This page provides guidance for:
- local health district (LHD) and specialty health networks (SHN) safety and quality managers
- facility leadership
- National Safety and Quality in Health Service Standards (NSQHS) committees
- other relevant stakeholders.
Our aim is to integrate ECAT into embedded local safety and quality systems. This includes resources provided by the Clinical Excellence Commission. It may need to be adapted to suit the local context.
Sound governance and safety and quality monitoring is essential.
Download ECAT Safety and Quality Monitoring Resources (PDF 233.0 KB) for:
- reports used to audit and monitor safety and quality in an emergency department (ED), including issues related to ECAT
- resources used to support safety and quality activities in an ED, including for issues related to ECAT.
Statewide ECAT program governance
The ECAT program is governed at a statewide level. Representatives include staff from the NSW Ministry of Health, Clinical Excellence Commission, Nursing and Midwifery Office, Health Education and Training Institute and the Agency for Clinical Innovation.
The Use of Emergency Care Assessment and Treatment (ECAT) Protocols (PD2024_011) provides guidance on the governance of the ECAT protocols, legislative requirements and essential education and training. The Protocol Development, Consultation and Review Report (PDF 449.9 KB) provides information on the development of the ECAT protocols.
Feedback mechanisms have been set up to manage the quality and safety of ECAT resources. This includes processes to identify and report issues, incidents, near misses and concerns.
Any potential or actual issues should be raised as appropriate. This can be done:
- via local safety and quality systems and processes
- via ED leadership
- directly to the Emergency Care Institute.
Any recommended changes to an ECAT resource are reviewed according to an established governance process.
While ECAT is being implemented locally, you can raise issues and concerns through normal clinical care and patient safety and quality processes or via ECAT implementation specific processes such as:
- executive sponsors
- clinical champions
- ED leadership teams
- feedback through the Emergency Care Institute.
Supporting resources
In this section:
- Safety huddles
- Quality Audit Reporting System (QARS)
- ims+ and incident management
- Electronic Medical Record reporting
- National Safety and Quality Health Service Standards Committees
- Morbidity and mortality meetings
Safety huddles
Safety huddles focus on safety risks that may affect patients, staff and anyone accessing healthcare. The huddles are multidisciplinary and take less than 10 minutes. They involve clinical and non-clinical staff and occur at the start of every shift.
These resources have been adapted from the Clinical Excellence Commission’s Safety Fundamentals information:
Quality Audit Reporting System (QARS)
The ECAT audit tool supports local monitoring of ECAT protocols used in emergency care settings.
As the ECAT program is implemented across NSW EDs, LHDs and SHNs should closely monitor the use of the ECAT protocols. The audits can be flexible. Depending on local needs, you can audit specific elements of the ECAT protocols. They can be added into existing audit and quality improvement projects and focused on:
- protocol selection
- interventions
- medication administration
- clinical assessments.
You can access the audit tool through the Quality Audit Reporting System (QARS). If you have no experience with QARS, ask for a demonstration from your local safety and quality manager.
Follow relevant privacy regulations and district policies to conduct data collection, analysis and feedback.
Objectives of the audit tool:
- Identify clinical quality and safety issues associated with the use of ECAT protocols in EDs.
- Assess adherence to ECAT protocols and guidance.
- Provide feedback to individual staff members, nursing and medical ED managers, hospital managers including operational nurse managers and executive teams.
- Inform quality improvement initiatives to enhance patient safety and care outcomes.
Use your existing ED audit team and its subject matter experts to do the audit and oversee the management of results. Your team should include representatives from emergency nursing, medicine and clinical governance.
The team guides the selection of the patient cohort to be audited, based on the local context. It considers:
- clinical safety issues raised through staff feedback or ims+
- high risk protocols
- high volume protocols
- high risk areas of care, e.g. medication prescription.
ECAT audits should be included in existing ED audit cycles. Audits should be conducted with a random sample of patients who have care initiated under an ECAT protocol.
| Phase | Audit type | Audit frequency | Sample size |
|---|---|---|---|
Implementation | Full ECAT audit | Weekly | N=10 |
Transition to business as usual | Full ECAT audit and/or focused audit for identified themes | Quarterly | N=10-20 |
Business as usual | Full ECAT audit and/or focused audit for identified themes | 6 monthly | N=10-20 |
For smaller sites (i.e. level 1 and 2 emergency departments) sample sizes for auditing could be based on a percentage of presentations per day (as per local discretion). For example:
- 0-10 presentations daily N=15% of presentations
- 0-20 presentations daily N=10% of presentations
Experts recommend providing constructive feedback that:
- emphasises areas of best practice and excellence
- identifies opportunities for improvement
- bases planned quality improvement initiatives on audit findings and stakeholder input.
Audit findings can be reported at various levels and used to:
- review ECAT use to identify trends or patient safety concerns
- identify areas for improvement and highlight best practice
- provide individual staff members with personalised feedback on their performance
- inform monthly accountability meetings, patient safety and quality or equivalent meetings
- report on aggregated data on overall compliance and safety issues to inform hospital managers, including operational nurse managers
- provide executive teams with high-level insights and recommendations for strategic decision-making.
ims+ and incident management
All identified clinical incidents, near misses and complaints must be reported by NSW Health staff in the statewide incident management system, ims+. Staff need to do this as outlined in Incident Management (PD2020_047). The Clinical Excellence Commission recommends that incident management should be based on the principles of immediacy, accountability and kindness.
