Administration Overview

Emergency staffing

• Aims
  • Provide care in a timely manner according to clinical urgency
  • Safe and manageable work conditions and reasonable job satisfaction
  • Threshold level of staffing for influx
  • Teaching roles
  • Non-clinical roles

Estimating medical workload

• Models of medical time per triage category x number of presentations per triage category
  • Cat 1 – 160min
  • Cat 2 – 80min
  • Cat 3 – 60min
  • Cat 4 – 40min
  • Cat 5 – 20min
• Add additional staffing for SSU
• Staff to ensure patients treated within ACEM benchmarks
  • See over page
• Need to meet other clinical and non-clinical roles that supplement patient care

ACEM benchmarks

• ACEM recommends
  • Minimum 30% non-clinical time for consultants (more for directors/DEMT)
  • Minimum 15% non-clinical time for registrars

Layout

• Should promote efficient patient flow and maximise access to every space with minimum of cross-traffic
• Triage should observe and gain access to ambulance entry and waiting room
• All spaces in acute should be directly observable from staff station
• Supporting areas should be centrally located
• Clinical support areas are often poorly planned with inadequate data entry points and storage
• Need to consider nighttime minimal staffing
• Security of staff and patients is paramount

• The electricity supply should be surge protected
• Physiological monitoring areas should be cardiac protected
• Other patient care areas should be body protected
• Average Australian ED with admission rate of 25-35% should have internal area of 50m2/1000 yearly attendances
  • Number of patient treatment areas 1/1100 yearly attendances
  • Number of resuscitation bays should be 1/15 000 yearly attendances
  • If average acuity, at least half of all patients treatment areas should have physiological monitoring available
• Minimum resuscitation bay size is 35m2 (including storage area) or 25m2 (excluding storage area)

• Recommended minimum distance between beds is 2.4m
• Each treatment area should be at least 12m2
• Mental health rooms should be at least 16m2 to allow a restraint team of five members
• Plaster room should be 20m2
• Procedure room at least 20m2
• Minimum functional SSU size is 8 beds
  • 1 bed /4000 attendances per year
• Waiting area 5m2/1000 yearly attendances
• One seat per 1000 yearly attendances

Quality improvement

• Continuous cycle, with measurement and monitoring to establish that improvement is required, planning of the change, implementation and re-evaluation and monitoring
• Traditional approach was retrospective to monitor pathology results, missed fractures, medical record reviews, death audits and patient complaints
• Modern quality system provides a framework that includes monitoring, audit and improvement of clinical aspects of care, processes, structure, competence of staff, education and training and has clear governance and accountability

Definitions

• Quality – Doing those things necessary to meet the needs and reasonable expectations of those we service and doing those things right every time
• Quality assurance (QA)
  • System used to establish standards for patient care, monitor how well these standards are met and correct unwarranted deviations from the standards
• Quality improvement (QI)
  • Raising quality performance to ever increasing levels
• Continuous Quality Improvement (CQI)
  • Management approach that focuses on providing a service that meets patients needs in such a fashion that the process itself leads to continuous improvement e.g. automatic data collection, statistical tools and team dynamics to develop quality processes

Definitions

• Total Quality Management (TQM)
  • Uses management approach of CQI and implies commitment of whole organisation to implementation of a quality plan
• Clinical indicators
  • Measures of the clinical outcomes of care
• Clinical guidelines
  • Provide a focus for standardisation and a reference point for peer review
• Benchmarking
  • Comparing performance with others and the use of best practice as a marker and goal
• Credentialling
  • Formal process to recognise and verify an individuals qualifications to enable a view of their capacity to perform a task safely

Continuous Quality Improvement (CQI)

• Deming cycle (Plan, Do, Study, Act) and repeat
• Covers:
  • Access and equity e.g. waiting times, access to inpatient beds
  • Safety e.g. medication errors, adverse events, body fluid exposure
  • Acceptability e.g. complaints/patient satisfaction
  • Effectiveness e.g. time to thrombolysis/antibiotics
  • Efficiency e.g. appropriate imaging, avoiding waste

