Edinburgh Emergency Medicine deliver their service across 3 Departments in NHS Lothian to approximately 200,000 patients a year. They believe in clinical excellence, provided within a strong multidisciplinary team ethos and with patient care at its centre.
In this part of the blog we aim to describe both how our new system has been designed to work and how we went about introducing this, frankly massive, test-of-change.
The primary aim of this test was to reduce time to first assessment but also to improve both staff and patient experience. We had previously had feedback from our patient group and had generated several hundred patient journeys over the preceding twelve months from a new medical student programme that had allowed us to identify that multiple handoffs, repetition of activity and excessive movement throughout the department was detrimental to everyone involved.
We decided to split our department into 5 separate teams or ‘Pods’. This was largely done as our department geographically aligned itself to this number as well as consultant day time numbers matching this number of pods. This created a Resus Pod, 3 Pods for Emergency Department patients and 1 Pod for the medical receiving (interface) team and other specialties. Each Pod would have 8-9 cubicles and our current numbers meant that we could aim to staff each Pod with the following:
- A senior doctor (Consultant or ST4+/Senior specialty doctor) - Several junior doctors or ANPs (numbers increasing throughout the day to match attendances) - 3 trained nurses - 1 clinical support worker
We would also have 2 ‘Bernadette Nurses’* to perform a rapid triage. One Bernadette nurse would receive patients arriving by ambulance and one would receive patients who self presented to the department. The role of the Bernadette nurse is to receive patients and take a brief history or handover which would allow them to triage the patient and either send them to a Pod or redirect them to an alternative service such as the Minor Injuries Unit or Early Pregnancy Unit. To maintain flow through these areas it was decided that observations and other investigations would not be done at this point but would be done immediately on arrival in the Pod. The Bernadette nurse would decide which Pod to send each patient to by using the real time MedTrak computer system to see which Pod had the capacity, along with feedback from a Support nurse who would inform them if a particular Pod was stressed due to capacity or acuity. Patients would be transferred to individual Pods by a CSW or porter.
Each Pod would have a nurse designated as Safety Lead and, with the senior doctor, they would be responsible for ensuring that patients were being met and cared for in a timely fashion including ensuring that care rounds occurred, pain scoring and neuro obs were being done and being responded to. They would be supported by a Support Nurse who would be available to respond and react to individual Pod needs.
The design is for each patient to be received directly into a Pod in a cubicle by a nurse, junior doctor or ANP and the senior doctor. As a team they would perform observations, take an initial history and decide on and undertake necessary investigations or treatments and potential early admission or streaming to a particular specialty. The patient would remain the responsibility of that Pod for the duration of their stay in the ED to ensure continuity of care, although fit-to-sit was to be encouraged to maintain capacity in each Pod.
2 Pods were designated as Primary Pods and would remain open at all times (excluding the Resus Pod). The other Pods would be closed during times of reduced activity and staffing so that the teams were not spread too thinly. If required the bed spaces from the closed pods could be used by the 2 primary pods to maintain capacity.
We also took the opportunity to plan for mini-pod pauses. These would be brief multidisciplinary meetings in each pod to discuss any concerns, review actions and ensure staff wellbeing which could then be fed back into the main departmental pauses that occur 2 hourly with the senior staff for the department and management from the hospital.
‘Without data you are just another person with an opinion’
- W Edwards Deming
From the initial idea of this model we were set the challenging timeframe of delivery of 4 weeks. We put together a working group and initially discussed the very basics of how this model of care could be delivered. This was followed by a staffing exercise to ensure that we could adequately staff this model with our existing staff numbers 24 hours a day.
We then set about deciding on our data metrics. We agreed that this process was primarily about 1st assessment and this became our primary outcome measure. We decided on a range of process measures including time to triage, length of stay in the ED and staff and patient satisfaction measurements. Our primary balancing measure would be time to first investigation. ‘What matters to you’ Day allowed us the opportunity to gather some useful baseline data regarding staff experience. We worked with our data analyst team to develop these metrics as well as a real time data dashboard that would tell us what was happening in both the department and the individual Pods.
