Introduction for clinicians and Additional Patient & Stay Characteristics

1. Stage 2 Introduction for clinicians and Additional Patient & Stay Characteristics www.ihpa.gov.au

2. Current Classifications for Emergency Care Current emergency care classifications used for ABF: • Urgency Related Groups (URG): based on triage, disposition and diagnosis • Urgency Disposition Groups (UDG): based on triage and disposition Both considered interim classifications

3. Current Classifications for Emergency Care Limitations of URGs and UDGs • Both rely on triage • Good indicator of urgency, but not complexity and/ or severity • Principal purpose is to manage workflow and prioritisation within emergency departments • Inconsistency in its application between emergency departments (i.e. urgency is a relative concept) • Both rely on disposition • Inconsistent with goal of avoiding admission where this is appropriate (i.e. does not reflect additional resources that may have gone in to treating a patient to avoid admission) • Other • Limited clinical meaning

4. Investigative Review Investigative review of classification systems for emergency care commissioned by IHPA in 2013 • Reviewed classifications developed/ used in Australia and other countries • Extensive clinical consultation • Analysis of existing cost data • Conclusions: • New classification needed to replace the URGs/UDGs • Should be based on a high quality costing study • Need to ensure any new data elements required for the new classification are able to be collected efficiently, minimising the impact on clinicians in particular

5. Aims of Current Study The current study involves both a costing study and development of a classification system. Key aims of the costing study: • Significantly improve estimates of costs at the patient level (emergency department stay) compared with current NHCDC. • Collect information on patient characteristics (in addition to those routinely collected) that has the potential to explain variation in costs between patients. • Review routinely collected information submitted towards the study to ensure that it is good quality. Key aims of the classification development component: • Develop, empirically test, and recommend a classification for emergency care which improves: • Explanation and prediction of variation in cost of emergency department stays. • Clinical meaning.

6. Data collection components • Part A: Service level characteristics • Examples: • General characteristics • Staffing levels by shift • Configuration (e.g. number of bays, treatment areas) • Part B : Clinician time • Collected over a 2 week period • Time allocated by patients • Time by types of activity/procedure • Part D : Cost data • Emergency department stays • Inputs for costing systems • Subsequent admitted patient episodes • Part C : Patient/stay characteristics • Routinely collected data: • ED stay: presentation date/time, clinical care commencement date/time, ED diagnosis • Subsequent admission: admitted patients NMDS • Additional data • Collected over a 4 week period. e.g.: • Diagnosis modifiers • Investigations/procedures • Time by treatment area

7. Additional Patient & Stay Characteristics Why new data elements? • The 2014 Investigative review of classification systems for emergency care indicated the need for: Greater prominence given to measures of severity, assessment and treatment complexity, co-morbidities and dependency. • Consultations indicated a need to consider a range of potential classification items, including presenting problem/complaints and procedures/investigations. • The intention is to test these additional items together with those already routinely collected, to identify which work best in explaining and predicting variation in cost, and also which contribute to improving clinical meaning of the classifications. • The study also provides an opportunity to examine data collection effort of these items.

8. Additional Patient & Stay Characteristics * Expected to be routinely collected by most sites ** May be routinely collected by some sites

9. Presenting Problem Presenting problem/complaint • To be tested as potential predictor of costs • Small number of presenting problems account for large proportion of cases • Evaluate the suitability of the study list for national collection Collection of presenting problem data • Currently collected by triage nurse and/or first attending clinician • Current collection methods may be updated for study • Local codes mapped where possible • Code set to be used instead of free text

10. Additional Diagnoses Additional diagnoses • Help assess the shift from urgency toseverity/complexity • Aim is to collect this where it impacts the emergency department stay, for example: Primary diagnosis: Hip fracture Additional diagnoses: Delirium Collection of additional diagnoses • There is a capacity to collect these in most, but not all ED systems. • However, the extent of actual recording is mixed. • Through the four-week study period, participating sites will be required to improve the collection of additional diagnoses.