• Vital characteristics
  • Leadership and strategic planning
  • Customer focused (patients, relatives, staff)
  • Performance-based with accurate and relevant data on performance measures
  • Focuses around clear governance structures and accountability
  • Effective communication and change management
  • Focuses on systems first and individuals second
  • Incorporates a risk-management framework with risk analysis and monitoring, risk mitigation and risk avoidance
  • Sound credentialling processes

National bodies

• Australian Council on Healthcare Standards (ACHS)
  • Evaluation and Quality Improvement Programme (EQuIP)
  • Framework for hospital to establish quality processes
  • Requirement for accreditation
• Australian Commission for Safety and Quality of Health Care
• ACEM facilitates training, introduction of clinical indicators, policy development and standards for ED’s
• IFEM has developed a consensus document

Quality in the ED

• The very nature of ED with temporary, often junior, staffing makes it error prone and under close scrutiny
• Staff must be committed to quality improvement with senior leadership and resources for patient care
• Common quality measures in ED
  • Time to thrombolysis or PCI
  • Waiting time by triage category
  • Did not wait rates
  • M&M
  • Flow measures – 4 hour total ED times, times to inpatient bed
  • Chart audits for specific complaints e.g. headache, abdominal pain
  • Time to analgesia
  • Time to antibiotics for sentinel diagnoses e.g. febrile neutropaenia, sepsis, pneumonia
  • Trauma audits e.g. missed cervical spine fractures, delays in craniotomy
  • Trauma registries
  • Patient and staff satisfaction surveys
  • X-ray and pathology follow-up

Business planning

• Business plan is an annual document detailing
  • Agreed performance dimensions of:
    • Revenue and expenditure
    • Activity
    • Efficiency
    • Quality of services
    • Capital expenditure
    • Information and communication technology
    • Special projects

• Budget 3 to $30 million annually
• ED plans
  • Typically look 5-10 years into the future to describe how organisations will respond to changing technology, altered demographics, shifting paradigms of care and reform, cost/quality/accessibility of healthcare
• Project plans
  • Highly focused on particular objective outcome to be achieved within a given time frame

Business plan content

• Budget
  • Explanation for any variance
• Activity
  • Attendances by triage category, admission rates and compared to previous years
  • SSU diagnoses
• Quality and efficiency
  • Waiting time by triage category
    • Average waiting time per patient by triage category AND
    • Percentage of pateints in each triage category seen within the timeframe specified
  • Percentage meeting 4 hour NEAT
  • Frequency and duration of ambulance bypass
  • Access block data (percentage of total admitted patients in ED >8 hours)
  • Research and educational achievements

• Projections
  • Projected budget for year ahead and projected expenditure
  • The assumption is the hospital executive expect iso-expenditure/iso-workload
• Equipment
  • Typically <$5000 items are met from global allocation to department
  • Higher cost items should require a full business case
• Facility maintenance
• Projects

Accreditation, specialist training and recognition

• Specialist training colleges are accredited by the Australian Medical Council
• Hospitals overall are accredited by the Australian Council on Healthcare Standards
  • 10 National Safety and Quality Health Service Standards within its framework

Accreditation

• ACEM separately accredits hospitals for post-graduate training
  • Level and number of emergency physicians providing adequate and appropriate supervision for trainees of all levels of experience and at all times
  • Appropriate number and casemix of emergency patients
  • Adequate specialist workforce regarding appropriateness of rosts, safe hours, access to leave and departmental performance
  • Compliance with CPD by FACEM’s
  • Appropriate medical and non-medical staffing
  • Design and equipment of the department
  • Appropriate range and level of support services
  • Appropriate education program
  • Opportunity for trainee research
  • Accreditation of an appropriate range of specialties within the hospital and access to rotations
  • Function and access block and impact on training/well-being