Our department has several hundred members of staff once all the nursing, medical, AHP and various vital support staff are calculated and ensuring that every team member knew what was happening, why it was happening and how it was going to affect them at the earliest opportunity was going to be key to any success. We needed a unifying brand and #PODSquad was born. The Narwhal was chosen as a logo (whales travel in Pods and the Narwhal is the unicorn of the sea, although we now know that a group of Narwhals is called a Blessing).
A small group of us sat and went through the plans adding in detail so that we could produce a standard operating procedure. This allowed us to try and consider, and plan, for a variety of contingencies such as increased activity or acuity. We used this detail to create the following video which we could then circulate around the staff and show at handovers to inform everyone of the test.
video guide2 - YouTube
Prior to the launch of #PODSquad the video had been watched over 700 times.
We ran a Flowopoly exercise modelling an average day’s activity through the department with the #PODSquad model of care to identify any major problems and any areas of concern. Whilst the model worked well we did identify the following 3 issues as points of concern:
1. At times of peak business the Bernadette nurse for self presenting patients would be overwhelmed (estimated that they could triage 12 patients per hour) and would need support from the Nurse in Charge.
2. If patients were not directed to sit in the waiting room to await results if sufficiently well then maintaining capacity in the Pods would be difficult.
3. We needed to ensure flow out of the Pods by early decision making regarding admission or transfer to another area such as the observation unit when appropriate.
We developed roles and responsibilities for all staff members and developed templates for the mini-pauses and main departmental pauses. We also undertook the process of ensuring that each area of the department would have the right equipment, right medications and sufficient monitoring. Prior to this we had cohorted patients in different parts of the department depending on their acuity. Our plan was now to spread acuity out across the department and we needed all areas would be adequately equipped. Staffing was mapped and assigned for the full 2 week test.
Our eHealth department agreed to support us by producing a new layout for the system on MedTrak and we had new signs delivered for the department to create the sense of physical change as well as process change.
Throughout this time we spent as much time as possible simply talking to as many staff members as we could to talk them through the process and answer any questions that might arise. We included spreading this message to every other department in the hospital and to the ambulance service so that no one would be fazed on arrival in the department.
At 0700 on Monday the 17th of June we were ready and we started our test.
Results to follow soon......
*I do not know why it was decided that the triage nurses were to be called Bernadette nurses but like all good doctors in certain circumstances I just do what my nurses tell me to.....
Edinburgh Emergency Medicine is currently undergoing a massive change looking at the process by which we receive, assess and manage patients attending our department.
Over the next 3 blog posts we will explain the following:
Why are we trying this change? And what is #PODSquad?
How have we gone about planning for #PODSquad
Has it worked?
The Emergency Department at the Royal Infirmary of Edinburgh sees between 350 and 430 adult patients per day. Over the past 18 months we have been challenged by rising attendances, rising times to triage, rising times to first assessment and a worsening 4 hour performance. Furthermore, patient complaints have increased and staff morale has dropped, resulting in increasing departures and leading to a general feeling of unhappiness across the department. This is unlikely to be an unfamiliar situation to anyone working in an Emergency Department anywhere in the UK at present.
A few years ago, faced with similar circumstances, we undertook a major Kaizen project to improve our department and created a system called One Patient Pathway. This system relied on a rapid, senior-led front-loaded assessment system where all patients were seen in a triage area and decision made on initial investigations and treatments. This led to patients being seen quicker and investigations and treatments being started earlier. It worked well. But as patient numbers grew the system began to struggle. When over 30 patients per hour arrive, the team were struggling to deliver bespoke care and the consultant struggled to review every patient to make clear decisions (one patient every 2 minutes). We made interventions such as creating parallel streams of work and creating guides and support to identify the patients in most need of care and what they needed but without replicating our early successes.
Elsewhere in the department we tried other interventions to improve patient and staff experience, such as creating a bespoke Minor Injuries Unit and an Ambulatory care/Observation Unit. Both of these have been successes in their own right but without an overall impact on the main department.
It was time to try something new.
The idea we had was not new. It had been used with success in the USA but we were unaware of it being used in the UK before. The idea was to split the department into a series of separate areas known as Pods, hence #PODSquad.
