1. Organisational processes
Pain in the ED: Meeting the Needs of Frequent Presenters at John Hunter Hospital
Michael Sager, Fiona Hodson & Dr Ines Arenal De La Piedad, Hunter New England (HNE) Health
Introduction
John Hunter Hospital (JHH) Emergency Department (ED) executive and the Hunter Integrated Pain Service (HIPS), identified a need to better manage patients who frequently present with complaints of pain. The project is built on previous redesign initiatives in HNE health:
Persistent Abdominal Pain (PAP) Project (1)
Older Person’s Journey & Frequent Presenters (2)
Chronic Disease Care Coordination Program (3)
The problem
Currently patients with persistent pain are managed in the acute system but evidence shows that this may not be the best approach e.g. patients with abdominal pain have multiple hospital admissions, extensive investigations, large numbers of invasive surgeries, prolonged hospital stays, unnecessary duplication of care, and a tendency toward deterioration rather than improvement in their pain and health over time (1). We hypothesised that this is a similar scenario for other frequently presenting pain cohorts such as backpain headache and some chest pains.
Findings
2009 John Hunter Emergency Department
iPM ED Data:
14,704 patients had a total of 30,736 presentations with pain or a pain related condition (49% of all presentations) (4)
511 patients presented 3 or more times for a total of 2,370 presentations
48 patients with 238 presentations fitted the scope
Chart audit :
Repeated presentations to ED which were complex and uncoordinated with no specific pathway
Extensive duplication of investigations, procedures and interventions
Multiple hospital admissions
Prolonged hospital stays
Other Findings:
Clinical management of frequent presenters with pain is inefficient and confusing for patients, staff and carers. This at times led to conflict and hostility within and between treating teams, patients, their families and hospital staff.
Solutions (cont) (To be implemented in separate phases)
Phase one:
Solution 3.1: Nursing staff training with regard to new processes
Solution 3.2: Medical officer and all healthcare staff training with regard to new processes
Solution 3.3: Patient education with regard to new processes and management plans
Education
Solution 4.1: Care coordination role to enhance communication between the ED, patient ,GP and other relevant care providers
Solution 4.2: Electronic storage of management plans and pathways
Solution 4.3: Yearly review of management plans and flags
Models of Care
Aim
To improve the patient journey by meeting the needs of patients who frequently present to the John Hunter Hospital Emergency Department with pain.
Objectives
Reduce ED length of stay and avoidable ED presentations in the defined cohort
Reduce avoidable acute hospital inpatient admissions and occupied bed days of defined cohort
Development of new model of care that is transferable across other chronic and complex care conditions
Solution 5.1: Communication plan for all stakeholders updated regularly
Solution 5.2: Care coordination role to enhance communication between the ED, patient ,GP and other relevant care providers
Solution 5.3: Develop ED electronic discharge and referral capability eg) GP, mental health and HIPS
Communication
Solutions
Stakeholders where engaged through working parties, focus groups and face to face interviews to develop a list of appropriate and workable solutions for the model of care.
New Model of Care
Solutions: Further implementation over following months
Phase two:
Alerts created in iPM will be shared with the Ambulance Service of NSW to allow flagging of patients so that management plans can be activated on scene
Ambulance Officers will be educated on the processes around activating management plans on scene
Electronic discharges from ED via CAP (Clinical Access Portal) will increase communication with GP’s and create an easier referral pathway to other care providers
Create partnerships with Primary & Community Networks to improve co-ordination between all care providers involved in the management of the patients. (? Creation of complex care co-ordinator position)
Scope
Male and Female aged 16 to 64 years of age with 3 or more JHH ED presentations over 12 month period 1/01/ /12/09)
Presenting problem of pain or a pain related complaint and a discharge diagnosis of 16 specified pain related ICD10 codes
Data from hospital Patient Identification System (iPM), at JHH ED and surrounding public hospital ED’s such as Calvary Mater, Belmont and Maitland hospitals to determine other patient presentation patterns
Excluded from the scope:
Children and young people <16 years of age
People aged 65 years and older
People presenting with needs in the sub categories of trauma, mental health, ophthalmology, ENT, obstetrics and gynaecology and respiratory
Expected Outcomes: New Model of Care
Provision of alternative clinicians/services or improved integration of existing services
Improved communication processes.
Organized systems of care rather than individual health care pathways
Reduced clinician fear related to misdiagnosis / under diagnosis
Unnecessary duplication of assessments and interventions such as pharmacological, procedural and surgical
Reduction of recurrent/episodic and readmission rates to ED and acute care
Organisational leadership, support & clinical governance
Preliminary Outcomes (4 week period):
58 patients identified in scope have new frequent pain presenter iPM alert added
6-8 patients in scope identified each week
12 pain management plans revised
7 new patients needing pain management plans referred and fast tracked to HIPS
3 new pain patients identified frequently presenting at other local hospitals
85% of after hours presentations of pain cohort are being now captured by ED staff with follow up and co-ordination of care
4 patients frequently presenting with pain to ED expedited up surgical waiting lists
Collaborations with other specialties eg) Neurology for frequent headache and migraine presentations
Method
The project team engaged staff at varied clinical levels by working with a wide range of stakeholders across the John Hunter Campus and wider community to develop a new model of care with strategies to enhance care for the defined cohort of patients frequently presenting with pain to JHH ED :
Collate and analyse data relevant to the clinical redesign project
Identify key issues and find root causes to the defined problem
Perform chart audits, staff, patient and clinician interviews, tag alongs and process mapping
Solutions: Implemented in two phases and prioritised over 3-6months
Phase one:
Solution 1.1: Weekly iPM report
Solution 1.2: Frequent presenter with pain alert on iPM
Solution 1.3: Stamping of triage sheet to alert medical officer of management plan
Solution 1.4: iPM alert linked to a flag on the electronic whiteboard
Identification
Solution 2.1: Appropriate and current management plans
Solution 2.2: Rapid assessments and fast tracking according to ED “red flags” guideline for persistent pain
Solution 2.3: Persistent pain clinical pathways
Organisational processes
Acknowledgements
Hunter New England Health Innovation Support Unit
Hunter New England Area Executive Team
JHH Emergency Department
Hunter Integrated Pain Service
Contact Details
Project Officer: Michael Sager
or Page 5606
References:
1.Lantry, G. (2007), “Persistent (Chronic) Abdominal pain: designing a new model of care in the acute care setting”, (Hunter New England Health)
2.Hunter New England Population Health (2008), Avoidable admission project HNEH, (Hunter New England Area Health Service)
3.Hunter New England Population Health (2006), Chronic disease services plan , (Hunter New England Area Health Service)
JHH ED iPM Data (accessed 2010)