• Need at least 2.5 FTE FACEM inclusive of director and DEMT
• Also need:
  • Appropriate and acceptable standards of patient care
  • Documented management policies
  • Functional electronic patient record
  • Formal system of quality management
  • Formal orientation program
  • Adequate EM textbooks and electronic resources
  • Access to mentorship

College procedure

• At least 5 yearly inspections of ED’s
• Annual reviews of Trainee Feedback Reports
• Director of ED should be supernumerary or at least 50% non-clinical
• DEMT must be employed at least 0.5 and undertake clinical work and at least 3 years post-fellowship
• A recommendation is then made and resolution of any issues must be shown before accreditation is provided for 6, 12 or 24 month training time

Conflict management

• Conflict only a problem when dysfunctional as otherwise it improves performance
• Always consider you could be wrong
• Talk directly with person you disagree with
• First ensure you actually disagree (summarise)
• Next determine what you disagree about
• Ensure all facts known e.g. social situation, Ix results, response to treatment
• Seek additional information together eg. Why don’t we look this up?
• Seek additional opinions e.g. Why don’t we walk with the Neurologist about it?

Conflict management techniques

• Compromise
  • Unlikely to be satisfactory for both parties
  • Use when goals are important but not worth effort of more assertion, temporary settlement necessary for complex issue, expedient solution required or if collaboration/competition unsuccessful
  • May lead to failure to achieve important goals, lack of self-value and cynicism
  • If underutilised, can lead to frequent power struggles, inability to negotiate effectively when required and unnecessary confrontation
• Avoidance
  • Use if trivial, no chance of satisfying concerns, potential disruption outweighs benefits

• Accommodation
  • Forgoing your desires and obedience
  • Use if you are wrong, issues are more important to others than you, harmony especially important
  • Can lead to overlooked ideas
• Competition
  • Mostly detructive
  • Useful if decisive action vital or you definitely know you are right and it is a very important issue
  • Leads to lack of feedback and learning

• Collaboration
  • Most time consuming but mutually beneficial method
  • Let’s work this out together
  • Useful if both parties have concerns and time for integrative problem solving
  • Can lead to too much time on trivial matters, diffusion of responsibility and work overload

Complaints

• The frequency of complaints is not an accurate gauge of patient satisfaction
• Incidence
  • 0.26 to 3.8 complaints per 1000 patients
  • ED complaints make up 14% of overall hospital complaints
• Reasons
  • Inadequate treatment 33%
  • Communication 31%
  • Access 26%
  • Administrative deficiencies 7%
• Most common motivations are seeking compensation and assurance that corrective measures will be made to prevent repeat episodes

• Clinical care
  • About 50% of complaints re: inadequate treatment are substantiated
  • Inadequate physical examination followed by missed or delayed diagnosis is a common complaint
  • Missed fractures are the most common missed diagnosis
  • Lack of treatment includes lack of analgesia, lack of X-rays/blood tests/urine tests, lack of antibiotics in subsequent bacterial infection and lack of splinting for ‘soft-tissue injury’ that turns out to be a fracture
• Communication
  • Introduce yourself, explain reasons for examination/Ix/Rv/admission/discharge/referrals or delays are all preventable
  • Failure to obtain informed consent can occur if assumed that attendance implies consent (can be challenged if presented by ambulance or police)

• Delays
  • Steps to improve waiting times, increase short stay throughput and prevent misdiagnosis of fractures have all reduced complaints

Responding to a complaint

• Effectively responding minimises the likelihood of adversity and escalation
  • Early, supportive, open, even-handed and constructive
  • Backed up by a clear, accountable and outcome driven complaints management process supported by hospital administration
• Immediate response
  • Genuine and supportive of right to raise issues
• Get senior involvement early to defuse situation
• Express regret and apologise without necessarily admitting error
• Document complaint and conversations with collateral history from involved individuals
• Determine the issues
  • Underlying issue is key 
• Supporting staff and confidentiality
  • Emphasise that complainant perceived an issue and that all viewpoints will be sought with a view to improving the service and preventing future complaints
  • Systems-based approach to complaints is crucial 
  • Offer counselling support