Each Pod would be staffed by a number of doctors, nurses, nurse practitioners and clinical support workers with a senior doctor such as a consultant assigned to each Pod. Patients would enter the department and after a rapid triage would be sent to one of the Pods. Each Pod would receive a mix of patients with varying triage categories. Patients would be received into the Pod by the team and would get an early assessment and decisions about investigations with initial treatments started. The patient would remain under the care of this Pod until a decision was made regarding destination.
The primary aim of the system is to reduce time to first care-provider by ensuring that a patients first significant point of contact is with their care provider, but we also are aiming to reduce time to senior review, time to analgesia and investigation and ultimately, time to discharge (either home or into the larger hospital system), whilst improving the experience for both patients and staff working in the department.
In the next post we will go into some more detail about how the Pod system works and how we prepared for the test and have undertaken this in the department.
Since September Dr Jon Patrick and and Art Psychotherapist Kate Pestell have been training the ED staff in mentalisation.
Why are we doing it?
So as a team I think we are pretty empathetic, this slips the busier and more stressed we get. When it slips we have negative team and patient interactions. The question is can mentalisation help us improve the care we give to our patients and strengthen our team relationships?
What is mentalisation?
The term mentalisation refers to the ability to reflect upon, and to understand one’s state of mind.
In addition mentalisation also helps us to understand the state of mind of other people. The benefits of mentalisation are:
1) Mentalisation enables us to understand our own contributions to problems and conflicts with others;
2) Mentalisation helps us to change our behaviours and calm down when we are upset;
3) Mentalisation allows us to relate to ourselves and other people with empathy and compassion; and
4) Mentalisation promotes our ability to effectively cope with conflict.
How are we doing this?
The one-day training sessions are continuing in to the New Year so if you haven’t had the chance to attend one yet please chat to your line manager.
Jon and Kate are running twice weekly sessions in the ED teaching room from 09:00-10:00 on Tuesday and Thursday mornings. These are open to everyone (whether you have been on the one day training or not). They are happy to discuss difficult cases or teach new techniques for mentalisation.
Please join us!
We are very grateful to the Edinburgh and Lothians Health Foundation for funding this project.
Outside the Emergency Department at The Johns Hopkins Hospital
I am sure we can all agree that working in an emergency department can at time be stressful, busy, emotionally charged and requires us to move from one case to the next often without thought or hesitation. There is also a well recognised issue with recruitment and retention of all staff in the specialty of emergency medicine. Our department attracts some of the most compassionate, hard working and kind staff you will find anywhere in the hospital and I was interested to find out what steps other organisations take to support their staff and encourage resiliency. In addition, how do they support them when they feel overwhelmed, things have not gone well or there has been an adverse event.
Since we last spoke I have been spending time with some pretty cool people at The Johns Hopkins Hospital learning about RISE (Resilience in Stressful Events). This is a peer-led support programme that is offered to all staff throughout the hospital. I have been intrigued and interested to find out why this was implemented, how it works, what the culture of their organisation is like and has it worked.
The literature states that organisations often fail to recognise the impact of adverse events on healthcare providers who can suffer emotional distress after the same incidents that harm patients. The concept of the healthcare worker as a “second victim” and the hospital often as a “third victim” is frequently mentioned. Those who become a “second victim” can experience a wide range of adverse effects including sleep disturbance, anxiety and even depression. This in turn leads to healthcare workers who are distressed and at risk of making further mistakes. There may be an increased rate of sick leave and subsequent turnover of staff which can be costly to an organisation.
The Johns Hopkins Hospital is only one of a few hospital in the United States to adopt a peer-led support programme. It was implemented initially on the paediatric ward in 2011 when several second victims were identified after a tragic and highly publicised death of child on the ward as a result of an adverse event. The programme was subsequently rolled out hospital wide in 2012. There are currently 35 trained peer providers who take it in turn to be “on-call” for the week.
The mission of RISE is “to provide timely support to employees who encounter stressful patient-related events - defined as including adverse events, medical errors, deaths, unexpected outcomes, non-accidental trauma, and difficult or violent interactions. Support is offered 24 hours per day and seven days per week in a peer-to-peer or group format depending on the request. The support is provided by peers: colleagues who work in the hospital environment and who have been trained to provide appropriate support.” It is confidential and completely separate from any investigation into how an adverse event occurred.
