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Patients experience delays in emergency departments for a variety of reasons and delays are often associated with patient flow blockages that occur within the broader hospital system. Combatting emergency department overcrowding and access block require a whole-of-hospital approach and thus meeting the 4-hour National Emergency Access Target (‘NEAT’) can present a multiplicity of challenges across departments. We had a chance to speak to some of the guest speakers for the 5th Annual Emergency Department Management Conference to get their views on challenges and strategies for improving NEAT performance.
What are the key challenges for your hospital in meeting the National Emergency Access Targets and what are your top 3 strategies for improving NEAT performance?
Engaging & communicating with frontline staff, given the rapid pace of change & large number of shift workers • Decide whether achieving NEAT or improving patient flow is your key aim; they have overlap, but are very different goals. • Know & monitor the rate limiting steps for patient flow in your own hospital; don’t blindly copy other hospitals’ ideas. • Keep asking the frontline staff to think of improvements, sieve & prioritise them, then have strong executive support to run trials with good data collection. Dr Simon Bugden, Emergency Physician, Caboolture Hospital, QLD
The greatest challenge is creating a culture where by the patient is considered first. The problem with targets is that staff don’t believe in a target but at the same time forget that target actually represents better care. Less time spent in ED is good for the patient; maybe the target should have been length of stay in ED rather than the percentage through in 4 hours. People change, getting staff to change the way they think and act about patient flow is the greatest challenge.
We have to better understand capacity management and patient flow. Demand is predictable and capacity is manageable. A stronger knowledge base about capacity and demand for both the ED and inpatients is imperative to creating solutions that actually solve the problem. Clinical redesign is a key focus for us. We need to empower staff to change the way they work that results in putting the patient first. Finally, reducing time in ED and time in inpatient beds by reducing waste and delays, this not only includes reducing external delays i.e. disability patients and access to residential care facilities but internal delays such as access to diagnostics, transport, specialist consultation and the list goes on. Dr Kathryn Zeitz, Director Improvement, Central Adelaide Local Health Network, SA
Key Challenges: 1. Managing the increasing demand with reduction in resources and funding. The growth in demand for health services is disproportionate to population growth. 2. The mismatch between ED activity and the available bed stock and secondary services, requiring a large proportion of transfers. 3. Availability of “exit” options for patients who are elderly, have chronic comorbidities and long term age related mental issues. Key Strategies: 1. Maximising ED throughput for discharged patients (80%) by innovative models of care, early senior led decision making and patient streaming. 2. Use of direct admissions to inpatient beds 3. Reorganisation of medical units and registrar rostering. Dr. Chris May, Director of Emergency department, Redlands Hospital
The challenges facing our department in achieving NEAT targets seem to be augmented by our geographical isolation. These include having adequate and quality resources (medical, nursing and clerical) to ensure that those providing care have the support to do this in the best and most effective way; having a physical environment that has reasonable capacity and that is conducive to optimal work arrangements and patient flow; culture, both organisational and departmental ; and consistency in leadership. Our ED leadership team has focussed on recruitment of a stable workforce (nursing and medical), limiting the use of locums and casual staff, whereby allowing engagement in change and a sense of ownership around key performance indicators.
We are lucky enough to have been engaged in the process of the redevelopment of our department in the coming year, allowing us to plan for optimal patient flow through the department and are looking forward to seeing this completed in 2014.
Our ED leadership team have been committed to the introduction of TeamSTEPPS®. The TeamSTEPPS® philosophy has laid the foundation for a patient safety focussed multidisciplinary culture, which whilst in its infancy has seen our department become more productive and efficient in the last 12 months. Sally Neumann, Clinical Services Coordinator, Emergency Services, Mount Gambier & Districts Health Service
Our inpatient admission times are our main challenge, we traditionally deal with up to 61% access block.
Our long wait patients can take up to 72 hours to leave the department (usually psychiatry).
We have instituted a hospital policy of “direct admission” whereby patients identified as requiring admission can be sent to the ward to be seen by the inpatient teams on the ward. There are caveats as to stability and excluding high risk patient groups. This obviously can only come into effect when there are beds available on the wards. There are major issues with overcoming the previous culture of keeping patients in ED until the inpatient teams were happy to have them on the ward. The response to that has been to make the time of transfer at the discretion of the ED.
We have trialled having a consultant, an RMO and a scribe as well as using a scribe with a consultant or registrar to improve productivity – we are currently seeking to extend this trial. With registrars this has led to an improvement in productivity and satisfaction due to removing the time spent in documentation. We are now taking the idea from proof of concept to data collection trials.
As with many EDs, we have also looked at increasing productivity of junior staff by linking interns to registrars.
Create 2 teams per day of a junior doctor and a registrar where the junior doctor scribes, the senior takes the history and examines the patient. A plan of care is formulated at first contact. The junior doctor continues care afterwards and chases results/referrals. The understanding is that the registrar/RMO team must maintain greater productivity than they are able to achieve separately. The junior doctors get to model care on the practice of more experienced doctors, they see more patients with potentially greater variety and their documentation is supervised case by case. With this model, there are far less concerns about accuracy of clinical findings and safety of practice. Mark Scott, FACEM, Caboolture Hospital, QLD