PFC 2005 - Emergency care: Patient Flow Collaborative - Victorian Government Health Information, Australia

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Patient Flow Collaborative 2005

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Events & presentations

PFC 2005 - Emergency care

Aim

To provide effective and timely emergency care for patients who need emergency treatment.

Change Concepts

Define stretch targets for ED throughput and develop and implement a policy framework that drives/mandates a maximum ED LOS
Media campaign on 'emergency care for emergency treatment only'
Implement 'pull' system that prepares next step in the patient process, i.e. monitoring patient delays via access to website /intranet
Implement delay categories with actions to be taken - policy to be implemented with training
Implement a monitoring system for status of patients in emergency departments to be reviewed at hourly intervals/two hourly intervals
Escalation policy for raising /strengthening management input. Policy demonstrates accountability and responsibilities for the organisation.
Identify shift coordinators that do not have clinical workload with responsibility to coordinate staff and resource in Emergency Department.
Develop a full clinical team to facilitate the emergency patient seeing the right person at the right time - nurse, doctor, physio etc
Develop protocols to enable 'fast track' streaming all categories of patients to deliver
- To right clinical person,
- With right patient,
- Right place,
- Right resource,
- Right length of stay
Implement fast track protocols for patients who need admitting e.g. Fractured Neck of Femur
Develop clinical team training modules to support development of Emergency Department clinical team
Establish Bed management team and Emergency Department Coordinator joint working - recognising pre planning of emergency, elective bed needs.
Map processes for admitting officer's admin functions
Map processes for communication to waiting patients -
- Waiting to be seen
- Waiting for admission
- Waiting for discharge
Develop 'single assessment' tool for all patients
Identify chronic disease management patients, who can be streamed to outpatients department/nurse lead/allied health clinics in future, provide information for patients
Develop specific units/bed areas:
- Medical assessment and planning units (MAPU)
- Emergency medical unit (EMU)
- GP unit within Emergency Department connected/adjacent to Emergency Department
- Minors Unit within Emergency Department
- Rapid Emergency treatment teams (REAT) or Rapid Assessment Team (Rats)
- Chest Pain evaluation unit (CPEU)
- Short stay Observation Unit
- Management of mental health patients
Establish management 'on call' support for Emergency Department
Form Agreement for rapid surgical assessment and transfer to wards 24 hours a day
Establish assessment and treatment pathways for main presentation categories, especially Short stay Observation Unit/ Chest Pain Evaluation Unit (CPEU)
Increase 'team' communication between Emergency Department; radiology wards and key departments for flow of Emergency Department patients, identify single contact person for multiple calls
Establish Emergency Department areas for treating lower acuity ambulant patients with assessment chairs, equipment and patient information to promote patients being treated and discharges (fast track) nurse only
Increase effective and efficient emergency care for older patients who could be managed in their own home - via patient pathways, information, hospital in the home services, develop advanced nursing roles for home treatment; after hours access to referral and assessment
Develop culture of whole hospital responsibility for emergency patients; incorporate IT tracking across all areas
Implement emergency outpatients department appointments, including next day slots
Increase management facilitation and responsibilities within Emergency Department
Phone hot-line available to obtain specialist support and priority test access
Emergency department staffing based on predicted demand by day of week and time of day
Geriatrician/general physicians located in Emergency Department to assess aged inpatients at risk (e.g. #NOF)
Planned discharge date assigned within 24 hours of emergency admission
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Key Change Principles

Manage patient journey, track delays and take action across whole service
All staff to be trained to assist with right patient, right place, right time, right resource, right staff member.
Pull systems to progress patient to the next step

Measures

Program Measures

Patient Journey Time in ED (SPC chart)
Percentage and Number of ED Patients Admitted to Ward in <12 hrs (SPC chart)
Percentage of ED Throughput <6hrs (SPC chart)

