Here are ten vignettes showing how changes were made in the emergency departments of hospitals taking part in the emergency department collaborative.
Auburn Hospital, New South Wales
Early pain assessment dramatically cuts time to analgesia
Auburn Hospital achieved one of the best results nationwide in reducing time to analgesia during the first phase of the collaborative with the introduction of early pain assessment at triage. This was achieved during a winter period that saw increased presentations and workloads in the emergency department.
Auburn's key achievements
- Demonstrated medical and nursing leadership
- Reduction in time to analgesia
- Introduction of fast track for patients with complication of early pregnancy
Ipswich Hospital, Queensland
Probable admissions spotted early
The Ipswich emergency department team introduced a number of innovative changes during the NICS collaborative. A ‘red spot’ system was introduced to start early assessment processes for patients identified by the triage nurse as probable admissions. Junior staff are required to discuss identified cases with a senior medical officer within 30 minutes of the initial assessment. This initiates ward registrar review earlier and provides for better patient management.
According to the hospital, "continuing with red spot is proving to be a very viable asset in the department. It has worked so well that the Director of the emergency department has furthered the ‘spotting’ system to all potential adult admissions."
Ipswich's key achievements:
- Demonstrated medical and nursing leadership
- An enthusiastic emergency department team
- Improved referral times
- Improved pathology turn around times and reduced inappropriate pathology testing
Redland Hospital, Queensland
Early treatment boosts patient spirits and comfort levels
The atmosphere in the waiting room of Redland Hospital has certainly improved as a result of the national emergency department collaborative. Through the assessment of patients need for pain relief on presentation by a triage nurse, and the early initiation of treatment, patients’ spirits and comfort levels have risen. The nurses in the emergency department noticed that the early pain management improved the atmosphere of the waiting room. Signs are now used in the waiting room asking patients to let staff know of their pain. The location of a ‘nurses tool kit’ in triage provides quicker access to medication and pain protocols. The emergency department team also introduced a program to reduce waiting time for mental health patients.
Redland's key achievements:
- Immediate results from the patients receiving early analgesia
- A 20% reduction in the length of stay for mental health patients presenting to the emergency department
- Development of a strong partnership with the hospital's mental health service
Bendigo Health Care Group, Victoria
Early electrocardiograms cut time to thrombolysis
Reducing the time to thrombolysis to less than 30 minutes for patients presenting to the emergency department with myocardial infarction was one of the projects undertaken by the emergency department of the Bendigo Health Care Group. The team reviewed their patient assessment protocols and have now ensured that the echocardiogram, which is critical for diagnosis, is performed within 10 minutes of admission. The Bendigo Health Care Group has not only achieved its target, but is now looking at an outreach service to the more remote centres.
Bendigo's key achievements:
- Engaged executive support
- Demonstrated medical and nursing leadership
- An enthusiastic emergency department team
- Achieved the target of 30 minutes for time to thrombolysis
- Developed process to spread improvements beyond the emergency department
Women’s & Children’s Hospital, South Australia
Congratulations from oncologist and parents
The Women’s and Children’s Hospital emergency department has made a number of improvements as a result of the NICS collaborative. The emergency department has improved the time for early administration of antibiotics for children who present with febrile neutropenia. The staff are now taking finger prick blood tests, rather than waiting for pathology test results, and parents are advised to apply local anaesthetic ointment to their children prior to coming to the hospital. Importantly, the efforts of the emergency department staff have been noticed, with other hospital departments acknowledging their efforts. They also received a letter from a local oncologist congratulating staff on their efforts and passing on positive feedback from parents.
Women's & Children's Hospital's key achievements:
- Demonstrated medical and nursing Leadership
- Consultation with oncologists to improve processes for management of children presenting with febrile neutropenia
- Early pathology testing to determine antibiotics required
- Target of 60 minutes from first presentation to treatment achieved
- Acknowledgement from other departments on improved care
- Positive feedback from parents
Hornsby Hospital, New South Wales
Strong team focus enables positive change
The Emergency Department Collaborative team from Hornsby Hospital chose to reduce the number of inappropriate pathology tests taken in the emergency department. They applied the ideas for change which were developed through the Rationale Investigation Ordering (RIO) collaborative project - funded through the NICS targeted grant program. The RIO project looked at changing the pathology ordering practices of medical staff to reduce inappropriate tests being performed.
A highlight from the RIO Collaborative was the 'traffic light' system. Hornsby introduced this system so that pathology tests ordered were grouped by colours, indicating the level of authority required for the requested test. This helped reduce the number of inappropriate tests being performed as medical staff knew ‘green’ tests were routine with no restrictions, ‘amber’ tests required the authorisation of a senior medical officer, and ‘red’ tests could only be ordered by consultant medical staff.
Movie ticket rewards were also used as an incentive to have pathology forms filled with correct clinical information. To promote the progress of the project throughout the hospital, a number of staff showed off their talents and created a cartoon strip which was attached to pay slips. The team not only exceeded their target to reduce the number of tests ordered by 25 per cent but also achieved a large cost saving.
Hornsby Hospital's key achievements:
- Strong multidisciplinary team focus for change
- Inclusion of junior medical staff critical for hospital wide acceptance and sustainability of change process
- Successful application of the “Plan, Do, Study, Act” improvement method
- The application of evidence-based practice change into the emergency department setting
- Significant reduction in inappropriate pathology testing in the emergency department
- Significant cost savings to the organisation
The South Australian Story
A state-based approach enables rapid pain relief
The South Australian Department of Human Services provided funding for eight public emergency departments to participate in the NICS emergency department collaborative. This group formed a state-based network, together with two private emergency departments that were also part of the collaborative. They met on a monthly basis to provide support, develop strategies for change and share information. The network proved very successful, reducing the median time to pain relief by 35 minutes from May to October 2002.