Resolution of a complaint

• Follow-up letter or interview allows facts to be laid out, any corrective actions proposed and repeat expression of regret
• Must address all issues raised
• 75% of complaints can be addressed/resolved by explanation and apology
• Changes in policy occurred in 2% of complaints and remedial action in 5%
• <1% of complaints involved the legal system

Complaints prevention

• Complaints process should integrate into risk management system
• System design
  • Well-equipped, well-designed and well-staffed ED with clear scopes of practice, analgesia protocols, rest rooms, refreshments and X-ray protocols minimises complaints
  • Verbal information on investigation turn-around times
  • Children and psychiatric patients that do not tolerate prolonged waiting times can be triaged to be seen earlier
  • Systems to follow-up abnormal pathology or imaging results should exist and be audited
  • Protected and formalised handover procedure
• People
  • Polite, well-groomed doctor who introduces themselves, shakes hands, makes eye contact and refers to patients by title and last name reduces complaints
  • Talking out loud any examination findings minimises accusations of inadequate examination
  • Adequate documentation is key

Specific scenarios

• Written formal complaints
  • Acknowledge as soon as possible, ideally within 3 days, together with apology
  • Commitment to investigate and act on any findings
  • Consider early phone call or face-to-face interview before written reply
• Catastrophic adverse events
  • Open disclosure model
    • Expression of regret, factual explanation of what happened, potential consequences and steps being taken to manage the event and prevent recurrence
  • Early informal phase where treating clinician informs patient and expresses regret with follow-up in formal open diclosure involving a trained team for the most serious events

• Grief reactions
  • Provide support, Open Disclosure system and sometimes financial support to facilitate family members to come or accommodation nearby
• Unreasonable requests
  • Try to establish a working relationship and ensure you’re not missing something/collateral history helps
• Persistent complainants
  • Try to own the complaint rather than pass it up the chain
  • Focus attention on conduct, not the person
  • Be firm and clear about what is and what is not going to happen
• Delays
  • Frequent and realistic communication by all staff to explain and predict delays is crucial

Patient safety

• Introduction
  • 1/10 admitted patients experience an adverse event, 50% due to medical error and 1/3 resulting in significant harm or death
  • Day of greatest risk is day 1 of admission
  • 50% preventable (70-80% of ED events are preventable)
  • Result of events
    • 50% minimal disability
    • 15% permanent disability
    • 5% death
  • Equates to 1/250 hospital admissions have avoidable death

• Common safety problems in ED
  • Patient identification: Patient ID, incorrect labelling, transfusion errors, medication errors
  • Hospital-acquired infections: Poor aseptic technique, junior staff performing procedures, poor screening/isolation of infectious patients
  • Misinterpretation of radiology
  • Failure to follow-up lab results
  • Medication errors: Verbal orders, dosing mistakes and compromise of administration of procedures
  • Communication errors: Ommissions in handover
  • Physical care errors: Confusion and falls increased in elderly in ED environment with access block
  • Triage errors: Imperfect science but in a setting of access block, incorrect triaging may occur or correct triaging but subsequent delayed time to be seen/admitted

• Specific ED factors
  • Staff factors: High proportion of juniors/doctors-in-training/rotational/shift-work
  • Clinical factors: Clinical severity (both more at risk and if adverse event does occur may have greater ramifications) and uncertainty
  • Physical factors: Noisy, busy, frequent intrusions/distractions
  • Linkages to other care systems: Poor communication with other services can lead to miscommunication
  • Overcrowding: Associated with increased morbidity and mortality due to resource limitations and delays in time to critical care