Example Case Study Measures

Total Daily ED Presentations for year (SPC)
Additional Patient Journey Times in ED (SPC)
- Arrival dt to Departure dt
  - All/Admitted/Discharged
- Arrival dt to Seen by Nurse/Doctor dt (Treatment dt)
  - All/Admitted/Discharged
- Seen by Nurse/Doctor dt to Bed Request dt
  - Admitted
- Bed Request dt to Discharge dt
  - Admitted
Total Daily ED Presentations by Triage Cat (Line daily for year)
Total/Average ED Admissions by DOW (Bar month sample)
Presentation to ED by time of day (Bar week sample)
Admission from ED by time of day (Bar week sample)
Discharge from ED by time of day (Bar week sample)
Avg LOS for ED Patients by DOW (Bar for year sample)
Actual LOS for ED Patients by DOW (Pareto chart for longest day)
Total ED Discharges + Deaths (DOW bar for year sample)
Avg ED Discharges + Deaths (DOW bar for year sample)
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HDM Monitoring

Provides complete monitoring of health services for monthly/quarterly and 6-monthly KPI/KRA performance, with comparisons to targets (where applicable) and the previous year
Includes a mixture of provisional data provided by health services and data from ESIS/VEMD/VAED
Encompasses ED processes, Elective Surgery Services, ICU/CCU, Patient Flow and Exit Block indicators
VEMD Indicators:
- % Time On Hospital Bypass
- % Admissions within 12 Hours
- % Triage Cat 1 Seen Immediately
- % Triage Cat 2 Seen within 10 Minutes
- % Triage Cat 3 Seen within 30 Minutes
- % Triage Cat 4 Seen within 60 Minutes
- % Triage Cat 5 Seen within 120 Minutes

HDM Supplementary Data

Daily Bypasses
- Bypass report by hospital and by day for the current month, and by month/year for YTD and last 2 years
- Tracks hospital and system performance against target
- Includes both actual bypasses and % time on bypass
- Updated daily
Time Series Chart
- Charts actual bypasses from Jan 1999 to current
- Includes commentary for key events
Emergency Presentations Growth
- Data by month and year from July 1998
- System-wide, metropolitan hospital overview, rural hospitals overview and hospital-level data
Admissions within 12 hours - Monthly Report
- System-wide overview: by month/year from July 1998. Includes "blocked" admissions (n), total admissions (n) and admissions within 12 hours (n and %)
- 13 metro overview: by hospital and month/year from Jul 2001 for % admissions within 12 hours, and monitors hospital performance against targets
- Updated fortnightly
Admissions within 12 hours - Time Series Chart
- Charts of blocked admissions and % of admissions within 12 hours from Jan 1999 to current
Triage Performance
- Triage performance by hospital and quarter
Emergency Department Activity - 13 Metro Hospitals
- A comprehensive report on YTD emergency department activity by hospital and month
- Includes average daily presentations, PCT patients, ED KPI/KRA performance,
- ED long stay patients, age breakdown and many other indicators
Respiratory Infections / Influenza Like Illness (ILI) Monitoring
- ILI monitoring starts in February and ends in September
- Tracks ILI diagnoses for presentations and admissions by hospital, week and age group
- Includes comparisons with same period in last 2 years
Victorian Infectious Disease Reference Laboratory (VIDRL) Website
- Fortnightly Surveillance Bulletins (May - September)
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Resources

Access to Emergency (83kb, pdf)

Ambulance Improvement Checklist (19kb, pdf)

ED Collaborative (75kb, pdf)

ED LOS and Inpatient LOS (124kb, pdf)

ED Nursing (73kb, pdf)

EMS Systems (82kb, pdf)

Frequent ED Users (97kb, pdf)

Improving Quality in ED (135kb, pdf)

Improving Quality to Decrease Costs (104kb, pdf)

Incident Monitoring in ED (568kb, pdf)

Information Gaps in ED (176kb, pdf)

Measuring Quality in ED (184kb, pdf)

Oklahoma Taskforce on ED (259kb, pdf)

Patient Safety and Prevention of Error in ED (226kb, pdf)

Predictors of Patient Dissatisfaction with Emergency Care (213kb, pdf)

Preventative Care in ED (96kb, pdf)

Quality and Education (131kb, pdf)

Quality in ED (127kb, pdf)

Six Sigma Improvement Ideas for ED (276kb, pdf)

TQM and ED (64kb, pdf)

TRISS (70kb, pdf)

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Toolkits

Emergency Care (1.25mb, MS Powerpoint)
Communication plan- staff, press, posters
Tracking system based on traffic light process highlights delays for each patient
Escalation policy
Streaming principles
Rigorous diagnostic (743kb, pdf)
Chronic disease management
The Goal (book)
Lean Thinking (book)