The programme is led by Professor Albert Wu. He is a Professor of Health Policy and Management and Medicine at Johns Hopkins. He leads the Armstrong Institute centre for measures of quality of care and patient safety and is a leading expert on disclosure and the psychological impact of medical errors on both patients and caregivers. He is so approachable and an all round good guy who is both interested and interesting. Since our first meeting he has set me to work reading many papers about the RISE programme/second victim/psychological first aid, peer reviewing for a journal and encouraging me to write more. I have been writing about my experiences and also an outline plan for a future project. We have been meeting regularly to discuss my progress.
Through Albert I have been lucky enough to also meet and spend time with several members of the RISE team. This allowed me an opportunity to pick their brains and find out first hand what it is like being a RISE provider. They were also able to give me some insight into the culture of their organisation and how it has changed over the years. I spent time with Matt Norvell the paediatric hospital chaplain, his main role is to provide emotional support to patients and families so it seemed a great fit that he was involved in RISE. I met up with Cheryl Connors who is a paediatric nurse and patient safety specialist with the Armstrong Institute for Patient Safety and Quality. Cheryl co-led the development of the RISE programme. Lastly, I met Laurie Rome a paediatric oncology nurse. I attended a monthly event that she facilitates held on the paediatric oncology ward called “Processing and Resilience Sessions.” This event was open to all staff on the ward. The goals of the session were to promote resilience, help with processing distressing events, learning strategies to manage stress, a forum to support each other and share stories and allow staff to get to know each other off the “shop floor.” Snacks were included (I think this helped) and interestingly it was all nursing staff apart from one doctor who turned up late. Many of the nurses were relatively junior and you could see that they benefited from speaking about what had been bothering them particularly having to work in an environment such as paediatric oncology. Senior nurses provided reassurance and solutions to junior nurses and people were really open and comfortable to chat. It was awesome to see an example of a department taking matters into their own hands. The staff enjoyed it and found it useful, with one nurse telling me “its like therapy for me.”
Next week I am due to attend the RISE team meeting to discuss how things are going and recent calls that have been received. While I have been spending time with the RISE team I have been part of the on-call team. Although I obviously don’t want there to be an adverse event, I am really hoping they get a call so that I can see the RISE team in action. There has not been any calls yet but fingers crossed!!
Everyone I have spoken to is incredibly positive about RISE and its importance, not just those directly involved in the programme. Everyone is aware of the programme and support its existence. They report a big drive throughout the hospital to improve staff resilience and note that in a very competitive and academic institution there has been a definite culture change and that people are more open and supportive. The programme has been fully supported and embraced by senior clinicians and hospital management. I have loved the opportunity to learn about a novel programme of peer support and I am interested to explore some specific aspects of this going forward and hope that we could take even some baby steps towards improving how we look after and support our own staff. I appreciate we may not experience adverse events every day but we do experience suffering and some traumatic situations on a daily basis and this in addition to the pressures of the environment we find ourselves working in means we are more susceptible to feeling stressed and are subsequently at risk of burnout.
RISE recognised on the cover of the hospital magazine.
View of Downtown Baltimore from the roof of my apartment.
As my ST4 year draws to a close, I am fortunate enough to be spending the last few weeks of it in Baltimore thanks to Medic One and The Robin Mitchell Fellowship. I was awarded the fellowship back in February and I have been hotly anticipating the opportunity to have time to develop myself, learn something new and ultimately share my experiences with my colleagues. I am coming to the end of my first week and wanted to tell you about where I am and what I have been up to…
Baltimore, known fondly as “Charm City” is a major city in Maryland with a long history as an important seaport. The population is approx 600,000 compared to Edinburgh approx 480,000. Currently the weather is hot and humid reaching 35 degrees most days. The city is steeped in culture, has beautiful architecture and is renowned for its seafood such as crab and oysters. It is also home to amazing academic institutions like Johns Hopkins University which is one of the top ranked universities to study medicine in the United States.
