1. ED Stream Workshop Acute MOC August 2013 ED Stream Workshop 1

2. List All MOC used in your Facility NSW MOH Model Of Care (2012)Hours of Operation 3.1 Triage + Registration24 hrs 3.2 Clinical Initiatives Nurse0700-2300 hrs 3.3 Resuscitation (including trauma)24 hrs 3.4 Acute Care24 hrs 3.5 Early Emergency Department Senior Assessment and StreamingNil 3.6 Early Treatment ZoneNil 3.7 Fast Track1030-1900hrs 3.8 Sub Acute24 hrs 3.9 Emergency Department Short Stay UnitsNil 4.1 Medical Assessment UnitNil 4.2 Surgical Assessment UnitNil 4.3 Hospital In The Home0700-2200hrs 4.4 Psychiatric Emergency Care Centre ServicesNil 5.1 Urgent Care CentreNil 5.2 Health Direct advice line24 hours 5.3 Connecting Care0800-1630 5.4 After Hours GP ClinicNil 2

3. Describe your Fast Track Model Key principlesBenefits of the ModelChallengesClinician run model (attach model guideline) Inclusion and exclusion criteria. Identified by Triage Nurse or FAST TRACK staff. Separate physical space and model to the rest of the ED. Must be recognised as a crucial role, rather than a complimentary role to the ED. Operational Plan to stipulate space, processes and staffing. Requires flexibility for a contingency plan for those who become evident that are not Fast Track. Requires escalation triggers to allocate appropriate resources. Capacity to manage high volume, low acuity patients in a reasonable timeframe. Gives structure and support to achieving NEAT for those discharged patients. Framework for Advanced clinical Nurses. Consumer satisfaction Staff Satisfaction Decreased Departmental overcrowding/ settled waiting room. Staffing profile Appropriate streaming from triage. Allocation of medical staffing Space Handing over patients into the sub acute stream if deemed necessary (Dr to Dr). Community awareness (initial phase) Sustainability and consistency (initial phase) 3

4. Differences between your Model and the definition in the “Emergency Department Models of Care July 2012” FAST TRACK (MoH MoC 3.7 - 2012) FAST TRACK (TRRH ED – 2013) Definition / Key Principles Pre Determined Inclusion/ Exclusion criteria Ambulant Non Complex (Single System) Seen Time – Discharge Time <2hrs Expedites Care Diverts patients into a particular stream Dedicated Senior Medical and Nursing staff working to optimise performance of Fast Track systems and the ability to make timely treatment and disposition decisions with minimal consultation Provides Care that is Standardised and targeted to specific conditions and injuries. Operating Hours reflect high demand periods Dedicated space and staff Commences treatment early Strict inclusion/ exclusion supported by business rules Clinical Protocols that promote early initiation of nursing care Rapid access to imaging and pathology Easy access to specialty outpatient, GP and community referrals Inclusion criteria included in Operations Plan (2011), meets these specifications. √ Ongoing - Work to be done -Consistent Medical coverage (Nurse Practitioner can lead model)and -Framework in developing Advanced Clinical Nurse role. Requires auditing process Medical availability 0800-2200hrs (inconsistent) Nursing coverage 1030-1900hrs (consistent) specifically for Fast Track, Nursing availability 0845-0300 for cubicle area (extension from FT area) √ Reliant on CIN, but uses a “pull” ideology from the WR Requires R/V, updating and “polishing” Currently CIN protocol (ACN phase 1) requires ACN Phase 2 to be developed to incorporate Wound management/ fracture management Imaging yes, Pathology discouraged √ 4

5. Identify the Resource Required for your Fast Track Model 5 What do you need to set it up?Tamworth ED Staffing (FTEs, Designation) 1x Nursing – 1030-1900hrs 7 days per week 1x Medical – Variable, but aim 1030-1900 between both M and E shifts. 1x Nurse Practitioner – Variable, although aim 1030 or 1230 starts Training In-services Although aim at developing Advanced Clinical Nurses accreditation implementation requirements Commitment Plan Sustainability (had NUM 1’s undertake QAP methodology in evaluating model) Guidelines, policies, Needs to be developed Physical space Yes and needs governing Clinical operation plans Yes (see slide 3)

6. Monitoring and Evaluation MonitorEvaluation Arrival - Time Seen Benchmark Australian Literature illustrates minimal contribution to timely intervention of care. Focus must be on accreditation of Nurses to meet ACEM definition in initiating early intervention as per a Local guidelines approved by the director Emergency Medicine. Length of Stay Benchmark Australian Literature illustrates moderate benefit in overall LOS in the ED, adding benefit to NEAT. Processes of Fast Track the patients journey through ED, benefit majority ATS cat 4’s and 5’s. 48hr Representation Benchmark NP monitors 48hr representations (if seen by NP) Ambulance- Transfer of Care Does not promote ambulance offloading into this area Over census patients in ED, Patients staying in this are overnight. Problematic as no nurse allocated to this area. 6

7. Evidence of Success Improvement in KPIs since implementation Triage Benchmarks LOS 48hr representation DNW Impact on overall service Sustainability Required post implementation review and recommendations Requires ongoing discussion and commitment – ward meetings/ excellence rounding Transferability Model to be reviewed prior to moving into redevelopment, aiming to promote Advanced clinical roles for nurses (in procedures, under the supervision of NP or MO) Aim to increase number of staff to suit the volume of daily through put (i.e. 2 x ACN : 1 x NP/ MO), similar to “RITZ” Model (rapid intervention treatment zone in the UK) different to “PIT” Physician in Triage Model. Attach supporting evidence 7

8. Evidence Trends/ Impact on Service 8 LAOR % DNW % Represent <48hrs % Admit < 4hours Admit < 6hours Admit < 8hours Discharge < 4hours Non admit Discharge < 6hours Non admit Discharge < 8hours Non admit Total Presentation Feb 100.849.63822--75--3320 Feb 110.9% (1) 6.9 (6.4) 6.7 (6.2) 20.244.466.276.491.496.23000 Feb 121.7 (1.8) 8.1 (5.8) 7.2 (5.7) 19.242.460.863.183.993.23211 Oct 122.6 (1.5) 4.3 (4.3) 5.4 (5.0) 26.652.170.674.689.195.43405 Dec 121.823.25627--80--3682 May 131.7 (1.4) 4.5 (3.8) 5.3 (5.1) 28.55672.976.992.396.83405 July 131.27*3.83*6*31*--82*--3350*