• Improving patient safety
  • Understand the environment and types of errors that are occurring e.g. Regular audit/review/M&M + Understand the physical ED environment and what may lead to risks
  • Identify specific risks: Clinical incident reporting systems
  • Report near misses: For every 1000 incidents, 100 will cause minor to moderate harm, 10 will cause severe harm and 1 will cause death. Can learn from near-misses that cause ‘no-harm’
  • Analyse and evaluate risks:
    • Root cause analysis: retrospective of what happened, why and what can be done  to prevent this in the future
    • Failure modes and effect analysis: Proactive modelling of common processes to ascertain where risks lie
  • Treat the risks: Up to 80% of errors are attributable to poorly designed systems that fail to account for human fallibility
    • Make the right thing to do, the easy thing to do and aid the detection of errors if they do occur

Management of patient safety incident

• Senior staff
• Clinical – Immediate medical attention, manage any complications, notify any staff taking over care
• Non-clinical – Explain to patient and carers as per Open Disclosure, reassure where possible, management staff members, document incident and conversations, complete safety system notification
• Australian Open Disclosure Standard
  • Encouraged
  • Limited evidence that reduces litigation, morally obliged, meets ethical/legal standards for health professionals, allows autonomy about ongoing care, meets patient/family expectations, may lead to improvement in service provision and may ameliorate negative psychological consequences of event for patients and healthcare worker
  • Do not admit liability but apologise for what has occurred i.e. I’m sorry this has happened vs. I’m sorry I did this to you
  • Tell them investgiation will commence and that they will be notified of outcome
  • Do not speculate about cause of events
  • Explain potential harms to patient and steps being taken
  • Explain process of investigation and key people/expected timeline 

Root cause analysis

• Root cause is one that removal of will prevent the undesirable outcome with certainty
• A causal factor contributes to the final outcome but removal does not prevent recurrence with certainty
• Four general principles:
  • Define and describe the event or problem (five whys technique)
    • Just asking why 5 times usually reaches root cause
  • Establish a timeline from normal situation until final crisis or failure
  • Distinguish between root causes and causal factors
  • Once implemented and constantly executed, RCA is transformed into a method of problem prediction

Graded assertiveness

• Probe, Concern, Challenge, Emergency

Handover

• Associated with 25% of adverse events
• Important to:
  • Reduce number of handovers through:
    • Decrease length of stay, Shift overlap and encouragement of staff to finish off problems
  • Limit disruptions
  • Concise overview with active issues, clear plan for outstanding tasks and contingency planning

Clinical decision making

• Incidence
  • Missed or delayed diagnoses in 5-10% of acute hospital admissions
  • Higher incidence per unit time is in ED (but more happens per unit time in ED)
  • 1.8% of ED patients (higher in elderly and those with higher acuity)
• Common sources of error
  • Incomplete information
  • Lack of drug information
  • Miscommunication of drug orders or test results
  • Lack of medication labelling
  • Interruptions

• Diagnostic error is the most common cause of adverse outcomes in ED
• Risk factors
  • Incomplete information
  • Need for treatment to commence before all info available
  • Supervision and skill mix of staff
  • Assumptions
  • Unclear responsibility for patient care e.g. ongoing care after admission, patient expects
  • Adverse work environmental factors

Cognitive errors

• Premature diagnostic closure (anchoring)
  • Failing to seek further info or check congruity of diagnosis
  • Significantly influenced by personality and diagnostic momentum
• Errors of omission
  • Failure to obtain necessary information or provide necessary treatment
  • Most common cause of harm
  • May be reduced by additional experience or training
• Confirmation bias
  • Tendency to persist with initial hypothesis despite existence of evidence to the contrary
• Attention coning
  • Tendency to focus on area of comfort or experience
• Representative bias
  • Distorting importance of information based on source e.g. Symptoms of ACS in women put down to anxiety, QAS notes ignored
• Commission bias
  • Tendency towards action when evidence supports inaction i.e. overconfidence
• Availability bias
  • Alteration of estimation of probability due to recent experience
• Ascertainment bias
  • E.g. missing second fracture after finding the first one
• Illusory correlation
  • When 2 things coexist but are not related 
• Framing effect
  • Tendency for benefits/risks to be interpreted differently if expressed relative vs. absolute terms
• Extrapolation error
  • Tendency to generalise treatment experiences and outcomes from trials in a different group of patients

