This project aims to reduce the time children spend in Gosford Hospital emergency department (ED) once the decision to admit to the paediatric inpatient unit (PIU) is made.
View a poster from the Centre for Healthcare Redesign graduation, November 2022.
Aim
To increase the percentage of children being admitted to the PIU within one hour of the decision to admit being made, from 9% to 50% within 12 months.
Benefits
- Enhanced experiences of care for children, care givers and their families during the child’s journey.
- Engaging and empowering children, their parents and caregivers in their treatment planning and experience.
- Increased efficiency indicated by the reduced length of stay in the ED and the PIU.
- Matching the patient’s care needs to the appropriate clinical resources, including improved care coordination and transfer of care within appropriate timeframes.
- Improved departmental and staff communication and strengthening of relationships to support collaboration around paediatric care planning.
Background
The Premier’s priority goal is that 81% of presentations to EDs are to be either admitted to an inpatient unit or discharged within four hours.1
The Central Coast Local Health District’s (CCLHD) key performance indicator is that 50% of all children are admitted to the PIU within the recommended timeframe. According to data collected from CCLHD Cerner FirstNet, from July 2020 to June 2022, CCLHD is achieving <17%.
CCLHD Cerner FirstNet, July 2020 to June 2022, >83% of children, aged between 0 and 5, presenting to CCLHD ED spend more than four hours in the ED waiting for a bed in the PIU. During this time, they may be exposed to a range of traumatic sights, sounds and experiences. Prolonged length of stay in ED for admitted patients is associated with poorer health outcomes.1
Multiple admission pathways, including elective admissions, feed into the PIU and put paediatric beds under pressure. This, combined with complicated medical review pathways, bed booking systems and communication issues, results in bed block in ED, delayed admissions into the PIU and failure to achieve emergency treatment performance targets.
This project aligns with the CCLHD 2022-2023 strategic priorities of:
1. Effective demand management with care delivered in the most appropriate place, maximising available capacity.
4. Our services and care models are person-centred and responsive to the preferences and needs of patients and consumers.
12. Information technology systems improve clinical workflows and support the availability and use of data to inform decision making.2
It also aligns with the NSW Paediatric Service Capability Framework 2017-2022,3 focussing on coordinated and integrated care.
Implementation
Diagnostics
- Consulting the steering committee
- Expansion of project team
- Refined scope
- Data analysis
- Tagalongs
- Patient surveys
- Staff interviews and surveys
- Process mapping (high and low)
- Focus groups
- File audits
- Benchmarking with other local health districts
- Root cause analysis and prioritisation of issues
- Mentimeter voting with stakeholders was used to assist prioritisation
Solutions
- ‘How might we’ statements used for solution generation with stakeholders.
- Seventy-three potential solutions were identified, and these were then themed.
- Seven themes identified and prioritised.
- EAST (how Easy, how Attractive, what are the Social implications and is this the right Time?) framework used.
- Literature review and benchmarking used to guide solution design.
Implementation
- Two solutions identified for implementation. Solution 1 – Multidisciplinary muddles and Solution 2 – Care navigator.
- Partnering with Improving Patient Access, Coordination and Transfer (IMPACT) Program to progress implementation.
- Identifying and building an implementation team.
- Solutions will be presented to the IMPACT program for progression.
- Project team will continue to explore funding options.
Status
Implementation – The project is ready for implementation or is currently being implemented, piloted, or tested.
Dates
- Implementation planned for early 2023
Implementation sites
Gosford Hospital emergency department and paediatric inpatient unit
Partnerships
- Agency for Clinical Innovation
- Illawarra Shoalhaven Local Health District
- South Eastern Local Health District
- South Western local Health District
- Sydney Children’s Hospital Network
- University of Tasmania
Evaluation
- Proposed evaluation data includes:
- Emergency treatment performance data (FirstNet data)
- Patient reported experience measures
- Use of paediatric clinical pathways
- Reduced ‘waiting for what’ time on patient flow portal
- Huddle attendance and participation
- Staff satisfaction surveys
Lessons learnt
- Choose your project team carefully and ensure there is a clinician included as well as those with capacity to influence.
- Consider competing projects.
- Fully assess the problem before generating solutions.
- Implementing projects during a pandemic is very problematic.
- Identifying hidden agendas of stakeholders is especially important.
- Commitment is required to prioritise quarantined time for project.
- Back fill for project team members.
- Having consistency of the executive sponsor is important to achieve overall success.
References
- NSW Agency for Clinical Innovation. Emergency Treatment Performance (ETP). Sydney, NSW: ACI; 2021 [cited 28/10/22].
- Central Coast Local Health District. Central Coast Local Health District Strategic Plan 2019-2024. Gosford, NSW, Central Coast Local Health District; 2018.
- NSW Minsitry of Health. NSW Paediatric Service Capability Framework. Sydney, NSW, NSW Ministry of Health; 2017.
Further reading
- Attwood L, Rodrigues S, Winsor J, et al. Improving delivery of health care to Aboriginal and Torres Strait Islander children. J Paediatric Child Health. 2015;51(5):534-540. DOI: 10.1111/jpc.12756
- Central Coast Local Health District. CCLHD Integrated Care Strategy Evaluation. Gosford, NSW; CCLHD; Mar 2018.
- Fulbrook P, Jessup M, Kinnear F. Implementation and evaluation of a 'Navigator' role to improve emergency department throughput. Australas Emerg Nurs J. 2017;20(3):114-121. DOI:10.1016/j.aenj.2017.05.004
- Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet. 2003;362(9391):1225-1230. DOI: 10.1016/S0140-6736(03)14546-1
- Health Roundtable. Sydney, NSW: The Health Roundtable; 14 Mar 2021 [cited 28 Oct 22].
- Hoysted C, Babl FE, Kassam-Adams N, et al. Perspectives of hospital emergency department staff on trauma-informed care for injured children: An Australian and New Zealand analysis. J Paediatric Child Health. 2017;53(9):862-869. DOI: 10.1111/jpc.13644
- NSW Ministry of Health. Healthy, Safe and Well: A Strategic Health Plan for Children, Young People and Families 2014-2024. Sydney, NSW; NSW Ministry of Health; 2014.
- NSW Ministry of Health. Review of health services for children, young people and families within the NSW Health system. Sydney, NSW: NSW Ministry of Health; 16 Sep 2022.
Contact
Leanne Roberts
Acting Director, Women, Children and Families Directorate
Central Coast Local Health District
Phone 02 4320 2498
Leanne.Roberts@health.nsw.gov.au