To ensure high standards for the use of the ECAT protocols and prioritise patient safety, robust incident reporting is essential. Report incidents and near misses via the ims+ Portal in line with policy and local process.
Quick reference guides (QRGs) support consistent incident notification and management of incidents or near misses that occur while ECAT protocols are in use. This will help find protocol issues at the local, district and state level.
Steps to access QRGs:
- Visit the ims+ SharePoint site (NSW Health staff only)
- Select the QRGs tile.
- Scroll through the list and select the guide you require, e.g. Notifying an ECAT Protocol related incident
When using ECAT protocols that may have contributed to an incident or near miss, notification and management should follow existing LHD and SHN governance processes.
The ECAT program and the NSW ECAT Program Executive Steering Committee can see themes and issues across the state. The committees will not have access to local reporting. This is in line with enabling privacy and autonomy at LHD and SHN level.
As custodians of ims+ data, the Clinical Excellence Commission can review ECAT-related incident data, if requested. Should any safety concerns or emerging safety issues become clear, the Clinical Excellence Commission will notify the Emergency Care Institute clinical lead.
Notifying an ECAT protocol related incident in ims+
Using ECAT and the protocol name in the details field will help identify incidents at state level.
Audience: All, NSW Health staff
Definition:
| ECAT protocol was directly related to incident or near miss for patient | ECAT protocol was directly related to incident or near miss for staff member |
|---|---|
ECAT protocol was in use at the time of the incident, or is to be considered to have contributed to the incident or near miss Note: Patient-related notifications may include refusing nurse-initiated care, protocol availability, workability, incorrect use, nurse-related deficiencies in training, experience, supervision, human factors and other circumstances | ECAT protocol was in use, however, may not have caused the incident for the staff member Staff member actions varied from direction in the ECAT protocol resulting in a near miss or incident for the patient or staff member Note: Staff member-related notifications include staff injuries, incorrect use, deficiencies in training, experience, supervision, human factors and other circumstances |
Managing an ECAT protocol-related incident in ims+
Audience: All managers, clinical governance, patient experience officers, patient safety managers
Actions:
- Manage incident in line with policy requirements
- Consider system versus individual performance issue or human factors
- For serious incidents, consider undertaking a reportable incident brief, flagging for investigation or the need for open disclosure in line with policy requirements
Contributing factors: Provide as many as relevant, remembering the highest numbered factors (1 and 2) will appear on the incident details reports.
Safety learnings: Consider opportunities for sharing lessons learned.
Electronic Medical Record reporting
ECAT Safety and Quality Monitoring Resources (PDF 233.0 KB) includes a range of Electronic Medical Record (eMR) reports that can be used to complete an ECAT audit and support monitoring of the use of the ECAT protocols.
National Safety and Quality Health Service Standards Committees
LHDs and SHNs have National Safety and Quality Health Service (NSQHS) Standards Committees to:
- oversee processes to identify and address variations in clinical practice and promote evidence-based clinical interventions
- ensure services respond to the needs of patients, carers and the wider community
- serve as an escalation point for high-risk issues related to patient safety and clinical quality
- review and oversee performance against safety and quality measures and key performance indicators set by the LHD or SHN and the Ministry of Health.
We advise LHDs and SHNs to add ECAT monitoring into their current processes, using the expertise of their NSQHS committees.
Morbidity and mortality meetings
At morbidity and mortality meetings or clinical review meetings, departments and facilities review the quality of the care and help clinical staff to learn. This process should include the use of ECAT protocols.
Recommended resources from the Clinical Excellence Commission:
Managing disruption to service delivery
In this section:
Downtime procedures
LHDs and SHNs have procedures for scheduled and unscheduled disruptions to the ECAT website or electronic healthcare record system. This includes medication administration applications, pathology and radiology ordering or clinical notes.
LHDs and SHNs are encouraged to have clear procedures that:
- identify the downtime of internet, electronic medical record applications and hardware
- notify disruption quickly so work to resolve can begin
- notify the State Wide Service Desk or LHD and SHN information, communication, and technology (ICT) as per local process
- communicate downtime to clinical staff, team leaders, managers, relevant executive and local ICT services
- communicate when the issue is resolved, return to electronic systems and commence recovery process.
There needs to be clarity around the data recovery process including:
- minimum retrospective data transcription within prescribed downtime periods; and
- clear expectations for data entry timeframes post downtime resolution.
After the disruption, conduct downtime debriefs that highlight successes, areas for improvement and future strategies to ensure seamless transitions between paper and electronic systems.
Interruption of access to the ECAT website
This may occur due to:
- local (hospital or site) internet outage
- outage of the website.
Refer to your LHD and SHN procedures for accurate information on how to notify interruption to access to the ECAT website.
Hard copies of Adult and Paediatric ECAT Protocols are stored in binders in the ED. They help maintain clinical workflows in these situations.
More about hard copies of protocols including currency and auditing
Downtime data recovery
Data recovery after electronic downtime in healthcare is crucial to ensure continuity of care and preserve patient safety.
Swift and accurate data recovery processes minimise disruption, so that healthcare providers can promptly resume patient care activities.
Refer to your local downtime procedures for accurate information for data recovery to be transcribed into the clinical health care record.
A note in the electronic health record will communicate that downtime has occurred and staff should refer to the paper charts that remain with the patient. At clinical handover, this information must be communicated to the receiving ward.