Rules for good decision making

• Be aware of baseline prevalence
• Actively seek reasons why your decision is wrong
• Consider consequences to the patient if you are wrong
• Entertain alternative hypotheses (broadly)
• Retrace logic behind decision (usually easy if a good decision)
• Remember: You are wrong more often than you think

Preventing cognitive error

• Forcing functions
  • E.g. Requirement to enter pregnancy status if ordering CT
• Automation and computerisation
  • E.g. IT systems that notify you of same patient name or adverse drug reactions upon prescribing
• Simplification
  • Reduce number of people involved in task and number of steps to minimum
• Reduce fatigue
• Checklists
• Rules and policies
• Identify high risk situations for diagnostic errors e.g. elderly abdo pain
• Use cognitive forcing strategies in high risk scenarios
• Better to send someone home or admit with no diagnosis than attribute a wrong one

Communication

• Avoid talking to people who do not have the authority to act, when important decisions need to be made quickly – i.e. go to the source
• Avoid excessive redundancy in speech
• Avoid excessive certainty
• Avoid offering reassurance, advise or diagnosis before main problems have been identified and workup complete
• Avoid attending only to physical issues
• Never interrupt at the beginning and only when necessary later on

Discharge planning

• Communication
  • Relatives, place of residence, HITH, community nursing, telephone contact with referrer if management plan significantly different from what was expected or if poor compliance with management plan expected
• Check contact details of patient as often wrong
• Discharge letter with patient (or if not reliable – fax directly to GP)
• Ensure transportation accessible

Unscheduled re-presentations

• Unanticipated return within 48 hours occurs in 3%
• Often have atypical pathology that is difficult to detect
• 20% admission rate on return
• Reasons
  • Patient-related in 50%
    • Failure to understand management – 35%
    • DNW
    • Persistent symptoms of non-serious nature
    • Chronic psychiatric issues
  • Inadequate initial treatment – 15%
  • New diagnoses – 20%
  • Progression of disease despite initial treatment – 15%

Violence

• Risk factors
  • Violence in last 72 hours
  • Male gender
  • Substance abuse
  • Psychosis
  • Personality disorder
  • Childhood abuse
• Hyperactivity is the most important predictor of imminent violence
• Prodromal features may be completely absent in patients with acute psychosis

• Risk factors for organic cause
  • Age >40 with no previous psychiatric illness
  • Disorientation
  • Altered conscious state
  • Altered vital signs
  • Visual hallucinations
  • Illusions
  • Unconcerned regarding personal privacy

Patient management plans

• Must understand vulnerability and complex comorbidities of frequent attenders while adopting a humane approach
• Medical care should follow standard procedures
• Past history and collateral from primary care providers is crucial
• Development and wide dissemination of individualised acute care plans can streamline assessment and management
• ED-based multidisciplinary service provision has been shown to be of benefit for the frequent attender
• Do not reduce ED attendance frequency however
• They actually increase ED utilisation but improve psychosocial factors including housing status, engagement with primary and community-care providers
• The ED may in fact be the best site of care for vulnerable patients and diversion to other services not appropriate

Harrassment complaints (ACEM)

• Maintain confidentiality and involve as few people as possible
• Innocent intent is not a defence
• Informal resolution process
  • Emphasises resolution rather than factual proof or substantiation
  • 1- Self-help: Address unwelcome behaviour directly
  • 2 – Seek assistance
  • 3 – Mediation
  • 4 – Resolution
• If informal resolution fails, can enter formal complaints process:
  • Lodgement, interview with complainant, interview with respondent and interview with as few witnesses as necessary to come to decision
• Disciplinary action may then follow

Duty of disclosure (ACEM)

