Senior Assessment and

streamingFrom Concept to creation

Dr Matthew Vukasovic

HOD Westmead Emergency

Need for change

ED waiting room…….back then

o Patients physically

segregated from the actual

ED

o Physical and psychological

barrier to patients

o Minimal observation of

patients possible

o Minimal therapeutic

interventions

Ambulance corridor

o Waiting room also functions

as a thoroughfare

o Patients feel neglected,

anxious and fearful

o NO added value for the

patient within the waiting

room

o Ambulance OST delays

• Casualties of a sick system

• Julie Robotham Medical Editor SMH

January 10, 2009

• A WESTMEAD Hospital scheme designed to slash costs and improve

performance statistics by getting patients out of ambulances more

quickly contributed to the deaths of two patients, who received sub-

standard care in the emergency department, internal investigations

claim

Our journey of innovation and

redesign

oCo-design project�Emergency and Cardiology Services

oIntegrated models of care�ED HOPE (MAU)

oNew models of emergency care�Fast Track

oProcess mapping projects

oRedesign projects� Trauma redesign project

oInternal waiting room proposal

2006 2007 20092008

Co- Design Project 2009

o Involving staff, patients

and carers to identify

current model of care

delivery and process

o Designing improvement

strategies

collaboratively

Patient and carer experiance

“When I came in, I think it was a little bit

long. I would say about 20 minutes,

anything could happen in 20 minutes.

They should have put me straight in.”

(Patient: Co-design project)

“After being assessed

by the triage nurse &

before going into the

Emergency ward I

was in quite a lot of

pain. It would have

been good to have

had some pain killers

and also to have

some privacy”

(NSW Patient survey)

That was very hard because the triage

nurse, she is trying to type your name

& address and I’m thinking can we just

get him in and I can do all of that later.

Then she sent me to the other counter

to register my husband” (Carer: Co-

design

“It was scary, a lot of

things go through

your mind when your

husband is sick. I was

grateful when we go

inside, once on a bed

I felt a lot better, more

secure”Carer: Co-design Project

Lessons learnt o Analysis of the ‘Front of House’ processes

o Functionality

o Patient safety

o Performance

o Aesthetics of the ED experienceo Analysis of the whole interaction for the

patient/carer

o Impact on clerical, nursing and medical staff

o Importance of project managemento Project plan

Trauma redesign project

o Improve experience for trauma patients

o Understand ‘as is’-current state’ vs ‘to be’- ideal state’

o 18 process maps

o Voice of the patient

o 1:1 staff interviews

o Focus groups

Trauma redesign workshop

5th August 09 1- 5pm

Process mapping project

• Delays to triage have been validated in the Emergency Department process mapping exercises

• Variable delays can be 10 minutes to > 1 hour to triage

Previous scenario’s

• Westmead 2009-2010

• Worsening Access block

• Worsening Triage benchmark performance

• High DNW rate

• High ED LOS

• Well known adverse effectso Adverse clinical incidents

o Performance degradation and delays in care

o Staff and morale issues

o Training and recruitment issues

o Patient dignity and privacy issues

‘AN ED WITHOUT A WAITING ROOM’

Presentation for NSW Health

November 20th 2009

What did we propose?(2009)

• Quick triage

o Redesigning clerical & triage processes

• Senior decision making team at point of entry

o Senior doctor and nurse (CIN)

• Early streaming models

• Internal ETZ to replace the waiting room

• Separate pathways for streamed patients

NO waiting room ED

Streaming

TRIAGE FRONT OF HOUSETEAM

Early decision making

ACUTE ED

FASTTRACK

MAU UNIT

ESSU/ETZ

Disposition

Early pregnancy

assessment

clinic

PECC

Our journey of innovation

oInitial SAFE-T pilot (Dec 2010)

�1 room

oESSU

�6 beds

oSAFE-T and ETZ (Feb. 2011)

�1-2 spaces plus 4 in ETZ

2010 2011 20132012

SAFE-T Phase 1• Clinical space

SAFE-T zone → 2 bed initial assessment

stream initiate zone (ASI), 5 treatment space

early treatment zone (ETZ)

• Staffing

• ED Physician/Registrar

• JMO

• RN

SAFE-T• Business rules• Early Assessment (Bloods,Imaging,exam.)

