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The Tale of 3 Ticks
George Braitberg & Susan Harding - 2015
Melbourne Health Melbourne Health is Victoria’s
second largest public health
service. We provide
comprehensive acute, sub-
acute, general, specialist
medical and mental health
services through both inpatient
and community based facilities
through the following services:
• The Royal Melbourne
Hospital– City Campus
• The Royal Melbourne Hospital
– Royal Park Campus
• North Western Mental Health,
North West Dialysis Service
• Victorian Infectious Diseases
Reference Laboratory.
RMH
• RMH currently receives more emergency ambulance transports
than any other hospital in the state.
• A new 42 bed Royal Melbourne Hospital ICU and a hybrid trauma
theatre with MRI capabilities will be opened in 2016 as well as the
Victorian Comprehensive Cancer Centre situated across the road
from the Emergency Department.
• The Department is internationally recognised as a Level 1
Trauma Centre treating 50% of the State adult trauma load,
including more than 900 major trauma patients per annum. A
purpose built helipad offers direct access to the hospital.
• The hospital has a strong emphasis on Neurosciences and
Cardiology offering 24 hour interventional angiography and
stenting
The RMH ED Our Vision
To develop a Centre of Excellence that will
be the leading institution in the provision of
patient centered emergency care and
consolidate links with Victorian, National and
International research institutions to develop
and deliver training and teaching in our
specialty.
The ED comprises a 54 bed unit which
includes a co-located 20 bed Short Stay.
Resuscitation 8
Adult Emergency/ Acute 20
Paediatric Emergency/ Acute 0
Low Acuity/ Sub-acute/ Fast track area 3
Emergency mental health assessment 0
Short Stay Unit (or equivalent) 20
Demographics
Patient attendances 65,793
Inpatient admissions 29793
Short Stay Unit (or equivalent) admissions from ED 10,669
Inter-hospital transfers from ED 10154
ICU/HDU admissions from ED 634
CCU admissions from ED 977
Trauma patients with ISS>12 900
Transfers to other hospitals' ICU 36
Transfers to other hospitals' CCU 171
Staffing
ED Staff Total FTE
FACEM Specialists 25
ED Registrars - ACEM Advanced Trainees 22
ED Registrars - ACEM Provisional Trainees 2
Non-ACEM registrar/ CMOs (able to be in-charge) 0
SRMO/SHOs (PGY2 and above) 8
Junior medical officers/ Interns 14
Care Coordinators 10
Other Nursing staff 115
Administrative staff- In clinical area 3
Administrative staff- In office area 4
Total 203
Australasian Triage Scale ATS
Categories ATS
Category Attendances
% of
Total
Immediate 1 699 1
10 Minutes 2 6,574 10
30 Minutes 3 29,559 45
60 Minutes 4 25,646 39
120 Minutes 5 3,234 5
ATS Category &
maximum % seen within
maximum
waiting time
Mean waiting
time (min) Median waiting
time (min)) DNW %
waiting time
ATS 1 100% <1 min <1 min 1
ATS 2 85.30% 2.9 <1 min
1.4
ATS 3 72% 25.3 14.5 3.9
ATS 4 75.70% 41.5 24.6 7.9
ATS 5 92.20% 47.3 30.2 13.6
Overall DNW% 5.6%* *includes left after clinical advice
Who are we?
1. Annual attendance of more than 65,000 adult patients.
2. It is a tertiary/quaternary referral centre.
3. Provides care to the highest acuity emergency patients in
Victoria with an admission rate of 45%
4. The ED currently receives more emergency ambulance
transports than any other hospital in the State.
5. The Department is internationally recognised as a Level 1
Trauma Centre treating 50% of the State adult trauma load,
including more than 900 major trauma patients per annum
6. There is a broad base of specialist expertise within the ED
covering clinical areas including Toxicology, Ultrasound
(including echocardiography), Retrieval medicine, Research,
Prehospital care, Medical Education, Infectious disease and
Simulation
What we do?
ED CORE BUSINESS PRINCIPLES
Our role is to:
– initiate timely assessment and management
in order to determine clinical priorities
– implement initial time critical interventions
– formulate a provisional diagnosis
– refer appropriately
Our Timestamps
• 80% patients seen within 30 minutes of arrival
• 80% patients have a bed request within 120 minutes of being seen
• 90% of patients are admitted to Short Stay within 4 hours
• 90% non-admitted patients are discharged within 4 hours
• 90% of ambulances are offload within 40 minutes
Research
Academic Emergency Department with expertise in – Toxicology
– Trauma
– Violence and Aggression
– Models of Care
– Systems analysis
– Discharge
– ED utilisation and representation
– Stoke and Chest Pain
In the process of establishing a Chair and concrete links within the University
• Melbourne Health uses Symphony as our Electronic Patient
Record system.
• Symphony provides an on-screen display of all the clinical data
relating to each patient’s episode journey
• The use of customized icons on the tracking screen provides
users with a quick visual tool to identify needs of patients
Background
Background
• Delays in patient handover
• Inconsistent handover information
• Discrepancies about patient last set of obs
• No ownership of patient state
• RiskMan reporting and escalation of issues
Problem
ACHS • Approximately 7 068 000 clinical handovers occur annually in
Australian hospitals
• Current handover processes are highly variable and may be
unreliable, causing clinical handover to be a high risk area for
patient safety.
• Breakdown in the transfer of information has been identified as one
of the most important contributing factors in serious adverse events
and is a major preventable cause of patient harm.
• Achieving sustainable improvement in clinical handover requires
standardised processes and information sets.