• A member who, in any jurisdiction:
  • Is charged with a criminal offence
  • Has their name removed from the register of medical practitioners
  • Has any condition, restriction/undertaking or suspension on their right to practice medicine
• Has a duty to inform the college within 14 days of so being charged or of receiving formal notification of such review

Statement on nightshift FACEM (ACEM)

• Concern over detrimental effect on workforce sustainability and burnout
• Need dramatic changes in whole of hospital rostering rather than simply increasing night shift FACEM presence
• Would only serve to exacerbate current inequity between metropolitan and regional/rural FACEM cover
• Need dramatic increase in funding that has not been proposed

Statement on ramping (ACEM)

• Consequences:
  • Delayed access to definitive assessment and care with likely poor outcomes
  • Reduced timeliness of ambulance responses with deteriorating response times to critical and emergent patients
  • Lost ambulance and personnel time with increased costs for overtime and crews
  • Potential impacts on funding for hospitals and ambulance services as affects KPI’s
  • Poor publicity leading to low staff morale
  • Increased stress and interpersonal conflict between patients, paramedics and ED staff
• Need accurate data to identify delays and effectiveness of interventions

• Time to transfer of care should routinely be <15 minutes and never >30 minutes
  • 85% within 15 minutes
  • 95% within 20 minutes
  • 100% within 30 minutes
• An episode >60 minutes should trigger an incident review
• Regular >30 min delays should trigger a systematic review of the hospital and ED

Statement on IV lysis for stroke (ACEM)

• Independent review found administration to selected patients within three hours of symptom onset may increase the odds of a better functional outcome, while at the same time increasing the risk of intracranial haemorrhage and conferring no mortality benefit
• ACEM considers discussion with patient and family/carers by treating clinicians and informed consent is vital to any decision around use
• Must discuss
  • No mortality benefit
  • NNT to achieve excellent outcome (mRS 0-1) is 10 or to achieve functional independence (mRS 0-2) is 13
  • NNTH of 42 (symptomatic ICH) and 122 (for death from sICH)
  • Disagreement around strength of evidence
• Should only occur if stroke service in place with:
  • Access to multidisciplinary acute care team with expert knowledge of stroke lysis
  • Pathways and protocols to guide acute phase management (particularly BP management)
  • Immediate access to imaging and radiology with specialist expertise in neuroimaging

Statement on Access block (ACEM)

• Whole of hospital approach is key
• Increased hospital capacity
  • Physical inpatient bed capacity
  • Improved hospital efficiency through clinical process redesign
  • Over-capacity protocols to share patient load more equally across campus
  • Improving and transparent bed management practices
  • Extending time-based targets to inpatient clinical units
  • Extending hospital function beyond business hours

• Reduced hospital inpatient demand
  • HITH/hospital-in-the-nursing-home
  • Improved access to ambulatory care
  • Chronic disease outreach programs
  • Frequent attenders program
  • Promotion of ARP’s
  • Improved access to step-down residential care
• Evidence-based interventions
  • No evidence for co-located GP practices, telephone advice lines and nurse walk-in clinics

Statement on Culturally competent care (ACEM)

• Cultural safety
  • Patient care in an environment ”that is spiritually, socially and emotionally safe, as well as physically safe for people; where there is no assault challenge or denial of their identity, of who they are and what they need. It is about shared respect, shared meaning, shared knowledge and experience of learning together”
• Cultural competency
  • Set of attitudes, skills and knowledge that allow an individual to interact effectively in cross-cultural situations
  • Requires continual reflection on their own cultural identity and recognise the impact of this on their medical practice
  • Focuses on ability of practitioner to tailor care to the patients’ social, cultural and linguistic needs

• Can:
  • Reduce unnecessary investigations
  • Increase accurate and timely diagnosis
  • Increase adherence to treatment and attendance at follow-up
  • Reduce reluctance to seek medical care
  • Reduce discharge against medical advice rates
  • Lead to better clinical outcomes
  • Improve patient wellbeing