• Early treatment (IV antibiotics,analgesia,fluids)

• 10 minutes per patient

• Disposition planning• Early streaming (SSU,MAU,wards)

• Acute care bed bypass/quarantining

• ETZ

• Discharge home or clinics

• Early Inpatient team review

Options from SAFE-T Zone

Pilot Study Dec 2010Characteristic Control group Intervention group Comments

Eligible patients – ATS categories 3, 4

and 5

67 90 More patients reviewed in same

bandwidth during trial period.

Length of stay – irrespective of ATS

categories

451 minutes

(95% CI 371 – 533)

324 minutes

(95%CI 276 – 410)

Median difference of 136

minutes (95% CI 61 – 211).

p=0.0003

Time to medical intervention – ATS

category 3

154.5 minutes

(95%CI 27 – 251)

n=34 patients

18 minutes

(95% CI 16 – 29)

n=43 patients

Median difference of 116

minutes

(95% CI 24 – 185)

p<0.0001

Time to disposition – ATS category 3 557.5 minutes

(95%CI 484 – 914)

n=34 patients

410 minutes

(95% CI 315 – 456)

n=43 patients

Median difference of 237.5

minutes

(95% CI 107 – 401)

p<0.0001

Time to medical intervention – ATS

category 4

72 minutes

(95% CI 37 – 128)

n=25 patients

32 minutes

(95%CI 17 – 49)

n=35 patients

Median difference of 37 minutes

(95% CI 12 -79)

p=0.0015

Time to disposition – ATS category 4 342 minutes

(95%CI 222 – 395)

n=25 patients

276 minutes

(95%CI 222-403)

n=35 patients

Median difference of 19 minutes

(95%CI -70 – 119)

sided p=0.66

Time to medical intervention – ATS

category 5

180.5minutes

(95%CI 119 – 229)

n=8 patients

27 minutes

(95%CI 4 – 75)

n=12 patients

Median difference of 124.5

minutes

(95%CI 63 – 185)

Two sided p=0.0003

Time to disposition – ATS category 5 413 minutes

(95%CI 295 – 547)

n=8 patients

124minutes

(95%CI 67 – 337)

n=12 patients

Median difference of 232

minutes

(95%CI 64 – 390)

Two sided p=0.01

SAFE-T trial data• Trial period → 24/02/2011 – 08/05/2011

• Comparison period →24/02/2010 –

08/05/2010

• SAFE-T zone hours of operation –

1000hrs to 1800hrsYear

Total2010 2011

Status Out of SafeT hours 5039 5468 10507

In SafeT hours 5146 5245 10391

Total 10185 10713 (↑ 5.2%) 20898

Time to first seen KPIATS category

Category 1 Category 2 Category 3 Category 4 Category 5

Year

2010 100 % 81.4 % 49.5 % 54.8 % 76.8 %

2011 99.6% 92.3 % 69.1 % 73.4 % 86.3 %

p- value p = 1.00 p < 0.001 p < 0.001 p < 0.001 p < 0.001

Year Percentage meeting criteria Time < 30 mins

2010 74.5 %

2011 79.5 %

p-value p < 0.001

Off-Stretcher time KPI (OST)

