Transcript ED Stream-Aute MOC Workshop Belmont

ED Stream Workshop
Acute MOC
August 2013
ED Stream Workshop
1
List All MOC used in your Facility
• 3.1Triage and Registration as per NSW Health
Emergency Department Models of Care July 2012
• 3.7 Fast Track
2
Describe your Fast Track Model
•
Key principles –
Expedite the journey for less-urgent/non-complex patients
Operating hours reflect high demand periods
Patients with a single system problem that can be discharged <2 hours
Rapid access to appropriate imaging and pathology
Uses dedicated staff – Nurse Practitioner (NP) 0.8FTE, other senior MO as identified by NUM/IC Nurse and
supported by NUM/IC Nurse as required.
•
Benefits of the Model
Fast track zones provide an alternative option to treat non-complex patients in a timely manner, reducing long
waiting times for minor problems and enabling NEAT to be met.
•
Challenges
Needs to be instigated at the discretion of the IC Nurse
IC Nurse needs to delegate a suitable Senior MO in the absence of NP
Not suitable night duty as Belmont Hospital does not have non urgent imaging after MN and pathology needs to
be couriered to JHH
•
Clinician run model (attach model guideline )
3
Differences between your Model and the definition in the
“Emergency Department Models of Care July 2012”
• Fast track is run from Belmont Hospitals cubicles –
Beds 10-14. They are not quarantined as Fast Track
beds and if needed are utilised by patients requiring
an ED bed for assessment.
• Fast Track is instigated and ceased on a needs
basis throughout the day by the NUM/IC Nurse
• No dedicated staffing other than NP when on duty
4
Identify the Resource Required for your
Fast Track Model
What do you need to run the model –
To run the model the way we do needs our NP on duty or an MO identified by NUM/IC Nurse. If run by MO, the
IC Nurse will usually need to commit some time to support the fast track whilst it is being utilised.
Staffing We do not have dedicated staffing or a dedicated FTE. The staff are utilised from the routine ED staffing and
amount to a NP or a MO and RN for the period of time designated to the need for Fast Track to be
implemented. The MO and RN are always senior members of staff in the ED.
Training There is no formal training for the Fast Track role. Senior staff are required when implemented.
Guidelines Guidelines have been modified from the JHH Safe Flow Project Guide (page 13) 2013.
Physical space The physical space required is usually 1-2 cubicles to alternate a patient being prepped by RN and the NP/MO
physically treating a patient in the other room.
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Monitoring and Evaluation
•
Identify how it supports KPIs and NEAT
Fast Track Model allows all triage category KPIs to be better met. Fast track patients would usually be
Category 4 and 5 with some Category 3s. The timely treatment of fast track identified patients allow those KPIs
to be met as well as freeing other ED medical staff to attend to the remaining patients in a more timely fashion.
The nature of fast track being that patients selected would be anticipated to have been treated in under 2 hours
supports the principles of NEAT .
Fast track moves patients throughout their journey in a timely fashion with minimal resource of space thereby
allowing beds to be freed throughout the ED to assist with ambulance offload KPIs
NP no. patients seen
% patients met NEAT
586 (Feb 2013 – July 2013)
100%
Off stretcher within 30mins
89%
Triage Category
Actual YTD %
Cat 1
100%
Cat 2
89%
Cat 3
85%
Cat 4
96%
Cat 5
87%
6
Evidence of Success
•
Improvement in KPIs since implementation –
Belmont ED KPI Comparisons
2011
2012
2013
Category 1 %
100.00
100.00
100
Category 2 %
82.64
80.74
89
Category 3 %
77.51
68.60
85
Category 4 %
71.33
68.11
96
Category 5 %
84.34
81.75
87
EAP
80.52
50.68
82
NEAT
59.55
56.81
74
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•
•
•
•
•
•
Impact on overall service – the previous graphs show the impact on overall service
at Belmont ED has improved since the inception of NEAT principles including Fast
Track MOC
Sustainability – maintained for last 6 months
Transferability – this MOC works for the number of patients seen in Belmont ED
and the criteria of patient presentations at this facility ie limited specialties.
Attach supporting evidence – after hours ASET, - anecdotal evidence to support
less ASET reviews waiting until the morning.
As a modification to the Fast Track MOC Belmont ED has implemented a Short
Stay Low Risk Chest Pain pathway and guidelines.
Attachments – After Hours ASET, Fast Track pathway, Low Risk Chest Pain Short
Stay Pathway
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FAST TRACK FLOW CHART
What is fast track?
