piloting a senior assessment and streaming model of care: from concept to creation
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Senior Assessment and
streamingFrom Concept to creation
Dr Matthew Vukasovic
HOD Westmead Emergency
Need for change
ED waiting room…….back then
o Patients physically
segregated from the actual
ED
o Physical and psychological
barrier to patients
o Minimal observation of
patients possible
o Minimal therapeutic
interventions
Ambulance corridor
o Waiting room also functions
as a thoroughfare
o Patients feel neglected,
anxious and fearful
o NO added value for the
patient within the waiting
room
o Ambulance OST delays
• Casualties of a sick system
• Julie Robotham Medical Editor SMH
January 10, 2009
• A WESTMEAD Hospital scheme designed to slash costs and improve
performance statistics by getting patients out of ambulances more
quickly contributed to the deaths of two patients, who received sub-
standard care in the emergency department, internal investigations
claim
Our journey of innovation and
redesign
oCo-design project�Emergency and Cardiology Services
oIntegrated models of care�ED HOPE (MAU)
oNew models of emergency care�Fast Track
oProcess mapping projects
oRedesign projects� Trauma redesign project
oInternal waiting room proposal
2006 2007 20092008
Co- Design Project 2009
o Involving staff, patients
and carers to identify
current model of care
delivery and process
o Designing improvement
strategies
collaboratively
Patient and carer experiance
“When I came in, I think it was a little bit
long. I would say about 20 minutes,
anything could happen in 20 minutes.
They should have put me straight in.”
(Patient: Co-design project)
“After being assessed
by the triage nurse &
before going into the
Emergency ward I
was in quite a lot of
pain. It would have
been good to have
had some pain killers
and also to have
some privacy”
(NSW Patient survey)
That was very hard because the triage
nurse, she is trying to type your name
& address and I’m thinking can we just
get him in and I can do all of that later.
Then she sent me to the other counter
to register my husband” (Carer: Co-
design
“It was scary, a lot of
things go through
your mind when your
husband is sick. I was
grateful when we go
inside, once on a bed
I felt a lot better, more
secure”Carer: Co-design Project
Lessons learnt o Analysis of the ‘Front of House’ processes
o Functionality
o Patient safety
o Performance
o Aesthetics of the ED experienceo Analysis of the whole interaction for the
patient/carer
o Impact on clerical, nursing and medical staff
o Importance of project managemento Project plan
Trauma redesign project
o Improve experience for trauma patients
o Understand ‘as is’-current state’ vs ‘to be’- ideal state’
o 18 process maps
o Voice of the patient
o 1:1 staff interviews
o Focus groups
Trauma redesign workshop
5th August 09 1- 5pm
Process mapping project
• Delays to triage have been validated in the Emergency Department process mapping exercises
• Variable delays can be 10 minutes to > 1 hour to triage
Previous scenario’s
• Westmead 2009-2010
• Worsening Access block
• Worsening Triage benchmark performance
• High DNW rate
• High ED LOS
• Well known adverse effectso Adverse clinical incidents
o Performance degradation and delays in care
o Staff and morale issues
o Training and recruitment issues
o Patient dignity and privacy issues
‘AN ED WITHOUT A WAITING ROOM’
Presentation for NSW Health
November 20th 2009
What did we propose?(2009)
• Quick triage
o Redesigning clerical & triage processes
• Senior decision making team at point of entry
o Senior doctor and nurse (CIN)
• Early streaming models
• Internal ETZ to replace the waiting room
• Separate pathways for streamed patients
NO waiting room ED
Streaming
TRIAGE FRONT OF HOUSETEAM
Early decision making
ACUTE ED
FASTTRACK
MAU UNIT
ESSU/ETZ
Disposition
Early pregnancy
assessment
clinic
PECC
Our journey of innovation
oInitial SAFE-T pilot (Dec 2010)
�1 room
oESSU
�6 beds
oSAFE-T and ETZ (Feb. 2011)
�1-2 spaces plus 4 in ETZ
2010 2011 20132012
SAFE-T Phase 1• Clinical space
SAFE-T zone → 2 bed initial assessment
stream initiate zone (ASI), 5 treatment space
early treatment zone (ETZ)
• Staffing
• ED Physician/Registrar
• JMO
• RN
SAFE-T• Business rules• Early Assessment (Bloods,Imaging,exam.)