LOS – In SAFE-T hoursIn SAFE-T hours Year

2010 2011

Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75

LOS (hours) All patients 6.0 3.9 8.8 5.5 3.2 8.2

LOS (hours) Discharged patients 3.8 2.5 5.3 3.5 2.3 5.1

LOS (hours) Admitted patients 7.6 5.6 10.5 6.9 4.8 9.9

In SAFE-T hours Year

2010 2011

Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75

LOS (hours) All patients 6.0 3.9 8.8 5.5 3.2 8.2

LOS (hours) Discharged patients 3.8 2.5 5.3 3.5 2.3 5.1

LOS (hours) Admitted patients 7.6 5.6 10.5 6.9 4.8 9.9

In SAFE-T hours Year

2010 2011

Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75

Category 1 P=0.358 5.1 3.7 7.2 4.9 2.9 7.8

2 P=0.118 6.4 4.4 9.2 6.2 4.1 8.6

3 P<0.001 7.5 5.3 10.5 6.5 4.2 9.4

4 P<0.001 5.7 3.6 8.4 4.9 2.8 7.6

5 P=0.017 3.5 1.9 5.4 3.1 1.7 5.0

In SAFE-T hours Year

2010 2011

Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75

Category 1 P=0.358 5.1 3.7 7.2 4.9 2.9 7.8

2 P=0.118 6.4 4.4 9.2 6.2 4.1 8.6

3 P<0.001 7.5 5.3 10.5 6.5 4.2 9.4

4 P<0.001 5.7 3.6 8.4 4.9 2.8 7.6

5 P=0.017 3.5 1.9 5.4 3.1 1.7 5.0

Conclusions• 5.2%(6.5%) increase in number of presentations

during the intervention period

• Statistically significant improvement in time to first seen and Off-stretcher time KPI across all categories

• Statistically significant decrease in DNW rate

• Median, 25th and 75th percentiles length of stay was reduced for all patients in 2011 compared to 2010

• Statistically significant LOS changes were noted in ATS categories 3 and 4 (14.3% and 11.8%)

Conclusions• Most of the LOS reduction were noted during SAFE-T

hours of operation for ATS categories 3 and 4 (17.9%

and 17.0%)

• Increasing SAFE-T hours of operation to 12 hours will

lead to statistically significant improvements in LOS

for categories 3 and 4 ( 16.5% and 17.3%)

• Positive effects despite significant worsening in

Access block and hospital bed occupancy rates

• Multiple ED throughput measures bundled in a

model of care have significant positive impact on

LOS

• Need to test your MOC in current environment

• Collect data to validate your MOC

• Publish this data if possible

• Provides necessary impetus to drive change

• Provides necessary evidence for your staff and

executive

The journey continues

o Building works 2012-2013

o New UCC opens ( 6 treatment spaces +2)

o New Resuscitation rooms open

• SAFE-T /ETZ opens (2 +8 treatment spaces)

o Trial AAU( planning for new AAU)

2013 2014 20162015

Models of Emergency Care

Emergency Services, Westmead Hospital

Defining the ideal patient

journey

... Emergency Department Models of Care Redesign

ED Front End processing

... Quick triage

and

registration

ED Front End Processing

... SAFE-T

ETZ Six chairs & two trolleys

Considerations for streaming patients through ASI model of care

• ED capacity including

� Workforce (availability of senior decision maker)

� Vertical v Horizontal patient

� Bed availability in acute care

ASI

Front of House CordinatorFront of House Cordinator

10 minutes

Admission stream• Acute (undifferentiated/complex)• AAU (Differentiated , allocated in pt team)

Senior Doctor

Junior Nurse

Senior NurseTriage level

Discharge stream• ETZ 2 hours

• UCC 2 hours• ESSU 2-23 hours• Waiting Room

Blocked streamIf appropriate MoCis access blocked send to ETZ

ETZ

ED RMOWorks in ASI & ETZ

Senior NurseCIN level

2 hours

Initiate treatment while awaiting transfer to ED MoC

Observe /treat patient for up to 2 hours prior to discharge

Speciality team review

Observe patient who symptoms are not well defined

access block

Provides increased ED Capacity when there is access block

Trauma and resuscitationFour resuscitation bays including 1 dual function isolation room

249234

258

228

262 258276

311 302 306

650 650672

714 706

752

679

728

767

677

9784 83

109128

144

104124

102 94

34 3546 49 43 35 35

50 5131

8 5 9 11 11 5 11 12 6 10

0

100

200

300

400

500

600

700

800

900

SPRING 2010 SUMMER

2010/2011

AUTUMN 2011 WINTER 2011 SPRING 2011 SUMMER

2011/2012

AUTUMN 2012 WINTER 2012 SPRING 2012 SUMMER

2012/2013

RESUS PRESENTATIONS BY TRIAGE CATEGORY

1

2

3

4

5

24 Beds

Acute care...

