9-10 May 2006 Melbourne

1. stream (1c)Emergency Department Design Helps the Patient JourneyPresenter: Associate Professor George BraitbergHospital: Austin Health 9-10 May 2006Melbourne

2. KEY PROBLEMS The old Emergency Department was a rabbit warren of added-on space that compartmentalised the Department into non contiguous sections

3. Old Emergency Department Waiting Room 3 Paediatric/ 2 Adult Plaster/Suture rooms Triage 4 procedure beds and 2 chairs 5 monitored 7 general Triage 4 SOU

4. INNOVATIONS IMPLEMENTED • Fast Track • Contiguous Cubicles • All Cubicles monitored • Expanded Observation Unit • Patient Privacy at Triage • Expanded role of Triage Physician • Additional Resuscitation Space and new design concept • Improved Educational facilities • Simulation Room • Radiology on site with designated ED radiographer

5. BURGUNDY STREET AMBULANCE ARRIVALS ICU/OT Lift ER 1 ER 2 Triage Security Waiting Room Fastrack Allied Health and Nurse Ed. Paediatrics Satellite Radiology Staff Base 2 &NIC ANUM/NP Stores and Pharmacy Staff Base 1 Equipment Store Tea Room Admin Entrance SOU/EMU Administration Seminar Room Shops/Foyer STUDLEY ROAD

6. Patient Triage Privacy Waiting Room Patient Triage 2 Patient Triage 1 MDT Room Allowed entry into Triage area

7. BURGUNDY STREET AMBULANCE ARRIVALS ICU/OT Lift ER 1 ER 2 Triage Security Waiting Room Fastrack Allied Health and Nurse Ed. Paediatrics Satellite Radiology Staff Base 2 &NIC ANUM/NP Stores and Pharmacy Staff Base 1 Equipment Store Tea Room Admin Entrance SOU/EMU Administration Seminar Room Shops/Foyer STUDLEY ROAD

8. Studies have shown that for patients who were categorised by triage as non-urgent, the length of stay was reduced for those treated in a streaming system compared with those potentially similar patients who were not streamed

9. Fast Track • Lower acuity case • Fast turn over of patients • Procedures: sutures, casting, splinting, incision/drainage • Must recognize the seriously ill patient • This area of the Emergency Department is staffed by Emergency Medicine residents (PGY3) and Nurse Practitioner/ Nurse Practitioner Candidates. • Fast track is an integral part of the Triage process

10. Fast Track • Studies have shown that for patients who were categorised by triage as non-urgent, the length of stay was reduced for those treated in a streaming system compared with those potentially similar patients who were not streamed • The studies reported streaming systems to be ‘generally safe’ where appropriate triage systems and patient selection criteria are adhered to. • Among patients who were categorised as non-urgent, 22% of those who were streamed expressed negative comments about their visit compared with 79% of those who were treated in a normal A&E setting. NHS data

11. Likely torsion of testicle Paediatric ingestions of poisons in a well child Follow up of eye problems for slit lamp examination Minor wounds requiring only minor interventions such as simple suturing, steri-strips and dressings. Follow up dressings for wounds managed in the Emergency Department previously. Any others for whom disposal is apparent and Emergency Department interventions are likely to be brief. Post LAMP procedure if appropriate nursing available Minor ENT conditions, eg epistaxis, FB etc Simple change of urinary catheter if trolley available Minor orthopaedic patients who could be referred quickly to the Fracture Clinic. Patients with deformed limbs after trauma who need prompt intravenous access and analgesia. Partial thickness burns of less than 10% body surface area, (ie minor burns) Deep venous thrombosis for ultrasound ?Neutropenic oncology patient – for quick intravenous access, antibiotics, bloods to laboratory and referral to Oncology. Fractured nose without wound. Possible facial fracture for x-ray Possible ingested foreign body in children Possible pneumothorax in a well young adult Ardagh MW, Wells JE, Cooper K, Lyons R, Patterson R, O'Donovan P. Effect of a rapid assessment clinic on the waiting time to be seen by a doctor and the time spent in the department, for patients presenting to an urban emergency department: a controlled prospective trial. N Z Med J. 2002 Jul 2;115(1157):U28.

