HM_DECEMBER_08_p24-25:HM_issue4_07-template 10/12/2008 12:49 Page 24 How to achieve the impossible in an Emergency Department Dr. Phil Munro describes how a programme in Glasgow to admit or discharge 98 per cent of all Emergency Department patients within four hours from time of registration was successful beyond all expectations W When the Scottish Government Health Department (SGHD) unveiled the Unscheduled Care Collaborative Programme it was met with equal measures of enthusiasm and trepidation. Our target for December 2007 was that 98 per cent of all Emergency Department patients should be admitted or discharged within four hours from time of registration. An interim target of 95 per cent was to be met by December 2006. This was an ambitious (and indeed many felt impossible) target, but we now had a clear governmental and managerial mandate to achieve this and were tasked with addressing it in our own hospital and across Glasgow. Those of us working in emergency medicine saw it as tremendous opportunity to improve the speed and efficiency of patient services. We also saw it as a potential means of securing additional resources for emergency care in a climate where for many years large amounts of funding had been poured into elective care and waiting list initiatives. It soon became clear that, at least in the short term, no major investment was likely other than in IT support and management facilitation of the programme. Having been interested for some time in the concepts of “lean” as applied to emergency health care I felt there we had to initially explore resource – neutral process redesign. 24 Information The first component addressed was that of information. We had been closely monitoring our ED waiting times for several years and noted their depressingly inexorable decline. Despite some increase in staffing and a high quality teaching programme, we were faced daily with spiralling problems of “exit block”; a term used to denote patients on trolleys awaiting admission to an in-patient ward. Sequential lines in the sand about patients spending overnight on trolleys in the ED had been crossed and we were seeing the resultant rise in critical incidents and complaints. We needed to present the information in a clear, easily charted and unambiguous fashion. Fortunately the SGHD had been careful to define “admission” such that we could not simply call a hallway or storage room a ward and move trolleys in to these areas thus “stopping the clock” as had occurred elsewhere in the UK. We used three primary measures; percentage of patients seen, assessed, treated and discharged from the emergency department within four hours of registration; the number who were not discharged or admitted within four hours (“breachers”) and also initially patients who breached 12 hours. These were used to performance manage the ED as well as inpatient specialties and clinical service managers by subdividing them into minor injuries, medical and surgical “flows”. A crucial aspect was that these had to be seen as “whole hospital” targets and not simply an ED problem. From the outset, we were careful to produce regular accurate performance figures and disseminated these very widely to all areas and specialties. Initially these were distributed monthly, then weekly, then daily and, at the time of writing, we are updated twice daily with a table of the performance of our nine regional hospitals. Clinical leaders We then set about improving all aspects of patient management, carefully involving clinical leaders, senior managers and support services. We tried to incorporate lean principles of reducing duplication, reducing waste, adding value and simplifying or abolishing queues where possible. These included: Value Added Triage to avoid triage simply acting as a meet and HM_DECEMBER_08_p24-25:HM_issue4_07-template 10/12/2008 12:49 Page 25 Emergency | targets greet or at worst a bottleneck. We taught nursing staff to order selected x-rays according to strict criteria, dispense simple painkillers and to be able to redirect specific patients back to their general practitioners. A demand analysis from arrival times in the emergency department allowing us to rearrange our medical staffing to better match workload. For example we moved staff from the less busy Thursday and Friday afternoons to the much busier Monday and Tuesday evenings. Removing the general medicine interns from the ED as they did not make decisions on admission or discharge and their work was subsequently duplicated by one or more levels of more senior staff before patients were moved on. Separating minor injuries into a separate stream and ring fencing Emergency Nurse Practitioners (ENP) to see, treat and discharge these patients. As a result minor injuries continue to be processed efficiently even when complex resuscitation cases were consuming senior medical resources. Creating a new ED admission document along with our colleagues in general medicine to act as an admission note for up to 72 hours. This dramatically cut duplication of admission paper work and streamlined the whole process of emergency admission. Creating a work board for portering staff to coordinate and prioritise tasks along with the nurse in charge of the ED. Combining all patients arriving with a general medical complaint (the most common group requiring admission) into a single queue. Previously, patients referred by general practitioners were seen separately by in-patient teams. By removing this distinction we were able to move to patients being admitted or discharged after a single complete assessment in the ED as opposed to two or more before a decision was made. Establishing a daily bed meeting led by our bed managers and attended by senior medical and nursing staff from the ED, senior nursing staff from the main admitting wards. These involve a rapid review of the previous day’s performance, current bed states including expected discharges, planned admissions and predicted emergency admissions resulting in a daily plan which is shared with our clinical services managers. Allocation of Estimated Date of Discharge (EDD) for each admitted patient. This can be identified within 24 hours in most cases and is flexible enough to change if the patient’s condition alters. Patients and their relatives are given written and verbal instructions that discharges will normally be before 12 noon on the day of discharge. Commitment These required no substantial investment other than a commitment to change and the enthusiasm of the medical, nursing and managerial staff to make these systems sustainable. We have subsequently invested in increased staffing for our ENP service to ensure consistent manning and we created a nine bedded Clinical Decision Unit (CDU) where highly selected medical patients are processed in a nurse-led protocol driven short stay unit (currently open Monday to Thursday). This resulted in an approximately 24 hour reduction in the length of stay for these conditions and along with the use of EDD has virtually abolished boarding medical patients into surgical wards. It is important to acknowledge our failed initiatives including a patient discharge lounge and a trial of rapid access consultant clinics to provide an alternative to admission that had no impact at all on throughput. Despite this the programme has been successful beyond all expectations. From August 2005 our average ED annual attendance rose from 46,000 to 47,887. During this time our average performance against the four hour target rose from 84.7 per cent to 95 per cent and at the time of writing it is holding steady between 98 per cent – 99 per cent. ‘‘ We could not simply call a hallway or storage room a ward and move trolleys in to these areas thus “stopping the clock” ’’ The clear message I would give to anyone faced with seemingly intractable problems of ED waiting times, exit block and lack of emergency admission capacity is that an identical situation was considered impossible to fix in Glasgow. Some investment in staffing and targeted interventions will be required but dramatic improvements can be achieved with creative re-engineering of admission processes led by a committed clinical and managerial team. [DR. PHIL MUNRO Consultant and Honorary Clinical Senior Lecturer Emergency Medicine Southern General Hospital Glasgow Phil.Munro@ggc.scot.nhs.uk 25