1 hours for ED assessment and commence clinical management plan. ED SMO will review patient within1 hour and make a decision (admit/discharge/AAU/ESSU) . The E-form will be completed and reflect this decision

Up to 2 hour for speciality team review and/or allocation to inpatient bed

Up to 1 hour to transfer care to admission stream or discharge stream

1 hour 2 hour 1 hour

Four chairs

Two TrolleysTwo Consult RoomsOne Procedure RoomWaiting Room

Urgent Care Centre

UCC: TOTAL PRESENTATIONS WITH LOS < 2 HRS

4494

53865515

6789

6586

5962 6009

6786

16651790 1814

2109

2549

2176

2611

3364

0

1000

2000

3000

4000

5000

6000

7000

8000

AUTUMN 2011 WINTER 2011 SPRING 2011 SUMMER

2011/2012

AUTUMN 2012 WINTER 2012 SPRING 2012 SUMMER

2012/2013

UCC Total Presentations LOS < 2 hrs Linear (LOS < 2 hrs)

Four bedsFour chairs

Emergency Short Stay Unit

(Discharge stream)

Urgent care

centre

SAFE-T

Acute care

Features of ESSU ModelSpecial purpose beds.High turnover.NOT interchangeable with ward beds.

ED Consultant-led:Patient selectionReviewDecision to discharge

ESSU: AVG LOS WITH LOS <4HRS

13:23

12:02

10:1610:55

11:25

10:01

9:109:44

8:147:45

139

91

275

155

219

252

276

335

435

469

0:00

2:24

4:48

7:12

9:36

12:00

14:24

SPRING 2010 SUMMER

2010/2011

AUTUMN

2011

WINTER 2011 SPRING 2011 SUMMER

2011/2012

AUTUMN

2012

WINTER 2012 SPRING 2012 SUMMER

2012/2013

HR

S:M

INS

0

50

100

150

200

250

300

350

400

450

500

NO

OF P

TS

AVG LOS LOS <4hrs Linear (LOS <4hrs) Linear (AVG LOS)

ESSU: TOTAL PRESENTATIONS WITH LOS <24HRS

608

421

951

810

1010 991

1108

1217

13771457

0

200

400

600

800

1000

1200

1400

1600

SPRING 2010 SUMMER

2010/2011

AUTUMN 2011 WINTER 2011 SPRING 2011 SUMMER

2011/2012

AUTUMN 2012 WINTER 2012 SPRING 2012 SUMMER

2012/2013

ESSU Total Presentations LOS <24hrS Linear (ESSU Total Presentations) Linear (LOS <24hrS)

Acute Admissions Unit

(Admission stream)

SAFE-T

Acute care

Features of the AAU Model of careDifferentiated patient admitted under an inpatient team but may need ....- team review prior to ward transfer

- complex investigations to determine disposition

- further observation prior to transfer to the ward

Urgent care

centre

To be admitted to the AAU the following is required:Management and disposition plan

Time indicator of when the patient is likely to be transferred to the inpatient ward

Trigger point when the transfer would be appropriate(eg when CT report is available)

Scenario 1

58 year old female presents with increasing back pain

Known metastases to sacral area

Background metastatic breast cancer

Last admission under Med ONC last week

Scenario 2

25 year old female presents with lower abdominal pain

LMP 3 weeks ago

•Temp 36, HR 69, B/P 120/72, RR 14

Scenario 3

65 year old male presents with one episode of PR

bleeding. Nil past history, Family history of Bowel Ca

Otherwise well

• HR 78, BP 110/78, TEMP 36, SpO 98, No postural drop

Scenario 4

52 year old male, sudden onset Left flank pain

Pain 10/10

Unable to pass urine

Scenario 5

33 year old male currently on chemotherapy for AML

Febrile with temp of 38.5, BP 130/70, HR 130/min

No beds in acute

Lessons learnt• Any new MOC requires staff collaboration and

engagement

• “Listen” to feedback

• Importance of education esp. ongoing

• Staff In-services over 3 weeks

• Clinical scenarios to illustrate ideal patient

journeys/pathways

Dicussion• Staffing

• Complex roles(need to be clearly defined)

• Senior decision maker

• Adding value(bloods,imaging,treatment)

• Streaming options(more difficult concept to grasp)

Discussion

• Role of ETZ

• 10 minute limit

• Rapid triage

• Ambulance offloads

• Access block