Dr Stuart Stapleton

Director, Emergency Department

Calvary Healthcare Bruce, ACT

Taking control of Your Destiny:The effect of a medical team model

for ED patients

Understanding CHCB ED

• Calvary Healthcare Bruce ED– Urban district ED in ACT

– ED basic structure approximately 25 years old• Total area about 1550 sq metres

• SSU, “paediatric area”

– ED census for 2014-15 FY = 56,321

– “Not for Profit”, “Public/Private Partnership”• Translate as “Not for Loss”

Some issues for the new director

• Dissatisfaction from the hospital executive about NEAT and waiting times

• ED Medical budget over by “up to $2.4M”

• Hospital executive change 2/12 after arrival

– CEO, CFO and DoNS

• Dissatisfaction amongst ED staff with various changes to model of care, executive uncertainty….

Control your own destiny or someone else will. Jack Welch

Basic Plan

• Get the ED to start functioning as team with common goals based around patient care

• Control our own destiny in factors we have control over– Pick the low hanging fruit for quick wins

• Go to the data….

CHCB ED Annual Census 2009-2014

0

10000

20000

30000

40000

50000

60000

Total presentations

Total Admissions

SSU admissions

The Data Told Us…

• Increasing workload

• We own at least 80% of the patient flow issues

CHCB ED Presentations/ATS 2009-2014

0

5000

10000

15000

20000

25000

30000

2009-20102010-20112011-20122012-20132013-20142014-2015

ATS 1 ATS 2 ATS 3 ATS 4 ATS 5

The Data Told Us…

• Increasing workload

• We own at least 80% of the patient flow issues, as they are discharged from the ED

– Need to get it right for the discharged patients

ED Medical Staffing

• Numbers per shift– Day/Evening: 2 consultants, 10 others

• Others: 2 interns, 2 RMO1s, mix SRMO/CMO/reg

– Night: 1 Reg, 1 SRMO/Reg, 2RMOs

• Geographical allocation– Acute Care/RR– Sub-acute/Primary Care– SSU

major loss of continuityworkload inequities excessive waits for patients who would be discharged

The Data Told Us…

• Increasing workload

• We own at least 80% of the patient flow issues, as they are discharged from the ED– Need to get it right for the discharged patients

patients

• Focus on the times when the patients arrive– Have staffing to match workload– Improved staff availability during handovers

ED Medical Team Model

• Between 0800-2400hrs, 3 teams of 4 MOs – Red

• Consultant led

• Morning team takes the night handover of all patients

• New patient from about 1000hrs

– Yellow• Consultant led – ED Admitting Officer, supervises Blue

team

• Starts receiving new patients from 0800hrs

– Blue• Registrar/Senior CMO led

• Starts receiving new patients from 0800 hrs

ED Medical Team Model

• Patients allocated to team at triage in order of arrival– Not automated via EDIS

– Reallocation by Yellow team leader or CNUM if workload imbalance

– Resus patients to the next team

• Each team responsible for managing its own workload

• Team leader point of contact for external clinicians

ED Medical Team Model

• Process unashamedly adapted from Nepean ED– Based primarily on work done at RPH, SVH and RNSH

• Associated business concepts– 80% of our patients are non-admitted and we own

their ED journey– Aim to see every patient within 30 minutes of arrival– Aim to have preliminary disposition plan within 60

minutes of arrival– Aim to have final disposition plan within 120 minutes

of arrival, including consultation request– Aim to have patient leave within 4 hours

Goals of the team model

• Improvement in seen times from 0800hrs

• Reduction in DNWs

• Better NEAT performance, especially for non-admitted patients

• Better supervision of junior MOs

• Better access to senior ED MOs for JMOs and nursing staff

• Improved patient satisfaction/decreased complaints at 12 months

ED Medical Team Model

• Implemented in Dec 2014

• Review of data

• Initial staff survey results

Coming together is a beginning; keeping together is progress; working together is success.

Henry Ford

Waiting Times and DNWs

0

10

20

30

40

50

60

70

80

2009 2010 2011 2012 2013 2014 2015

Av Wait

%Seen on Time

%DNW

Seen times, NEAT and Access Block

0

10

20

30

40

50

60

70

80

90

2009 2010 2011 2012 2013 2014 2015

%Seen on Time

NEAT %

Admitted NEAT %

ACEM Access Block%

D/C NEAT %

What do the staff think?

• Very basic survey

– Roles

– Duration in ED practice

– Perceived effects of the Medical Team Model

• More detail at the 12 month mark

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Much worse Sowehatworse

Nodifference

Somewhatbetter

Much better

Rate the ED MTM in terms of knowing who is looking after a specific patient in the ED (n=30)

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Much better Somewhatbetter

No Change Somewhatworse

Much worse

ED MTM effect on decision making processes for ED patients (n=30)

0%

5%

10%

15%

20%

25%

30%

35%

Much easier Somewhateasier

No change Somewhatharder

Much harder

Does the ED MTM make your job harder? (n=30)

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Much moredifficult

Somewhatmore difficult

No change Somehatbetter

Much easier

The ED MTM has made it easier to access Senior ED MOs (n=30)

0%

10%

20%

30%

40%

50%

60%

70%

Much slower Somewhatslower

No change Somewhatquicker

Muchquicker

Perception of timelines for decision making for ADMITTED patients (n=30)

0%

10%

20%

30%

40%

50%

60%

70%

Muchquicker

Somewhatquicker

No change Somewhatslower

Much slower

Perception of timelines for decision making for DISCHARGED patients (n=30)

Has the ED MTT been a positive change for the ED? (n=30)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Positive/Very Positive

Patients in ED

ED Admin

ED Nursing

ED Medical

ED other clinical

Non-ED clinical

Things to work on….

• Triage nurse control of allocations in EDIS

• Resus response

• Trainee supervision, especially with WBAs

• Team leader dependency

• ED size – especially assessment areas

• Overnight

Coming together is a beginning; keeping together is progress; working together is success.

Henry Ford

Thank you