Healthy ED Healthy Hospital

Summary

Aim

By December 2019, patient flow processes within the ED will support safe and timely access to care for patients presenting to TMH ED.

Benefits

• TMH Emergency Treatment Performance (ETP) will improve from 65% to 71%, indicating an improvement in patient flow and access to care.
• Patients presenting to the ED will have treatment started sooner and have access to a senior decision maker earlier in their patient journey. Time seen will reduce by 50% from a current median time of 111 mins to 55 mins.
• The ED will operate in 'crisis level' less of the time resulting in less stressed staff and better patient outcomes – reducing from 57% to 25% of crisis level.
• Triggers for crisis level classification will have robust actions and accountability.
• Adverse patient and staff outcomes will decrease.
• TMH will be permitted to leave the NSW Ministry of Health (Ministry) 'watchlist' (a reporting and accountability framework targeted at non-performing EDs).

Background

In the last six months of 2017, TMH ED recorded seven significant incidences resulting in patient harm. In every one of these incidents, ED activity levels was a contributing factor. One of these incidents was of a lady, Mrs Hockey, who, while waiting four hours in the waiting room, suffered a stroke. This affected staff working in the ED dramatically and provided clear motivation for change.

In November 2017, the Ministry placed TMH on the 'watchlist' for consistently poor ETP.  The ED had performed lower than 10% of the target 81% for multiple consecutive months. This watchlist process was time intensive, involving weekly reporting and accountability teleconferences with the Ministry. The mandate from all levels of the Lower Hunter Sector and District Executive Leadership Teams was for the ED to improve performance and be removed from this process.

In May 2018, the ACI Clinical Redesign Graduate Certificate program was offered to the team as an opportunity to apply Clinical Redesign Methodology would be beneficial in helping us identify service gaps, areas of need and work towards solutions for change.

Implementation

• The most vital part of our project was doing detailed diagnostics.
• Our diagnostics included, patient and staff interviews, process mapping, data analysis, working groups, focussed task surveys, literature guided analytics, medical record audits, observational audits as well as workforce capability audits.
• Brainstorming groups and other work groups then worked on solutions.
• We came up with four solutions for implementation and prioritised them according to influence and impact.
  • Solution One – Develop a better STEP (Short Term Escalation Plan) with robust actions and accountability.
  • Solution Two – Implement personalised professional development pathways for our nursing staff.
  • Solution Three – Redesign our 'front of house' model of care.
  • Solution Four – Design and develop an area to keep patients vertical but still safe and cared for (MAITZ model: Maitland assessment, investigation, and treatment zone).
• All four solutions have been implemented and part of business as usual.

Status

Sustained – The project has been implemented and is sustained in standard business.

Dates

July 2018 to July 2019

Implementation sites

Healthy ED Healthy Hospital has been implemented at The Maitland Hospital Emergency Department. While the implementation is specifically ED based, the greater hospital and its key stakeholders were vital for collaboration, solutions and implementation.

Partnerships

• ACI Centre for Healthcare Redesign – presenters and support staff
• Rotary Club of Maitland Sunrise
• Rotary Club of East Maitland

Results

The four solutions were measured against various metrics including ETP, sentinel events, ED length of stay, ED activity levels, patient journey timeline analytics and staff credentialing statistics across the entire project timeframe. All metrics indicated improvement compared to the same period in 2017/18 despite increases in activity, acuity, and patient complexity.

• ETP improved from baseline 65% to reach 71% for three months.
• Time of arrival to doctor seen by improved by 38% from 111 minutes to 69 minutes for all patients.
• ED activity levels improved from 53% of time in crisis levels to 43%.
• Sentinel events reduced from seven incidents in 2017-18 to zero.
• Average length of stay for all patients improved by 4% from 251 mins to 245 mins.
• Average length of stay for all patients who presented with abdominal pain improved by 32%.
• Patient journey timeline analytics indicate the MAITZ model can reduce each part of a patient’s journey by up to 40%, resulting in a significantly decreased length of stay than for the same kind of patients not treated in this zone.
• Average length of stay for a patient with abdominal pain treated in MAITZ is 67% faster than this cohort’s length of stay before implementation of the model (267 v 756 minutes).
• Staff enrolment and credentialing in professional development pathways increased from 33% to 75%.
• Acute bed availability is improved however this is not quantified.

Lessons learnt

• Diagnostics are pivotal in finding the right problem to fix.
• Be brave enough to look for problems outside of what you already think you know. If we had have implemented solutions to what we thought was the problem, we would have not had anywhere near as much success as we did.
• Our greatest challenge was convincing staff that increasing resources was not the only solution to a very complex problem.

References

1. Renouf T, Pollard M, Fleet L, Abbott C, Whalen D, Dubrowski A. SPIRALS: a new cognitive approach to clinical reasoning in the emergency department. InMedical Education Scholarship Forum Proceedings. 2018 Oct 3 (Vol. 4).
2. Jarvis PR. Improving emergency department patient flow. Clinical and experimental emergency medicine. 2016 Jun;3(2):63.

Further reading

• Emergency Care Institute Models of Care

Article

• Rutman L, Stone K, Reid J, et al. Improving Patient Flow Using Lean Methodology: an Emergency Medicine Experience. Curr Treat Options Peds. 2015;1:359. https://doi.org/10.1007/s40746-015-0038-0

Contacts