Since arriving in Baltimore I have come to understand that things are complex here and the word “diverse” springs to mind. The city has a significant problem with violence, crime and drugs. It is known as the heroin capital of the United States. To be more prepared for this aspect, I probably should have taken Dr Carter’s recommendation and watched “The Wire” before arriving! Top tip from the taxi driver: avoid areas with small blue flashing lights on the top of the street lights as this indicates a high crime area. There are well documented health disparities and inequalities not only within Baltimore but also when comparing the population of Baltimore to the rest of the United States. This is clear to see just walking around the city.
The aim of my trip was to get exposure to and learn about a peer-led resilience programme (RISE) that is offered to hospital staff experiencing stressful events at Johns Hopkins, experience another health care system with observation in the Emergency Department at Johns Hopkins Hospital and to attend the summer institute course on Human Factors and Patient Safety at the Bloomberg School of Public Health of The Johns Hopkins University.
My experience to date in the field of human factors is mostly through simulation training, where there has been an emphasis on situational awareness, team dynamics, effective leadership and communication. As a department we also discuss cases at our monthly M&M meetings and when looking at why things have gone wrong or our performance has been suboptimal we often reference Reason’s Swiss cheese model of accident causation. Throughout my training so far there is also frequent reference to high-performing industries such as aviation, their approach to safety and how healthcare can learn from such industries. I was interested to learn more about human factors and the concept of human factors engineering, changing the system and the processes to “designs out” errors. The science of human factors accepts that healthcare professionals, like all humans, make errors. Human factors experts focus on designing systems that make it “easy to do things right and hard to do things wrong.”
During my first week in Baltimore I attended the human factors in patient safety course. This was a three-day course and was essentially a condensed version of the year long course. The course was predominantly delivered by Dr Ayse Gurses and Dr Mike Rosen. Dr Gurses is the Director of the Armstrong Institute Centre for Health Care Human Factors. She is a human factors engineer with expertise in patient safety, healthcare technology design and usability evaluation. Her areas of interest include transitions of care/handovers and working conditions for nursing staff. Dr Rosen is a human factors psychologist with special interest in the areas of teamwork and patient safety as well as simulation-based training, performance measurement and quality and safety improvement. The class was small with only 10 students, most of which were taking the course for credit as part of their masters or doctorate in public health. Only one other student was a practising medical doctor. Everyone was friendly and most were coming to the course and “human factors” from a different perspective which really helped contribute to in class discussions and learning.
I turned up on day one having completed the required pre-course reading of almost 30 different papers!!! Initially I was nervous and felt very out of my depth. It was all seeming very “academic” and the last time I had read actually read a anywhere near that many papers was studying for the dreaded critical appraisal exam! As I soon learnt, reading the papers served as a bit of background to the various topics which were covered in lectures throughout the course. These included an overview of human factors engineering (HFE), physical ergonomics, cognitive ergonomics, teamwork in patient safety, macro-ergonomics, introduction to HFE methods, retrospective and prospective risk assessment methods and an overview of organisational theory. Throughout the course we worked in pairs to critically appraise a paper of our choice related to the application of human factors principles in a healthcare setting which was presented on the final day. We also worked in two groups over the three days on a project applying human factors engineering principles to a real life clinical problem. Again this was presented on the final day as a PowerPoint presentation.
By the end of the course I came to realise that this topic is vast and that the course only really scratches the surface. I have a better understanding of the importance of human factors engineering when it comes to designing safe healthcare systems. I felt that I could contribute with some real experience of frontline healthcare to the class and have some understanding of the challenges of working in such a complex environment. I am by no means now an expert in the field of human factors but I have definitely learnt some essential concepts, methods and tools which can be applied to patient safety interventions and quality improvement efforts. It also has me wondering if NHS Lothian has any human factors specialists, something I must look into on my return. Hopefully this is something that I will be able to continue developing and learning about throughout my training. It was thoroughly enjoyable to take some time to learn something new, not for an exam, but just out of interest.
Anyway, I will update you all soon on the next week of my adventure. I hope you are enjoying the wonderful weather in Scotland and that the department is less busy as a result (who am I kidding?!) The morale boosting ice-lolly freezer better be well stocked!!