• Early treatment (IV antibiotics,analgesia,fluids)
• 10 minutes per patient
• Disposition planning• Early streaming (SSU,MAU,wards)
• Acute care bed bypass/quarantining
• ETZ
• Discharge home or clinics
• Early Inpatient team review
Options from SAFE-T Zone
Pilot Study Dec 2010Characteristic Control group Intervention group Comments
Eligible patients – ATS categories 3, 4
and 5
67 90 More patients reviewed in same
bandwidth during trial period.
Length of stay – irrespective of ATS
categories
451 minutes
(95% CI 371 – 533)
324 minutes
(95%CI 276 – 410)
Median difference of 136
minutes (95% CI 61 – 211).
p=0.0003
Time to medical intervention – ATS
category 3
154.5 minutes
(95%CI 27 – 251)
n=34 patients
18 minutes
(95% CI 16 – 29)
n=43 patients
Median difference of 116
minutes
(95% CI 24 – 185)
p<0.0001
Time to disposition – ATS category 3 557.5 minutes
(95%CI 484 – 914)
n=34 patients
410 minutes
(95% CI 315 – 456)
n=43 patients
Median difference of 237.5
minutes
(95% CI 107 – 401)
p<0.0001
Time to medical intervention – ATS
category 4
72 minutes
(95% CI 37 – 128)
n=25 patients
32 minutes
(95%CI 17 – 49)
n=35 patients
Median difference of 37 minutes
(95% CI 12 -79)
p=0.0015
Time to disposition – ATS category 4 342 minutes
(95%CI 222 – 395)
n=25 patients
276 minutes
(95%CI 222-403)
n=35 patients
Median difference of 19 minutes
(95%CI -70 – 119)
sided p=0.66
Time to medical intervention – ATS
category 5
180.5minutes
(95%CI 119 – 229)
n=8 patients
27 minutes
(95%CI 4 – 75)
n=12 patients
Median difference of 124.5
minutes
(95%CI 63 – 185)
Two sided p=0.0003
Time to disposition – ATS category 5 413 minutes
(95%CI 295 – 547)
n=8 patients
124minutes
(95%CI 67 – 337)
n=12 patients
Median difference of 232
minutes
(95%CI 64 – 390)
Two sided p=0.01
SAFE-T trial data• Trial period → 24/02/2011 – 08/05/2011
• Comparison period →24/02/2010 –
08/05/2010
• SAFE-T zone hours of operation –
1000hrs to 1800hrsYear
Total2010 2011
Status Out of SafeT hours 5039 5468 10507
In SafeT hours 5146 5245 10391
Total 10185 10713 (↑ 5.2%) 20898
Time to first seen KPIATS category
Category 1 Category 2 Category 3 Category 4 Category 5
Year
2010 100 % 81.4 % 49.5 % 54.8 % 76.8 %
2011 99.6% 92.3 % 69.1 % 73.4 % 86.3 %
p- value p = 1.00 p < 0.001 p < 0.001 p < 0.001 p < 0.001
Year Percentage meeting criteria Time < 30 mins
2010 74.5 %
2011 79.5 %
p-value p < 0.001
Off-Stretcher time KPI (OST)
LOS – In SAFE-T hoursIn SAFE-T hours Year
2010 2011
Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75
LOS (hours) All patients 6.0 3.9 8.8 5.5 3.2 8.2
LOS (hours) Discharged patients 3.8 2.5 5.3 3.5 2.3 5.1
LOS (hours) Admitted patients 7.6 5.6 10.5 6.9 4.8 9.9
In SAFE-T hours Year
2010 2011
Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75
LOS (hours) All patients 6.0 3.9 8.8 5.5 3.2 8.2
LOS (hours) Discharged patients 3.8 2.5 5.3 3.5 2.3 5.1
LOS (hours) Admitted patients 7.6 5.6 10.5 6.9 4.8 9.9
In SAFE-T hours Year
2010 2011
Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75
Category 1 P=0.358 5.1 3.7 7.2 4.9 2.9 7.8
2 P=0.118 6.4 4.4 9.2 6.2 4.1 8.6
3 P<0.001 7.5 5.3 10.5 6.5 4.2 9.4
4 P<0.001 5.7 3.6 8.4 4.9 2.8 7.6
5 P=0.017 3.5 1.9 5.4 3.1 1.7 5.0
In SAFE-T hours Year
2010 2011