Belmont
Hospital
Fast track is dedicated area in the ED to treat ambulant, non complex
patients who can be discharged within < 2 hours.
Fast track aims:-
Timeline
(Minutes)
Key Step
Who
Performs
0
Arrival
5
Triage
TRIAGE
NURSE
10
Registration
ADMIN
CLERK
20
Move to
consult room
ED
NURSE
25
Nurse/support
preparation
ED
NURSE
30
Assessment
MEDICAL
OFFICER
 Expediting the care of ambulatory patients with less urgent complaints
T
R
A
C
K
E
D
 Diverting the care of patients who meet particular clinical criteria
through a separate stream in the ED
 Using a dedicated geographical area (Procedure room and Room 14)
and staffed by dedicated senior medical and nursing staff as they
have the ability to make timely treatment and disposition decisions
with minimal consultation.
 Providing care that is standardised and targeted to specific conditions
and injuries.
Fast Track zones provide an alternative option to treat non-complex
patients in a timely manner, reducing the long waiting times for minor
problems and significantly improving patient satisfaction and outcomes.
Key Principles: Expedite the journey for les-urgent/non-complex patient
 Use dedicated pre identified staff
 Operating hours should reflect high demand periods and be instigated
at the discretion of the IC Nurse and senior MO
 Commence treatment early
 Strict inclusion and exclusion criteria
 Clinical protocols that promote early initiation of nursing care
 Rapid access to appropriate imaging and pathology and supported by
the TA role.
 Patients with single system problem that can be discharged in < 2
hours
40
Stay in consult
room for
treatment
Plaster area
 Easy access to specialty outpatient, GP and Community care referral
system and supported by ACAT nurse.
120
Home
Phase
F
A
S
T
*Adapted from JHH SafeFlow Project Guide (page 13), 2013.
Results pending/
observation room
MEDICAL
OFFICER
ED
NURSE
MEDICAL
OFFICER
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Triage – Chest
Pain
Dr Loten or Dr Maguire on duty
Monitored Bed
Does not fit criteria or
abnormal result blood or
ECG
ECG + Initial bloods
including Troponin
Fits criteria with normal
initial bloods and ECG
Low risk chest pain
Non low risk chest pain
ECG/Initial bloods are
abnormal, including LBBB or
paced rhythm
Over 70 years of age
Hx:- IHD, CABG or stent
High risk ACS or alternative
serious diagnosis eg PE
ECG/Troponin normal
Less than 70 years of age
No history IHD, CABG or
stents
Review by ED Consultant
ED bed
Med Registrar review
Dr Maguire or Dr Loten –
Low risk ACS
8hr Troponin and repeat
ECG
Ward Short Stay
Admission Bed
Not monitored
Stable – No chest pain
2/24 observations, no
monitor
Unstable/Chest Pain –
Immediate ECG and notify
Repeat Troponin and ECG
as per admission notes at
designated time
Cardiology review
Normal – D/C by ED MO
ED MO on ext. 32226
10
Meeting NEAT afterhours for EDs without ESSU
Please note ALL patients must meet the Elderly and Vulnerable
Discharge Policy Criteria, have a postural BP, and U/A attended.
Patients must be prescribed and GIVEN adequate analgesia, their
regular medications, active IV or oral hydration. Patients must be
given nutrition at regular meal times (Delirium prevention).
M
Negative
for
delirium
COGNITION
Patient confused with sudden decline, with either
known or unknown cause. Attend CAMI.
YES
Carer able
to cope
BEHAVIOURS
Difficult behaviours are present or carers
expressing extreme difficulty in caring for the
patient. Attend Modified Carer Stress form.
Positive
for
delirium
NO
Carer unable
to cope and
need complex
SW
intervention
YES
YES
PAINS
Current analgesia adequate for pain management,
and performing ADLs.
YES
MEDICATIONS
Patient or carer able to safely administer prescribed
drugs (including prn) either independently or via
Webster or similar.
NO
YES
WOUNDS
Simple wound requiring Community nurse or
Private nursing intervention.
NO
YES
CONSTIPATION
Pathway followed with good result and NO ongoing
faecal incontinence.
NO
YES
HYDRATION
Patient adequately hydrated without electrolyte
imbalance or other complications.
NO
NO
E
G
NO
R
E
E
T
D
R
MOBILITY
Fall leading to current presentation, recurrent or
recent increase in falls with known cause.
Patient can weight bear transfer independently
from sitting position and walk short distance with
usual walking aid.
A
S
E
V
I
E
W
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