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 the first 2 parts of this blog we looked at why we were undertaking this project and how we set about doing it. Now, one month after we started, we are in a position to share our early results.
This is only the first stage of this journey and it certainly has not been an easy one. On our first day we had the second most attendances we have ever had (only missing the record by a single patient) and without the patience, enthusiasm and support of our entire team we would have not gotten this far.
So the results:
Our primary outcome was Time to first assessment (1st HCP).
Prior to #PODSquad our median time for first assessment was 105 minutes, this median has now been reduced to 60 minutes. A reduction of 43%
Median time to triage has been reduced from 12 minutes to 8 minutes; a reduction of 33%.
Median Length of Stay for patients has been reduced from 207 minutes to 181 minutes; a reduction of 13%.
Median time to first test has increased from 23 minutes to 36 minutes; an increase of 57%, but as the following charts show this has also resulted in a reduction in the numbers of FBCs and troponins we are performing. This indicates that we are undertaking more targeted investigations in our patients.
Consequently all of these changes have consequently improved our 4 hour performance.
This has improved from a median of 79% prior to the start of #PODSquad to a current median of 89%, albeit with a peak of 93% for the first few weeks of July. 4 hour performance for patients discharged from the ED is now sitting with a median of 95%.
As a consequence of all this our department is less crowded and our conversations at our safety pauses are much more focussed on patience care and experience. We have improved continuity of care for patients and staff are getting breaks more consistently and we are delivering more teaching.
These successes have not been without challenges and there undoubtedly areas of this system that are not working well for either staff or patients. And whilst performance has improved, it still is not as good as it could or should be. We are still yet to fully understand how the system works, especially when we are very busy or areas decompensate and this, understandably, results in increased stress for staff members.
So we are now moving into a process where we will begin to target the areas of the system which could be better with targeted Quality Improvement projects with the intention of refining and improving the processes.
Our family has taken a step in the right direction and now, with continued hard work, patience and enthusiasm we will continue this journey.
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 workerWe 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 DemingFrom 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 #PODSquadHas 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.