Median Percentile 25 Percentile 75 Median Percentile 25 Percentile 75
Category 1 P=0.358 5.1 3.7 7.2 4.9 2.9 7.8
2 P=0.118 6.4 4.4 9.2 6.2 4.1 8.6
3 P<0.001 7.5 5.3 10.5 6.5 4.2 9.4
4 P<0.001 5.7 3.6 8.4 4.9 2.8 7.6
5 P=0.017 3.5 1.9 5.4 3.1 1.7 5.0
Conclusions• 5.2%(6.5%) increase in number of presentations
during the intervention period
• Statistically significant improvement in time to first seen and Off-stretcher time KPI across all categories
• Statistically significant decrease in DNW rate
• Median, 25th and 75th percentiles length of stay was reduced for all patients in 2011 compared to 2010
• Statistically significant LOS changes were noted in ATS categories 3 and 4 (14.3% and 11.8%)
Conclusions• Most of the LOS reduction were noted during SAFE-T
hours of operation for ATS categories 3 and 4 (17.9%
and 17.0%)
• Increasing SAFE-T hours of operation to 12 hours will
lead to statistically significant improvements in LOS
for categories 3 and 4 ( 16.5% and 17.3%)
• Positive effects despite significant worsening in
Access block and hospital bed occupancy rates
• Multiple ED throughput measures bundled in a
model of care have significant positive impact on
LOS
• Need to test your MOC in current environment
• Collect data to validate your MOC
• Publish this data if possible
• Provides necessary impetus to drive change
• Provides necessary evidence for your staff and
executive
The journey continues
o Building works 2012-2013
o New UCC opens ( 6 treatment spaces +2)
o New Resuscitation rooms open
• SAFE-T /ETZ opens (2 +8 treatment spaces)
o Trial AAU( planning for new AAU)
2013 2014 20162015
Models of Emergency Care
Emergency Services, Westmead Hospital
Defining the ideal patient
journey
... Emergency Department Models of Care Redesign
ED Front End processing
... Quick triage
and
registration
ED Front End Processing
... SAFE-T
ETZ Six chairs & two trolleys
Considerations for streaming patients through ASI model of care
• ED capacity including
� Workforce (availability of senior decision maker)
� Vertical v Horizontal patient
� Bed availability in acute care
ASI
Front of House CordinatorFront of House Cordinator
10 minutes
Admission stream• Acute (undifferentiated/complex)• AAU (Differentiated , allocated in pt team)
Senior Doctor
Junior Nurse
Senior NurseTriage level
Discharge stream• ETZ 2 hours
• UCC 2 hours• ESSU 2-23 hours• Waiting Room
Blocked streamIf appropriate MoCis access blocked send to ETZ
ETZ
ED RMOWorks in ASI & ETZ
Senior NurseCIN level
2 hours
Initiate treatment while awaiting transfer to ED MoC
Observe /treat patient for up to 2 hours prior to discharge
Speciality team review
Observe patient who symptoms are not well defined
access block
Provides increased ED Capacity when there is access block
Trauma and resuscitationFour resuscitation bays including 1 dual function isolation room
249234
258
228
262 258276
311 302 306
650 650672
714 706
752
679
728
767
677
9784 83
109128
144
104124
102 94
34 3546 49 43 35 35
50 5131
8 5 9 11 11 5 11 12 6 10
0
100
200
300
400
500
600
700
800
900
SPRING 2010 SUMMER
2010/2011
AUTUMN 2011 WINTER 2011 SPRING 2011 SUMMER
2011/2012
AUTUMN 2012 WINTER 2012 SPRING 2012 SUMMER
2012/2013
RESUS PRESENTATIONS BY TRIAGE CATEGORY
1
2
3
4
5
24 Beds
Acute care...
