By Jane Senior ECI Advanced Trainee Introduction Who am I? Why - - PowerPoint PPT Presentation

A descriptive study and evaluation of a contemporary team based model of care introduced by Australian emergency departments in response to time based access targets

By Jane Senior ECI Advanced Trainee

Introduction

• Who am I?
• Why research team based care?

Methods

• Literature research‐ only 4 papers identified as

relevant, none of which were Australian based

• Pilot Study‐ 3 known ED

Objectives

• To describe a new “team based” model
• To describe any changes to routinely collected

ED performance data

• Discover other information including

perceived effectiveness and impact on ED quality of care

Study design

• Retrospective descriptive study
• Survey‐ 24 questions
• ED directors or representative
• 35 ED invited to participate

‐included Top 10 major metropolitan and major regional of the National Health Performance Authority ranking of ED by compliance with NEAT Jan‐March 2013 ‐other ED known

• 20 confirmed to be working in a TMOC and agreed to

participate in study

Emergency Departments Surveyed

• The majority of the surveys

were completed by the director of ED (13/18)

• 5 of the 7 states/territories

were represented

• Most were mixed departments

(12/18), the remainder seeing adults only

• Majority of ED working in

TMOC are classed as major referral (12/18)

• Majority saw >60,000 patients

per annum (14/18)

Reasons for changing to TMOC

• 10/18 had only been

working in a TMOC in the last 12months

• 5/18 in 1‐3 years
• 3/18 greater than 3 years

“many issues were seen as driving this- clearly NEAT”, “expectations from admin about meeting NEAT” and “Essentially imposed from above”.

The Team

Half the teams were made up of Doctors only and the other half composed of Doctors and Nurses.

Who participates in the team

• Average number of total members in the team for doctors was 5 in both the day and evening

shifts and 3.7 during the night shift. (sample size 18)

• The average number of nurses working in the team was 3. This was consistent at all times of day

(sample size 9)

Operational information

Team members were identified electronically (10/18), by coloured stickers (7/18) and on the whiteboard (3/18)

“we use coloured labels that clasp onto the uniform as the stickers stuck to the floor of the department instead!”.

Patients were allocated geographically (8/18) or sequentially (8/18)

“for the fast track patients are allocated geographically but for the main department they are allocated sequentially”

• During weekdays Monday

through Friday half (9/18) the ED worked 24 hours a day as a team with the other half (9/18) working extended hours (8‐23hrs) “variable and depended on available staffing” “not at all at weekends or on public holidays”

• During the day there were

many more teams with 5/18 having 2 teams, 8/18 having 3 teams, 4/18 having 4 teams and 1/18 had 5 teams.

Impact on ED performance data

2 4 6 8 10 12 14 16

NEAT overall increased %DNW reduced Average time to being seen by a Doctor reduced Triage wait times reduced Time to admission decision from triage reduced Doctors satisfaction improved Nurses satisfaction improved Doctors sick leave reduced Nurses sick leave reduced

ED performance data

Yes No Don’t know

What is the most important aspect of making the TMOC work?

“TBC needs both an adequate number of senior decision makers, and enough junior doctors to effect the instructions given” “adequate numbers of staff- junior and senior” “All the above are important- important not too fragment effort and concentrate in main ED where all can be monitored”, “all of the above are important parts of the model” “Executive buy-in”

When does the model become ineffective?

Only 6 of the 18 employed more staff “had employed more staff but that was to deal with increasing presentations not purely working in the TMOC” “Currently requesting additional registrar and nursing staff to make model work better” “this is the main reason why it has had little impact” Staffing

• less effective at night due to reduced

numbers

• when there are members missing
• reduced junior staffing numbers make it

less effective

• when not enough staff to put teams

together

• Night time‐ less staff, more junior staff
• If the team is too small for the number of

patients it needs to see

• Staff sick leave. Doctors then need to

cover multiple areas

• Model suffers if one or more shifts unfilled

due to roster shortages or sick leave

• Yes, when there are doctors off sick

ED overloaded / surges

• at times of surge multiple patient moves

made double handling an issue

• Periods of continuous peak demand
• When surges of patients lead us to be

swamped

• where ED is overloaded and too many

patients in the waiting room and no where to see them

• doesn't work well when access blocked
• We have 2 acute teams and one Fast Track /

Paediatric team, with slight staffing differences....depending on the flux of patients and which area is busy mismatch of resources can be an issue.

• lack of flow
• sudden influx of patients, the teams become
• verwhelmed. This is a common occurrence.
• Bizarrely, sometimes less pressure on individual teams to function. Individual team

members may not realise that department out of control Senior role

• When the senior person on duty does not

support the role

• does depend on quality of registrar leadership

in team ‐we try to have a more experienced reg.

• n each team but leadership skills vary
• Don't always have ED consultant for every team
• Sometimes when there are too many seniors in

a team there is lack of clarity as to who the team leader actually is

• There is an expectation that the juniors will do

the "grunt work" after senior decision making input

• The seniors need to accept that 1: there should

be one defined leader for each period and this leader needs to be identified. 2: that they may have to assume primary care for patients

What can be done to improve the model?

Staffing

• adequate staffing
• increased senior staffing,
• more senior staff,
• consistent senior staff
• greater seniority of the team leaders
• improve sick leave cover
• bigger teams to help with surges
• 24/7 flow coordinators
• more nurses
• extend to nursing staff (but they are fixed
• n geographical allocation rather than

team)

• We are about to trial a geographical

model in the main arena with a team of doctors/nurses per side Team

• more direct supervision of the team

approach

• team specific stats

Beds

• ED renovation/redesign could improve

geographical team based care

• better inpatient buy in
• enough beds in ED
• available inpatient beds

89% believed that the TMOC had improved the quality

• f care in the ED
• I think it makes it much more personal

experience for junior medical staff and they tend to identify with their team ‐ I think a well functioning team provides better quality care

• 15% improvement in NEAT overnight from

55% to 70% Sustained and improved (range 70‐80%) since. Average LOS decreased 1 hour!! (saving of 200 pt hours per day)

• But not all of the Emergency Physicians

believe this to be the case

• much better accountability, less hiding

from workload, early decision making and involvement of seniors, better work flows

• Clear communication and tasking are

important.

• It is much easier to manage a small group
• f 4‐5 clinicians rather than 15 ‐18.
• Team care as opposed to sequential care

means that the patient is not endlessly repeating the same story.

• There is some healthy "competition" to

ensure that your team's patients are seen and sorted and there is some anecdotal evidence that this improves overall compliance.

• Team based models work as long as there

is work done around leadership and role delineation.

• Teams in Emergency departments are
• ften dynamic in view of the individual

members.

• It is important that the team leaders

understand the needs of the team and are effective in coordinating activity in order to be efficient as well as effective

Conclusions

• 89% felt working in a TMOC had improved quality of

care in ED

• Larger ED
• Average size of the team 5‐9 participants although

not enough information to make recommendations about size or makeup

• Adequate staffing and an effective Senior leader are

seen to be a strong marker to make the model work

Acknowledgements

• NSLHD Human Research Ethics Committee
• Dr. Sally McCarthy – ECI
• Matthew Murray – ECI
• Dr. Robert Day – RNSH
• Dr. Paul Preisz – St Vincent’s
• Dr. de Villiers Smit – The Alfred

Questions?