Dr Lisa Niklaus Consultant Emergency Medicine Dr Tony Joy ST5 Emergency Medicine October 2012

QUEUE FOR TRIAGE, BANK HOLIDAY JUBOLYMPICS THE SOLUTION?

Triage – initial assessment Majors – Cubicle assessment Majors – Cubicle assessment Investigations Majors – Ambulance handover Treatment Dr Review

Triage – initial assessment Investigations Majors – Ambulance handover Treatment Dr Review

 Two triage nurses for walk in patients  Nurse coordinator taking ambulance handover  ‘Recipe book’ of investigations to be requested  Intermittent nurse requesting of x-rays  HCA for blood tests / ECGs  5.5 WTE Consultants (two per day)  16 Middle Grades  12 FY2

 One Consultant  One Consultant  Roles: Ward rounds at 0900, 1400 and 1800 Covering majors, paeds, resus, clinical decision unit (CDU) Reviewing patients Reviewing cards in the queue Clerking patients Review clinic Supervision & training of juniors Managing the shift

 Pilot…  Consultant 12-16, Middle Grade  [Locum MG – support for additional consultant ]  Nurse  HCA  RAT mobile…

RAT 1 – Dr & Nurse for walk-in patients

RAT 2 – Dr & Nurse for ambulance patients

 Brief history from patient / paramedic  Focused examination if required RAT two team go with patient into cubicle  Request blood tests / urinalysis / ECGs  Request imaging  Initiate treatments  Stream: to specialties or other providers  ‘See & Treat’ simple conditions  Juggle

Pre-RATPost-RAT Time to initial assessment38% < 30 mins69% < 30 mins Time to treatment20% < one hour 55% < two hours 30% < one hour 70% <twohours Consultant sign off10%44% Time to ECG55% < one hour92% < one hour Time to blood tests42% < one hour68% < one hour Time to x-ray request31% < one hour46% < one hour Time to analgesia53% < one hour73% < one hour

 Time critical treatments that make a difference to quality of care  Ordering scans early  Starting simple treatments that could enable discharge within four hours  Reducing unnecessary investigations  Streaming to specialties  See & treat

 ‘its not a good use of my skills as a consultant’  ‘we don’t have enough doctors’  ‘we don’t have enough nursing staff’  ‘we don’t have any space’  You do more than you think  Are you doing this already, in a less structured way?  Same work, done differently  Do you need a designated area?

 RAT team disappeared ‘Incentive money’ discontinued Changing ways of working within nursing team?  Out of hours Middle grades struggle to keep system going  Rapid assessment may lead to over- investigating  Intense working – can feel like only person seeing patients