ED Stream Workshop Calvary Mater Newcastle Fast Track MoC August 2013 Rebecca Robertson 1

List All MOC used in your Facility Triage MoC Resuscitation MoC Multi-Disciplinary Emergency Express MoC (FAST TRACK) ESSU MoC 2

Describe your Fast Track Model Key Principles Expedite the journey for single system complaints that can be discharged in < 2 hours Multi-disciplinary approach Primarily Nurse co-ordinated ( hrs) Doctor allocated to Fast Track- (D3 Shift ) Commence treatment early Clinical protocols that promote early initiation of treatment such as NIX, NIA, physiotherapy support Operating hours which reflect high demand periods Establishment of an appropriately skilled Emergency Express team (advanced nursing practices) Utilises dedicated staff Inclusion and exclusion criteria 3

Describe your Fast Track Model Benefits of the Model Early and timely access to quality care Primarily Nurse Co-ordinated allowing the medical officers to focus on more acute injuries or illnesses SRMO or higher designation is allocated to the area who can make discharge decisions independently Physiotherapist support (Long term goal is to have primary consult physiotherapy) Training requirements mean that staff allocated to work in the area are appropriately skilled, informed and drive the KPI’s Acute Wound Service is also run through the Multi-Disciplinary Emergency Express Area (Note: These patients come back as a clinic and planned ED presentation) Strict inclusion and exclusion criteria for the MoC mean that admitted patients or long staying patients don’t impinge on the flow of Emergency Express Strict business rules around the use of Emergency Express space supports staff when pressured to place unsuitable patients through the MoC during high activity in ED and access block Improvement in non-admit NEAT target buffing up overall hospital NEAT target Decreased LOS for patients requiring treatment for single system complaints Provides treatment area separate from acute treatment areas Decreased DNW 4

Describe your Fast Track Model Challenges We attended the review within current budget Nil CIN Role at the CMN ED which means triage and the Emergency Express Nurse have to initiate CIN activities when able If Emergency Express Nurse and Triage Nurse are busy there is delay in early initiation of treatment or provision of analgesia Changing the culture of putting inappropriate patients (patients that don’t fit the inclusion and exclusion criteria of the MoC) in times of high pressure and high demand Changing the culture that Emergency Express patients can wait, as they do not have life threatening complaints Restricted hours of operation Untrained staff- Need funding for ongoing education 5

Differences between your Model and the definition in the “Emergency Department Models of Care July 2012” Multi-Disciplinary (Physio support, SW, D&A, Nurses & Doctors) Acute Wound Service Nil CIN 6

Identify the Resource Required for your Fast Track Model What you need to run the model Such as Staffing (FTEs, Designation) Nursing Trained and Specialised Nursing Staff (EEN or RN) - Morning and afternoon shift (16 hours a day) 7 days a week Medical: SRMO, PGY3 or above – D3 Shift ( ) 7 days a week Physiotherapist: Current: Nil funded Physiotherapist Ideal: Funded Physiotherapist 7 days a week 7

Identify the Resource Required for your Fast Track Model Training, implementation requirements Nurses: Attendance of ‘Let’s Make Cubes NEAT!” 2 Day training Course or 1 day orientation to Emergency Express or equivalent training and supervision Previous worked in Sub-acute area to gain an understanding of how the ED functions as a whole Ability to recognise the deteriorating patient- attended online BTF and e-DETECT (adult and junior) training Must have sound nursing skills in wound care and application of emergency equipment such as crutches, zimmer splints, slings etc. Paediatric skill Set Emergency Express nurse must comply with the NSW Health Clinical Practice guideline PD2010_32 Competent Paediatric Nurse Must have completed Resus4kids within 3 months of working in the Emergency Express area Must have evidence of attending Child Protection Training Doctors: SRMO level /PGY3 or above with ability to discharge decisions independently 8

Identify the Resource Required for your Fast Track Model Guidelines, policies, Emergency Express MoC Plaster Room Business Rules Rules in the MoC document in regards to use of the eye room and paediatric dedicated safe room EDSAS MoC 9

Identify the Resource Required for your Fast Track Model Physical space The CMN ED has 4 designated consult rooms and a designated plaster room. This area is separate from the acute treatment areas. 10

Monitoring and Evaluation Identify how it supports KPIs and NEAT We have been working on our non-admits for the last 12 months and have dramatically improved our performance in non-admit NEAT Target. We are aiming to increase the percentage of NEAT non-admits performance to greater than 90%. Without further funding for initiates of other MoC such as the EDSAS MoC or an improvement of hospital access block further improvements will be difficult. 11

Monitoring and Evaluation Identify how it supports KPIs and NEAT Decreased LOS in the Emergency Department for Australasian Triage Scale(ATS) Category 2, 3, 4 and 5 non-admitted patients Decrease in time to be seen by a Medical Officer Improved time to treatment e.g. antibiotics, pain relief, symptom management Increased discharges within 2 hours of presentation Improved staff focus on efficient quality care for single system injury or illness and non-complex patients Improved “Did not Wait” performance Decrease in unplanned representations within 7 days Improved NEAT performance target for non-admits Improved ATS waiting times for category 2, 3, 4 and 5 patients Improved patient satisfaction Improved access to timely analgesia Improved staff satisfaction 12

Evidence of Success Improvement in KPIs since implementation Improvement in DNW Improvement in non-admit NEAT Target from to Improvement in patients transferred to ESSU in 4hrs We have also seen a decrease in waiting room aggression and decrease in complaints generate from the waiting room and fast track area 13

Evidence of Success Impact on overall service Improved non-admit NEAT target through the adoption of Emergency Express MoC has significantly impacted and increased overall Hospital NEAT target. Overall Cumulative for calendar year 68.48% The June 2013 NEAT figure for CMN ED % TARGET =71% 14

Evidence of Success Sustainability Knowledge Specialised Training for Nursing Staff Secure re-current annual funding to run “Let’s make cubes NEAT! 2 day training course to up-skill nursing staff Protection of real estate! 15

Evidence of Success Transferability of Multi-Disciplinary Fast Track For ED’s with a similar activity, acuity, admission rate and classification (level 4 or above) Would need champions Training 16