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Some advice from the ED of the year

There are lessons for everyone inside the Australasian ED of the year.

Being at the forefront of innovative service delivery is key for any emergency department – and that’s exactly what Sydney’s Prince of Wales Hospital’s ED is striving for.

The results of a two-year remodel and redesign of services has led to the PWH team being named the Australasian ED of the Year, with one of the group taking home the Australasian ED Nurse of the Year accolade.

The team at the PWH emergency department sees more than 54,000 adult patients a year. The ED has 89 registered nurses and 69 medical officers.

“It’s an extremely busy ED and the expectations that people are in and out of the department really quickly put lots more strain and stress on best practice,” says Elizabeth Ryan, nurse manager of the PWH ED. “It means we need to have good practices in place to make sure that what we do is safe.”

Clinical nurse consultant Wayne Varndell, who was recognised with the individual honour for his commitment to leadership in educating colleagues, believes that emergency departments need to focus more on building systems that can adapt to the local community needs and demands.

“ED is the front door to every major discipline and specialty out there,” he says. “We are primarily responsible for the resuscitation and stabilisation of patients and we need to improve our communications with our inpatient team specialists.”

Ryan, Varndell and the entire ED team undertook five key projects over the last year. Here, Nursing Review explores each specific areas of focus to discover what this award-winning group has implemented.

Care tailored to the patient demographic

The PWH emergency department sees 15,000–16,000 out of area or overseas patients a year. These clients are often unable to access local primary care or continuous care arrangements.

To help these patients, the leadership team has set up a review clinic within the ED that is staffed by three extended-practice nurses. EPNs can review patients, augment treatment and escalate or discharge patients from the service.

“There is a lot of discussion [in EDs] about access block – where patients can’t get access to wards,” Varndell says. “However, we also suffer from exit block – how do we get the patients out safely? So the review clinic is a safety for that.”

Review clinics are common in the UK and often bridge the gap between primary and secondary care. In this instance, it prevents patients being “lost to the healthcare system”.

The review clinic now has 24 appointment slots a day, with additional appointments available from 8am. The clinic also provides outpatient services for specialist teams over extended public holiday periods when the main outpatient department is closed.

According to the group’s submission for the award, “through negotiation with executive sponsors and nursing administration, an application to augment the emergency FTE to permanently incorporate the ED Review clinic and EPN role has been accepted”.

This will now be an alternate development pathway for nurses within the ED. The team has education and training materials specific to the role, and a publication has been drafted for submission to the Australasian Emergency Nursing Journal.

The ED navigator

In order to help people move through the facility more efficiently and improve performance against national targets, the team introduced an ED navigator. The role, which commenced in February 2014, is filled by a senior nurse on an eight-hour shift.

Of the 10,075 patients who presented to the ED from midday to 8:45pm between February and May, 3423 had involvement with the navigator during their visit.

Patients managed by the ED navigator were admitted in far less time after arrival than those who didn’t see them. Furthermore, when the navigator was on duty, there was a reduction in the length of stay for discharged and admitted patients.

Having the navigator as part of the team has improved patient flow, quality of care and bedside support for nursing and medical staff, Ryan says. She was sceptical at first about the impact of the role but now highlights the value it adds to the patient experience.

“Introducing the navigator has meant that someone can really focus on the patients,” she explains. “They assess patients once they have been in the department for two hours and have discussions” with the patient about their treatment and the medical staff or treating teams.

“They can fast track further investigations and/or treatment and encourage the wards to take their patients more promptly,” she continues, confirming the position has been very successful, and the team is now recruiting someone to fill the position permanently.

Focus on the aged

Prior to the start of the Age Care Emergency Service, patients from local facilities made up about 16 per cent of all presentations.

ACES was developed to streamline services and care for residents within aged-care facilities. This nurse-led service, made up of a clinical nurse consultant and the on-duty ED admitting officer, involved the duo working with local facilities and their attached GPs.

Throughout the first six weeks of the project, the average length of stay for the 355 patients who came to the ED from RACFs dropped from 5.8 hours to 3.8.

On top of this, another 109 patients avoided a trip to the ED – being treated collaboratively by ACES and community care providers.

“We managed to keep over 80 per cent at home and actually reengage the GP services as well as the services the hospital provides on an outpatient basis,” Varndell said. “This project – which unfortunately has to cease after six months – had a fantastic impact and we are looking to negotiate funding for it again.”

Quality improvement

Leading improvements in patient care is a top priority of the PWH ED. However, busy clinicians often don’t find the time to conduct such activities.

To combat this, the team has implemented a quality projects officer – to oversee implementation of the quality framework as well as create and implement systems to monitor improvement activities.

“The quality officer, who is not a nurse but is employed by our department, has been really good at keeping us all on track and co-ordinating a lot of activities,” Ryan says. “It has been really good to have that co-ordinated – especially with the new national standards where there is an audit for absolutely everything. [It’s great] to have somebody doing an umbrella view of the department and where we are up to with different projects.”

This part-time position has been funded for another 12 months.

Professional development

Staff keeping up to date with evidence-based practice, updating skills, and ensuring ongoing access to education are critical to making sure the ED runs smoothly.

PWH ED has implemented eLearning to help nurses extend their scope of practice. Each module is portable across multiple platforms, including iPhone, Android, iPad and PC.

Students are able to do each module at their own pace, and Ryan confirms this has been successful in motivating staff to complete further studies.

Those who have then chosen to complete tertiary-level qualifications have also been supported through a practical in-house program. It focuses on elements including writing for scholarships/grants, identifying and interpreting research, academic writing and more.

“In the last two years, we have had 25 of our staff go on to do specialist emergency qualifications, either at master’s or graduate diploma level,” Ryan says. “The staff who have gone on to do their master’s have all graduated with a distinction average – something to be very proud of.

“[Varndell], in particular, and our nurse educator, are both fantastic mentors for our staff and really encourage [them to pursue] further tertiary qualifications.”


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