• When a standard process for clinical handover is used, the safety of
patient care will improve as critical information is more likely to be
transferred and acted upon
http://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-Sept-
2012.pdf
Aim
• To introduce a visual prompt to indicate
patient Ready To Go (RTG)
• To improve timely transfers
• To improve quality & safe care
• To identify stakeholder accountability
• To identify & manage clinical deterioration
and to reduce MET calls post transfer from
ED (within 4/24 timeframe)
Clinician RTG Introduction of the Clinician Ready To Go (RTG)The blue doctor’s tick on the
tracking grid identifies that a patient is ready to go and an admission plan has
been completed.
Nursing RTG
The Nursing Ready To Go (RTG) will only be enabled 30 minutes before the bed is
ready.
The nurse’s tick completes the safe discharge process by providing information on
falls and pressure risks as well as providing a set of vital signs before transfer.
1. The introduction of the Clerical Ready to Go (RTG) can only be completed
once the nurse’s tick is visible on the tracking grid.
2. The clerical green tick signals that the clerk has completed the paperwork
within the remaining period of time within the 30 minutes.
3. This completes the team component of the 3 Tick process and is the final
step for the patient to safely leave the ED.
Clerical RTG
3 ticks = Admission Plan
Follows the ISBAR format
If not reviewed by inpatient team,
interim orders are documented
Impact
• Quick, visual prompt for patient status
• Quality control with observations to be completed 30/60
before allocated bed ready time
• Safety measures to stop patients from transitioning to the
ward if unstable
• Clinician, nursing and clerical accountability for patient care
• Auditing process to identify delays in patient transfers – ward
ready versus actual departure times
The Hospital gets a view
The ED gets a view
Keep Times Real
• The 3 ticks process depends on the bed
manager allocating a time for bed
availability.
• If the time is “rubbery” and changeable the
timing of our ticks is variable.
• Hence there needed to be a change to the
organisation’s response to “bed ready”
times
Shared Responsibility
ED
• Document Admission
Plan
• Document medical care
• Take Vital Signs 30
minutes before transfer to
the ward
• Ensure all “paperwork” is
performed in a timely way
Wards
• Allocate a time the bed is
ready
• Take responsibility for the
time
• Only call the ED if there is
information needed that is
not in the electronic
record
Admission orders audit 09/02 – 28/04/15
• Total number of 2118 documents
• Random Sample of 213 Interim Orders reviewed
(10%)
• 211 (99%) had all fields completed
• 155 (73%) documented the name of the
register/consultant referred to (many with contact
details)
• 193 (91%) contained clinical information that
would enable the ward to continue care without
needing to make any further enquires
0
5
10
15
20
25
30
35
40
Interim Orders (by Unit)
Good Communication examples
• “4/24 obs and normal MET call criteria. Not for
resuscitation if deteriorates - to contact family
and for comfort measures. Analgesia as charted.
Med Reg to complete admission, with thanks.
Okay to eat and drink.”
• “SOB, feeling "unwell" for 4 days, recent admit
under RAPU 2 weeks ago thought depression.
likely depression again? Clear CXR, bloods
normal. FOr RAPU admit and geriatric/psych
follow up. not for Abx unless febrile or clinically
unwell”
• “admit gastro - usual meds but decrease PNL to
25mg and withold metformin until lactate comes
down, actrapid sliding scale, IV cepazolin 1gm
tds and flagyl 500mg TDS, IV fluids but oral
intake as tolerated, clexane, team to chase CT
abdo result from this week done at MIA (need to
exclude abscess)”
Examples where
communication can be
improved
• “Xrays and bloods”
• “Chest infection”
• “? Dehydration”
• “Analgesia”
50
60
70
80
90
100
110
120
130
200
220
240
260
280
300
320
340
360
380
400 Results
EDLOS (median minutes) DTA (median minutes)
0
10
20
30
40
50
60
70
80
90
0
50
100
150
200
250
300
350
400
Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15
NEAT
DTA (median min)
AEDLOS (median mins)
Organisational NEAT
Discharge
SSU NEAT
0
1
2
3
4
Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15
MET Calls within 4 hours of admission
How do you make it sustainable?
Accountability Individual EP KPIs
KPI % change from
report 1
Seen by doctor within 30
minutes
12%
Admit to SSU within 4
hours
15%
Decision to admit within
120 minutes
13%
The vision is to develop an
Academic ED with expertise
particularly in toxicology, trauma,
and violence and aggression
management, models of care and
systems analysis.
Quality
Challenges
Lessons learnt I
1. Professional courtesy and communication
– All teams who see patients in the ED must inform the
referring doctor about the management plan before
leaving the ED
2. Documentation
– Once the inpatient team has reviewed the patient the
expectation is that they will complete a medication
chart and document their plan in the progress notes
Mismatch between the ED and IP team expectations
Lessons learnt II
3. Mismatched Expectations
– The ED staff will document the medications and fluids
required for the interim period before the patient can
be completely clerked. The ED expects the inpatient
team to review the drug chart completed in the ED and
amend or add medication as part of the admission
process
4. Admitted patients in the ED
– The ED will provide a safe environment and respond to
acute deterioration but will not continue to manage the
patient’s ongoing needs.
Lessons Learnt III
- The value in feedback
- The limitation of ward based and ED based view
- The challenge of implementing processes simultaneously
- The significance of a team based process –medical,
nursing and clerical
- RiskMan reporting / feedback will peak
- Process would identify ED efficiencies
- Still an ongoing work in progress with ISBAR print out
Tale of 3 Ticks
Questions:
For further information contact:
Thank you
