non- clinical support. This includes e.g. Administrative / Clerical support, Hotel Services, Radiology, Pathology services. It has been identified through staff consultation and feedback that currently there are duties being undertaken by clinicians that may be able to be incorporated into the Administrative Officer scope of practice.
These include:
Booking of ambulances for transfers or taxi’s
Booking of Outpatient appointments or quick access clinics
Providing discharge corresponded and GP letters that have been completed by clinicians
Completing CARPS requests for ISS
Assisting shift coordinator and consultant with admin tasks
It has also been identified that within this MoC two new administrative roles should be incorporated:
a Ward Clerk for the EECU and
a Communications Clerk. This role occurs within other LHN ED’s as the central point of contact for both external service providers, internal staff wanting to speak to the most appropriate clinician caring for a patient or consumers wanting to find a loved one.
This MoC includes both new roles and changes work flow process and roles for other groups of staff therefore a consultation process will be undertaken.
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Australasian Health Facility Guidelines. Part B – Health Facility Briefing and Planning, 0300 – Emergency Unit
Critical Care Services, Central Adelaide Local Health Network. Model of Care Emergency Department new Royal Adelaide Hospital
SA Health. Delivering Transforming Health our next steps.
SA Health. Improving the Patient Journey. Everybody Matters, Fact Sheet