12. BURGUNDY STREET AMBULANCE ARRIVALS ICU/OT Lift ER 1 ER 2 Triage Security Waiting Room Fastrack Allied Health and Nurse Ed. Paediatrics Satellite Radiology Staff Base 2 &NIC ANUM/NP Stores and Pharmacy Staff Base 1 Equipment Store Tea Room Admin Entrance SOU/EMU Administration Seminar Room Shops/Foyer STUDLEY ROAD

13. Direct Ambulance Entrance External Decontamination Internal Decontamination X Ray Control Resus 1 Negative pressure Individual Temperature Control X Ray Gantry Observation area

15. Pendants (correctly positioned and with appropriate services) allow these leads and tubes to be lifted above the general traffic of staff around a critical patient • To allow true functionality, some services must be duplicated on each side so as to prevent criss-crossing of tubes/leads over the patient. • The addition of scavenge in R1 is a requirement of O&HS in the presence of Nitrous

17. Main Areas • All cubicles are monitored • Some cubicles are designated HDU where more senior nursing staff are allocated

18. EMU

19. TV, Shower, bath, 1 nurse per 4 patients 24 hour and 48 hour stay patients

20. Model of Care - EMU Extrapolation of this data indicates the ratio of observation unit beds to emergency presentations ranged from 1:2,330 up to 1:12,882 with an average of 1:7,442 Guidelines from the British Association of Accident and Emergency Medicine were published in 1989. These guidelines stated that the short stay ward ‘is an essential part of every accident and emergency department’ and suggest provision of one bed per 5,000 new attendances. (BAEM 1989 quoted in Goodacre 1998) The Austin therefore needs anywhere from 6– 10 beds. We have settled on 8 • Austin 6% of Emergency Department attendances • Prior to EMU, average daily patient to ward admission rate was 40, now 31)

21. Admission Profile from ED

23. BURGUNDY STREET AMBULANCE ARRIVALS ICU/OT Lift ER 1 ER 2 Triage Security Waiting Room Fastrack Allied Health and Nurse Ed. Paediatrics Satellite Radiology Staff Base 2 &NIC ANUM/NP Stores and Pharmacy Staff Base 1 Equipment Store Tea Room Admin Entrance SOU/EMU Administration Seminar Room Shops/Foyer STUDLEY ROAD

24. BURGUNDY STREET AMBULANCE ARRIVALS ICU/OT Lift ER 1 ER 2 Triage Security Waiting Room Fastrack Allied Health and Nurse Ed. Paediatrics Satellite Radiology Staff Base 2 &NIC ANUM/NP Stores and Pharmacy Staff Base 1 Equipment Store Tea Room Admin Entrance SOU/EMU Administration Seminar Room Shops/Foyer STUDLEY ROAD

25. Separate Waiting Room Separate Procedure area

26. Why have EMU • Save inpatient beds • Increase surgical throughput • Cost efficient • DHS pays WIES and $100 per patient co-payment • Decompress bed blocked ED

27. HOW WE DID IT • The new ED was 3 years in the planning with focus groups and user groups. We were in the fortunate position of having architects listen to us and allowing us to plan our workflow • All Emergency Department staff were involved with 2 members taking on operational management, Fergus Kerr and Keiran Colgan, once “big picture” layout was completed • Key Success Factors: • User groups have a high level of ownership • Executive support

28. LESSONS LEARNT • What we recommend to other hospitals • Walk the floor plan in your head over and over again. • Ask yourselves – how do I get the patient to here? How can I minimise duplication? • What we would do differently • Larger Observation Unit. • Plan for increased activity