ed stream workshop acute moc august 2013 ed stream workshop 1
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ED Stream WorkshopAcute MOC
August 2013
ED Stream Workshop
1
List All MOC used in your Facility
NSW MOH Model Of Care (2012) Hours of Operation
3.1 Triage + Registration 24 hrs
3.2 Clinical Initiatives Nurse 0700-2300 hrs
3.3 Resuscitation (including trauma) 24 hrs
3.4 Acute Care 24 hrs
3.5 Early Emergency Department Senior Assessment and Streaming Nil
3.6 Early Treatment Zone Nil
3.7 Fast Track 1030-1900hrs
3.8 Sub Acute 24 hrs
3.9 Emergency Department Short Stay Units Nil
4.1 Medical Assessment Unit Nil
4.2 Surgical Assessment Unit Nil
4.3 Hospital In The Home 0700-2200hrs
4.4 Psychiatric Emergency Care Centre Services Nil
5.1 Urgent Care Centre Nil
5.2 Health Direct advice line 24 hours
5.3 Connecting Care 0800-1630
5.4 After Hours GP Clinic Nil
2
Describe your Fast Track Model
Key principles Benefits of the Model Challenges Clinician run model (attach model guideline)
• Inclusion and exclusion criteria .
• Identified by Triage Nurse or FAST TRACK staff.
• Separate physical space and model to the rest of the ED.
• Must be recognised as a crucial role, rather than a complimentary role to the ED.
• Operational Plan to stipulate space, processes and staffing.
• Requires flexibility for a contingency plan for those who become evident that are not Fast Track.
• Requires escalation triggers to allocate appropriate resources.
• Capacity to manage high volume, low acuity patients in a reasonable timeframe.
• Gives structure and support to achieving NEAT for those discharged patients.
• Framework for Advanced clinical Nurses.
• Consumer satisfaction
• Staff Satisfaction
• Decreased Departmental overcrowding/ settled waiting room.
• Staffing profile
• Appropriate streaming from triage.
• Allocation of medical staffing
• Space
• Handing over patients into the sub acute stream if deemed necessary (Dr to Dr).
• Community awareness (initial phase)
• Sustainability and consistency (initial phase)
3
Microsoft Word Document
Differences between your Model and the definition in the “Emergency Department Models of Care July 2012”
FAST TRACK (MoH MoC 3.7 - 2012) FAST TRACK (TRRH ED – 2013)
Definition / Key Principles
• Pre Determined Inclusion/ Exclusion criteria
• Ambulant• Non Complex (Single System)• Seen Time – Discharge Time <2hrs• Expedites Care• Diverts patients into a particular stream• Dedicated Senior Medical and Nursing staff working to
optimise performance of Fast Track systems and the ability to make timely treatment and disposition decisions with minimal consultation
• Provides Care that is Standardised and targeted to specific conditions and injuries.
• Operating Hours reflect high demand periods
• Dedicated space and staff• Commences treatment early• Strict inclusion/ exclusion supported by business rules• Clinical Protocols that promote early initiation of nursing
care
• Rapid access to imaging and pathology• Easy access to specialty outpatient, GP and community
referrals
Inclusion criteria included in Operations Plan (2011), meets these specifications.√√√√√Ongoing - Work to be done -Consistent Medical coverage (Nurse Practitioner can lead model)and-Framework in developing Advanced Clinical Nurse role.
Requires auditing process
Medical availability 0800-2200hrs (inconsistent) Nursing coverage 1030-1900hrs (consistent) specifically for Fast Track, Nursing availability 0845-0300 for cubicle area (extension from FT area) √Reliant on CIN, but uses a “pull” ideology from the WRRequires R/V, updating and “polishing”Currently CIN protocol (ACN phase 1) requires ACN Phase 2 to be developed to incorporate Wound management/ fracture management
Imaging yes, Pathology discouraged√
4
Identify the Resource Required for your Fast Track Model
5
What do you need to set it up? Tamworth ED
Staffing (FTEs, Designation) 1x Nursing – 1030-1900hrs 7 days per week1x Medical – Variable, but aim 1030-1900 between both M and E shifts.1x Nurse Practitioner – Variable, although aim 1030 or 1230 starts
Training In-servicesAlthough aim at developing Advanced Clinical Nurses accreditation
implementation requirements Commitment PlanSustainability(had NUM 1’s undertake QAP methodology in evaluating model)
Guidelines, policies, Needs to be developed
Physical space Yes and needs governing
Clinical operation plans Yes (see slide 3)
Monitoring and Evaluation
Monitor Evaluation
Arrival - Time Seen Benchmark Australian Literature illustrates minimal contribution to timely intervention of care.Focus must be on accreditation of Nurses to meet ACEM definition in initiating early intervention as per a Local guidelines approved by the director Emergency Medicine.
Length of Stay Benchmark Australian Literature illustrates moderate benefit in overall LOS in the ED, adding benefit to NEAT.Processes of Fast Track the patients journey through ED, benefit majority ATS cat 4’s and 5’s.
48hr Representation Benchmark NP monitors 48hr representations (if seen by NP)
Ambulance- Transfer of Care Does not promote ambulance offloading into this area
Over census patients in ED, Patients staying in this are overnight.
Problematic as no nurse allocated to this area.
6
Evidence of Success
Improvement in KPIs since implementation
Triage Benchmarks LOS 48hr representation DNW
Impact on overall service
Sustainability Required post implementation review and recommendations Requires ongoing discussion and commitment – ward meetings/ excellence rounding
Transferability Model to be reviewed prior to moving into redevelopment, aiming to promote Advanced clinical roles for nurses (in procedures, under the supervision of NP or MO)
Aim to increase number of staff to suit the volume of daily through put (i.e. 2 x ACN : 1 x NP/ MO), similar to “RITZ” Model (rapid intervention treatment zone in the UK) different to “PIT” Physician in Triage Model.
Attach supporting evidence
7
Evidence Trends/ Impact on Service
8
LAOR%
DNW%
Represent <48hrs %
Admit < 4hours
Admit < 6hours
Admit < 8hours
Discharge< 4hoursNon admit
Discharge< 6hoursNon admit
Discharge< 8hoursNon admit
Total Presentation
Feb 10 0.84 9.63 8 22 - - 75 - - 3320
Feb 11 0.9%(1)
6.9 (6.4)
6.7(6.2)
20.2 44.4 66.2 76.4 91.4 96.2 3000
Feb 12 1.7(1.8)
8.1(5.8)
7.2(5.7)
19.2 42.4 60.8 63.1 83.9 93.2 3211
Oct 12 2.6(1.5)
4.3(4.3)
5.4(5.0)
26.6 52.1 70.6 74.6 89.1 95.4 3405
Dec 12 1.82 3.25 6 27 - - 80 - - 3682
May 13 1.7(1.4)
4.5(3.8)
5.3(5.1)
28.5 56 72.9 76.9 92.3 96.8 3405
July 13 1.27* 3.83* 6* 31* - - 82* - - 3350*
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