• Take a cultural history of all patients
• Incorporate diverse cultural beliefs and priorities into management plans
• All patients have access to support people according to cultural needs
• All patients are given opportunity to speak to a cultural and/or religious representative of their choosing
• All patients who do not speak English as a first language are provided access to professional interpreter services and information in their primary language, including Indigenous language speakers
• Effective relationships with local primary healthcare providers that care for CALD groups
• Feedback mechanisms in place for consumer engagement that represents the cultural diversity of the departments patient population
• Work ethic of reflection on cultural safety and competence

Statement on NEAT (ACEM)

• Time-based targets are an important part of a suite of tools to promote and monitor health systems to provide timely care for patients
• Hospital overcrowding, and subsequent access block, are the greatest threat to quality acute medical care
  • Adversely impacts hospital performance, efficiency, patient safety, excess deaths, clinical errors, delayed time-critical care and increased morbidity
  • 40% of staff time is spent caring for patients waiting for beds rather than new patients in large ED’s
• Useful tool to drive systematic changes in care delivery and improve patients journeys through hospital
• Not an end in themselves as needs to drive quality, evidenced-based pathway improvement
• Shown to improve overcrowding, hospital function and patient outcomes
• Emphasis on time alone, rather than quality of patient care, can adversely affect patient outcome and staff morale

Statement on overcrowding (ACEM)

• Refers to situation where ED function is impeded primarily because the number of patients waiting to be seen, undergoing assessment and treatment, or waiting for departure exceeds either the physical bed and/or staffing capacity of the ED
• The decision as to whether an ED can safely manage a given patient load rests with the Emergency Physician in charge
• Mainly due to access block
• Associated with adverse events, violent behaviour errors, delayed time to critical care, increased morbidity and excess deaths
• Markers of ED overcrowding:
  • Ambulance ramping
  • Inability to place critically unwell patients in suitable areas
  • Patients undergoing clinical treatment in a non-clinical area, where privacy and resource access is delayed or reduced
  • Admitted patients receiving lower standard of care than they would within the wards
  • Obstruction to access and egress routes from the ED

Statement on Ambulance diversion (ACEM)

• Use has reduced in recent years across jurisdictions with realisation that it does not resolve underlying issues of severe hospital overcrowding at the bypassed hospital; delays and compromises patient care; and leads to domino effect on other hospitals, which then go on bypass
• Any use for overcrowding should trigger internal disaster protocol and should be the subject of a full review after the episode has finished
• Must have exhausted all internal mechanisms to avert crisis
• Should never be for financial reasons and should never be done to protect beds for elective procedures or potential deteriorations
• Must be temporary with automatic return to normal after pre-determined time being the preferred mechanism
• Cat 1 patients should never be diverted

Statement on alcohol harm (ACEM)

• 1/5 Australians drink at level that increases lifetime risk of alcohol-related illness or injury
• 44% of Australians drink at levels that risks acute injury each 12 months
• ED presentations overall increased 3.4% each year for last 5 vs. population growth of 1.4%
• 1/12 ED presentations in Australia are alcohol-related
• At peak times, this rises to 1/8
• 98% of clinical staff have received verbal abuse from intoxicated patients
• 92% of clinical staff have received physical abuse from intoxicated patients
• An ultra-brief screening and intervention to reduce risky drinking delivered in ED has a small individual effect size but the potential for a larger population effect

Protocol development

• Key stakeholders
• Reason for protocol
• Inclusion 
• Exclusion
• Process
• Complications and management
• Monitoring
• Planned audit

Impaired doctor

• Notifiable conduct defined by AHPRA as:
  • Practicing while intoxicated with drugs or alcohol
  • Sexual misconduct in the practice of the profession
  • Placing the pubic at risk of substantial harm due to impairment
  • Placing the public at risk because of a significant departure from accepted professional standards

Last Updated on October 6, 2021 by Andrew Crofton