The South Australian group also focused on reducing time to thrombolysis. The three emergency departments that undertook this project reduced the overall time to thrombolysis by between 25 per cent to 50 per cent with a 43 per cent increase in patients receiving thrombolysis within 30 minutes. The hospitals developed different models of care that were suited to their own organisation including:
- Treatment initiated by emergency department consultant based on an evidence-based protocol driver
- Treatment initiated following consultation with cardiology in the emergency department
- Introduction of a cardiology flying squad initiating treatment in the emergency department
The network's key achievements:
- Key executive sponsorship of the network
- Strong support and endorsement from the South Australian Department of Human Services
- Overall reduction in time to analgesia for participating emergency departments
- Overall reduction in time to thrombolysis achieved for South Australia
- Development of ongoing professional network for improvement in emergency care
The Sydney Children’s Hospital, New South Wales
Nurse initiated analgesia cuts time to pain relief
The Sydney Children’s Hospital has a strong evidence-based approach to care, which combined with the quality improvement skills acquired through the emergency department collaborative, has led to some remarkable improvements in its emergency department. The hospital focused on reducing the time it took to offer pain relief to children presenting to the emergency department. Although they were already achieving a time of 30 minutes prior to joining the collaborative, they set an ambitious target time of 15 minutes. With the introduction of a nurse-initiated analgesia protocol, which enabled nurses to provide prompt pain relief, they not only achieved their target but have sustained it beyond the end of the formal collaborative period.
The team were excited by their results and commented, "We have finally implemented nurse initiated analgesia, with many patients receiving analgesia within five minutes of triage. There is still potential for improvement as more nurses complete the learning package and come on board."
The team continued to use the quality improvement skills gained through the Collaborative for the introduction of an evidence-based oral rehydration protocol for children with suspected gastroenteritis. This protocol aims to expedite the care in emergency and educate parents in the use of this technique at home.
Sydney Childrens Hospital's key achievements:
- A strong multidisciplinary team approach
- The application of quality improvement methods to introduce evidence-based guidelines
- A strong focus on improving patient care by a high achieving team
- Providing families with information and guidance for the management of gastroenteritis
Westmead Childrens Hospital, New South Wales
Fast track system lifts parent's confidence in care
The Children’s Hospital at Westmead was one of four paediatric emergency departments that participated in the NICS emergency department collaborative. While other emergency departments in the collaborative were aiming to reduce the time to pain relief for patients on admission, the Children’s Hospital at Westmead was already achieving well below the collaborative target time. Consequently, they decided to focus on reducing the waiting time for treatment for children presenting with simple conditions and minor injuries. The team introduced a fast track model of care, where children presenting with simple conditions are managed by a nurse practitioner who has advanced levels of clinical practice skills. This caused a dramatic reduction in the average waiting time for some children, from 110 minutes to 40 minutes, and also reduced the number of health professionals children saw in one visit. Feedback indicated that this new system gave parents more confidence in the care provided.
Westmead Childrens Hospital's key achievements :
- Strong nursing leadership with medical and executive support
- Introduction of the nurse practitioner role in the emergency department
- A patient-centred process that included educating parents on the management of their child’s condition on discharge
- Streamlining patient care with reduction in patient waiting and discharge times
- Sustainable processes achieved by using permanent staff to manage the fast track care
Armadale Memorial Hospital, Western Australia
Staff dedication and fast track system sustains reduced time to pain relief
The Armadale Memorial Hospital produced outstanding results in reducing time to pain relief, as part of the collaborative. The hospital’s new emergency department had experienced a 30 per cent increase in patient numbers over two and a half years, causing increased waiting times for patients with simple conditions, staff stress, and customer complaints. Through participation in the collaborative, the team achieved its target of cutting time to pain relief to 30 minutes, a result which saw them become one of just seven EDC sites to achieve a greater than 50 per cent improvement in the time to pain relief. Importantly, the hospital continued to sustain this improvement beyond the initial collaborative period.
The Armadale team also introduced a fast track system to streamline care and reduce patient waiting time for treatment. This system, where a nurse or doctor is dedicated to managing patients presenting with simple conditions, was introduced on the weekends and public holidays (times of high demand). Despite increasing numbers of people presenting to the emergency department, the number of patients that did not have to wait for treatment remained constant. In addition, waiting times for patients with more acute problems did not increase.
During the collaborative, not only did patient surveys indicate an increased level of satisfaction with the care provided, but a staff survey showed an improvement in staff performance and morale. Patient complaints were also halved.
The changes implemented and sustained at Armadale’s emergency department have been noticed, with other Western Australian hospitals interested in learning from their experiences in improving patient care.
Armadale Hospital's key achievements:
- Highly motivated emergency department team
- Strong executive sponsorship
- Increased patient satisfaction and improved staff morale
- Increase in staff measuring effectiveness of treatments and actively seeking evidence to improve care
- Reduced time to pain relief six months sustained beyond the Collaborative period
- Halving of patient complaints
Further information
For more information on these stories, or on the emergency department collaborative program, contact Sue Huckson on (+61 3) 8866 0410 or email emergencycare@nhmrc.gov.au.