11. Diagnosis modifiers Guidelines for collection: • Required element • Yes/ present, No/ not present, or N/A • Derived from, and substantiated by, clinical documentation • Not applicable used for Dead on arrival, Died in emergency department,Did not wait to be attended by a health care professional

12. Diagnosis modifiers

13. Diagnosis modifiers

14. Diagnosis modifiers

15. Diagnosis modifiers

16. Diagnosis modifiers

17. Procedures/activities (EXAMPLES) The following are examples of procedures/activities on which data will be collected for this project. Please note these lists are samples only, and not an exhaustive list – please refer to the Data request specification for the full list of procedures/activities and relevant codes Life support/respiratory 1 Assisted ventilation 2 Basic life support (CPR) 3 Cardioversion/defibrillation 4 Endotracheal intubation 5 Endotracheal extubation 6 Thoracotomy/internal cardiac massage 7 Initiation/management of non-invasive ventilation (CPAP/BIPAP) 8 Management of intubated patient Anaesthetic 10 Procedural sedation 11 Regional block 12 Ischaemic (“Bier’s”) blocks Cardiovascular 20 Arterial cannula 21 Administration of blood/products 22 Central line 23 External cardiac pacing 24 Pacing wire insertion 25 Ionotropic or blood pressure lowering infusion 26 Rapid IV fluid resuscitation 27 Peripheral IV insertion (IVC) 28 Thrombolysis 29 ECG

18. Additional activities - Nursing 130 Triage 131 Initial nursing assessment 132 Clinical observations 133 Clinical discussion 134 Third party conversation 135 Nursing summation and disposition 136 Other bedside nursing care and doc. 137 Nurse chaperone 122 Family conference 123 Handover 124 Supervision/teaching 125 End of life discussion – patient &/or family/carer Medication administration 90 Administration of insulin (IV or SC) 91 IV medication dispensing, administration, checking 92 Oral medication dispensing, administration, checking 93 Verifying and dispensing controlled medications (e.g. opioids) 94 Patient controlled analgesia (PCA) set-up Procedures/activities (Examples) Regional procedures 30 Abscess/collection aspiration or drainage 31 Chest tube/catheter/thoracostomy 32 Fracture/dislocation reduction 33 Splint or sling application 34 Plaster (POP)/backslab application 35 Walking aid dispensation (incl. pt educ.) 36 Bandaging/strapping sprained joint 37 Foreign body removal 38 Eye irrigation 39 Joint aspiration 40 Lumbar puncture 41 Nasal packing/cautery 42 Nasogastric/PEG tube insertion 43 Pleural aspiration 44 Suprapubic catheter 45 Urethral catheter 46 Vaginal speculum examination 47 Rectal examination 48 Wound suture/stapling – simple 49 Wound suture/stapling – complex 50 Wound gluing 51 Wound cleaning and dressing 52 Peritoneal aspiration 53 Advanced patient cooling/warming setup

19. Procedures/activities (Examples) Diagnostics 80 Ordering a diagnostic test (imaging, pathology) 81 Image ordering with radiology consult 82 Blood specimen collection 83 Non-blood specimen collection 84 Clinical ultrasound (bedside) 85 Bladder scan (ultrasound) 86 Laryngoscopy (flexible or rigid) 87 Oesophagoscopy/gastroscopy (flexible or rigid) 88 Sigmoidoscopy/colonoscopy (flexible or rigid) 89 Other point of care diagnostic tests, measures or investigations Additional activities – Medical 110 Initial treating clinician bedside evaluation 111 Initial treating clinician synthesis & documentation 112 Additional treating clinician bedside evaluation 113 Additional treating clinician synthesis & documentation 114 Third party conversation 115 External clinician phone consultation 116 External clinician in-person consultation 117 Initial senior assessment 118 Senior review – verbal only (advice to treating clinician) 119 Senior review – patient examined 120 Medical escort to and from imaging/CT or ward 121 Treating clinician summation and disposition 122 Family conference 123 Handover 124 Supervision/teaching 125 End of life discussion – patient &/or family/carer