Emergency Department Models of Care 2012 - NSW Health

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Benefits of the model ■ Early diagnosis – patients are seen initially by a senior ED Physician to establish amanagement plan and expected disposition■■■■Reduced duplication in assessment and diagnosticsImproved turnaround times for diagnostics services and specialist consultationsReduced delays in transferring patients to the inpatient unitMinimised delays to accessing clinical equipment as all bed areas are set up instandardised way.Challenges ■ Ensuring sufficient availability of senior medical staff will require devolution of lower levelclinical tasks and support to other providers; and/or increasing senior medical staffingnumbers■■■■■Changing the practice of Junior Medical Officers reviewing Acute Care patients beforeSenior Medical Officers.Appropriate use of standardised clinician pathways, for example, a chest pain pathway tooptimise patient clinical care and risk stratification for all patientsImplementing a standardised clinical handover tool/process that encompasses handoverwithin the ED and then to specialty teams and inpatient unitsDelays in transferring patients to the ward because there is a culture of:- consulting teams requiring a full assessment and diagnosis before accepting patients tothe inpatient unit- negotiating patient transfers with ward staff, for example, to accommodate ward staffmeal breaks- patients deemed too sick for the ward but not sick enough for a High Dependency unit- patients kept overnight in ED due to lack of overnight delegation of ward transferdecisions (to accommodate referral calls ‘en bloc’ being made to admitting consultantsin morning).Poor engagement from diagnostic services regarding timely access to services and results.Case for implementationAll EDs should have an area which allows for the care of unstable, complex patients. Thefollowing questions are important when reviewing your acute model of care:■■■■■■■Does your ED have an appropriate area for treatment and monitoring of unstable,complex, high acuity patients?Does your ED experience delays in moving patients to monitored beds due to acute bedsbeing occupied by less complex, less acute patients?Are delays experienced in completing diagnostics, and the formulation of managementplans and disposition decisions?Is there duplication of work between senior and junior medical staff in the diagnosis andmanagement of unstable, complex, high acuity patients?Are delays experienced by the Inpatient Team reviews of acute patients?Are delays experienced in transferring patients to an inpatient unit?Are clinical pathways in place for the management of common presentations to ED?PAGE 22 NSW HEALTH Models of Emergency Care
What you need to runthe modelStaff■■A sufficient number of available Senior Medical staff who are trained and experienced tomake timely decisions about investigations, management plans and dispositionAn appropriate mix of the clinical skills of nursing and medical staff to care for acutepatientsPhysical space■Most EDs will already have an established acute care area. If not, an area of ED withcardiac-monitored treatment spaces should be dedicated to the assessment and care ofacute patients only, and should be located close to the resuscitation and triage rooms.Business rules:■■■■■■■A team approach to patient management – the team should consist of a senior decisionmakerdirecting junior RMO and nursing staff.Timely access and turnaround times for diagnostic (medical imaging and pathology)services that meet the needs of EDs for making timely decisions.Use of clinical pathways (for example chest pain pathway, sepsis pathway) and otherstandardised management processes to reduce variation in clinical management and tosupport best practice.A standardised process in place to handover patients from ED Medical staff to theconsulting inpatient team. This would ideally be a handover from an ED Consultant to aSpeciality Consultant to minimise the requirement for speciality Registrar review in ED(Refer to NSW MoH PD2009_060 Clinical Handover – Standard Key Principles PolicyDirective).Timely access to Specialist Consultants for the purpose of expediting safe patient care.This will require guidelines in place that support a specialty Registrar review within onehour from the time of the review request.Consistent utilisation of the Decision to Admit policy to expedite admission to theinpatient unit (Refer to NSW MoH PD2009_055 Emergency Department – DirectAdmission to Inpatient Wards Policy Directive).Timely (1 hour) transfer to the ward bed.Monitoring andevaluationED measures■■Waiting time for treatment by triage categoryProportion of patients seen up-front by a senior emergency physicianED and whole-of-hospital measures■■■■■■■ED patient total length of stayNational Emergency Access Target (4 hour)Time to Transfer of CareTime to Specialty consult/reviewTime to transfer to an inpatient unitPatient outcomesPatient complaints and reported incidents.Models of Emergency Care NSW HEALTH PAGE 23
Page 2 and 3: NSW MINISTRY OF HEALTH73 Miller Str
Page 4: Executive SummarySince the publicat
Page 7 and 8: 1.2 A review of Emergency Modelsof
Page 9 and 10: ■■■patients who need only a s
Page 11 and 12: SECTION 3Emergency Department Model
Page 13 and 14: In determining your skill mix requi
Page 15 and 16: Benefits of the model ■ Improved
Page 17 and 18: 3.2 Clinical Initiatives NurseResus
Page 19 and 20: ■■Demonstrated ability to inter
Page 21 and 22: Predictive planning■■■■■
Page 23: 3.4 Acute Care2 hoursED Senior Asse
Page 27 and 28: Key principles ■ This is not a st
Page 29 and 30: Monitoring andevaluation■Waiting
Page 31 and 32: Challenges ■ Establishing guideli
Page 33 and 34: 3.7 Fast trackED Senior Assessment
Page 35 and 36: What you need to runthe modelStaff
Page 37 and 38: 3.8 Sub-acute2 hoursED Senior Asses
Page 39 and 40: 3.9 2 : 1 : 12:1:1This model requir
Page 41 and 42: Monitoring andevaluation■■■
Page 43 and 44: Why use the model?Key principlesBen
Page 45 and 46: What you need to runthe modelStaff
Page 47 and 48: SECTION 4Streamlining access to acu
Page 49 and 50: Challenges ■ Identification of
Page 51 and 52: ■■■Patient Flow pathways and
Page 53 and 54: Case for implementationWhat you nee
Page 55 and 56: Operating Principles■■■■■
Page 57 and 58: Case for implementationWhat you nee
Page 59 and 60: Mental Health LiaisonNursesApproxim
Page 61 and 62: 5.1 Urgent Care CentreThe Urgent Ca
Page 63 and 64: 5.3 Connecting CareWhat is the mode
Page 65 and 66: SECTION 7Self-Assessment ToolsInclu
Page 67 and 68: NHS Gloucestershire 2006, UK Urgent

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