1 hours for ED assessment and commence clinical management plan. ED SMO will review patient within1 hour and make a decision (admit/discharge/AAU/ESSU) . The E-form will be completed and reflect this decision
Up to 2 hour for speciality team review and/or allocation to inpatient bed
Up to 1 hour to transfer care to admission stream or discharge stream
1 hour 2 hour 1 hour
Four chairs
Two TrolleysTwo Consult RoomsOne Procedure RoomWaiting Room
Urgent Care Centre
UCC: TOTAL PRESENTATIONS WITH LOS < 2 HRS
4494
53865515
6789
6586
5962 6009
6786
16651790 1814
2109
2549
2176
2611
3364
0
1000
2000
3000
4000
5000
6000
7000
8000
AUTUMN 2011 WINTER 2011 SPRING 2011 SUMMER
2011/2012
AUTUMN 2012 WINTER 2012 SPRING 2012 SUMMER
2012/2013
UCC Total Presentations LOS < 2 hrs Linear (LOS < 2 hrs)
Four bedsFour chairs
Emergency Short Stay Unit
(Discharge stream)
Urgent care
centre
SAFE-T
Acute care
Features of ESSU ModelSpecial purpose beds.High turnover.NOT interchangeable with ward beds.
ED Consultant-led:Patient selectionReviewDecision to discharge
ESSU: AVG LOS WITH LOS <4HRS
13:23
12:02
10:1610:55
11:25
10:01
9:109:44
8:147:45
139
91
275
155
219
252
276
335
435
469
0:00
2:24
4:48
7:12
9:36
12:00
14:24
SPRING 2010 SUMMER
2010/2011
AUTUMN
2011
WINTER 2011 SPRING 2011 SUMMER
2011/2012
AUTUMN
2012
WINTER 2012 SPRING 2012 SUMMER
2012/2013
HR
S:M
INS
0
50
100
150
200
250
300
350
400
450
500
NO
OF P
TS
AVG LOS LOS <4hrs Linear (LOS <4hrs) Linear (AVG LOS)
ESSU: TOTAL PRESENTATIONS WITH LOS <24HRS
608
421
951
810
1010 991
1108
1217
13771457
0
200
400
600
800
1000
1200
1400
1600
SPRING 2010 SUMMER
2010/2011
AUTUMN 2011 WINTER 2011 SPRING 2011 SUMMER
2011/2012
AUTUMN 2012 WINTER 2012 SPRING 2012 SUMMER
2012/2013
ESSU Total Presentations LOS <24hrS Linear (ESSU Total Presentations) Linear (LOS <24hrS)
Acute Admissions Unit
(Admission stream)
SAFE-T
Acute care
Features of the AAU Model of careDifferentiated patient admitted under an inpatient team but may need ....- team review prior to ward transfer
- complex investigations to determine disposition
- further observation prior to transfer to the ward
Urgent care
centre
To be admitted to the AAU the following is required:Management and disposition plan
Time indicator of when the patient is likely to be transferred to the inpatient ward
Trigger point when the transfer would be appropriate(eg when CT report is available)
Scenario 1
58 year old female presents with increasing back pain
Known metastases to sacral area
Background metastatic breast cancer
Last admission under Med ONC last week
Scenario 2
25 year old female presents with lower abdominal pain
LMP 3 weeks ago
•Temp 36, HR 69, B/P 120/72, RR 14
Scenario 3
65 year old male presents with one episode of PR
bleeding. Nil past history, Family history of Bowel Ca
Otherwise well
• HR 78, BP 110/78, TEMP 36, SpO 98, No postural drop
Scenario 4
52 year old male, sudden onset Left flank pain
Pain 10/10
Unable to pass urine
Scenario 5
33 year old male currently on chemotherapy for AML
Febrile with temp of 38.5, BP 130/70, HR 130/min
No beds in acute
Lessons learnt• Any new MOC requires staff collaboration and
engagement
• “Listen” to feedback
• Importance of education esp. ongoing
• Staff In-services over 3 weeks
• Clinical scenarios to illustrate ideal patient
journeys/pathways
Dicussion• Staffing
• Complex roles(need to be clearly defined)
• Senior decision maker
• Adding value(bloods,imaging,treatment)
• Streaming options(more difficult concept to grasp)
Discussion
• Role of ETZ
• 10 minute limit
• Rapid triage
• Ambulance offloads
• Access block
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