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CEM/IFEM Symposium: Quality and Safety in Emergency Care Nov 15-16 London 2011

International Emergency Medicine Perspectives on Quality and Implementation of Best Practice: PERSPECTIVE. CEM/IFEM Symposium: Quality and Safety in Emergency Care Nov 15-16 London 2011 Dr Carmel Crock FACEM

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CEM/IFEM Symposium: Quality and Safety in Emergency Care Nov 15-16 London 2011

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  1. International Emergency Medicine Perspectives on Quality and Implementation of Best Practice:PERSPECTIVE CEM/IFEM Symposium: Quality and Safety in Emergency Care Nov 15-16 London 2011 Dr Carmel Crock FACEM Director, Emergency Department, Royal Victorian Eye and Ear Hospital, Melbourne, Australia & Chair, ACEM Quality Subcommittee

  2. Outline

  3. Population & Emergency Dept Visits Population • Australia ~ 22 Million - 2010 • New Zealand ~ 4 Million- 2010 Emergency Department visits • ~ 6 Million per year Australia • ~ 1 Million per year New Zealand

  4. Australian Challenges http://www.theodora.com/wfb/photos/australia/australia_photos_45.html http://www.ozanimals.com/image/albums/plants/OzPlant/Acacia-pycnantha-Golden-Wattle.jpg

  5. Marine Challenges http://www.iscvid2011.com/images/uploads/snorkel_cairns_greeen_island_great_barrier_reef.jpg http://picasaweb.google.com/lh/photo/yIzUrgSMNvTEbFaNdBidGg http://anakbawang.com/wp-content/uploads/2010/04/Box-Jellyfish-attack.jpg

  6. Terrestrial Challenges http://www.idilium.com/spiders/redback%20spider%203.jpg http://australianmuseum.net.au/image/White-Lady-Spider-Catherine-Jubb

  7. http://images24.webshots.com/25/8/65/103786536xKBuGM_ph.jpg

  8. Everyday challenges City • Ambulance ramping • Access block • Increasing presentations • Access to primary care Country • Staffing rural/remote EDs • Rural/remote ambulance service

  9. Australasian Triage Scale (ATS)

  10. Emergency Presentations Waiting Time Statistics in Major Public Hospitals 2009-2010 • Proportion seen on time 70% • Median waiting time to service delivery 23 minutes • 90th percentile waiting time to service delivery 115 minutes • Proportion ending in admission 27%

  11. Policy on a Quality Framework for Emergency Departments “ACEM recommends all emergency departments should have a documented quality framework.”

  12. ACEMRecommends All Emergency Departments should have a Designated Quality Team with defined

  13. This Team should Include Staff who are

  14. ACEM Strongly Recommends Developing a Balanced Quality Program Policy for EDs

  15. 1. Clinical Profile ED should demonstrate... Regular clinical audits (examples): • high volume or high risk clinical conditions • documentation standards • clinical guideline compliance/variance • consultant sign-off for high risk patients • time to critical interventions • time to analgesia • written discharge instructions • unplanned returns to emergency department

  16. 1. Clinical Profile … • Participation in Clinical indicator collection • Australian Council on Healthcare Standards (ACHS) indicators • ACHS previously 9 for emergency medicine • ACHS increased to 21 in 2011

  17. ACHS ED Indicators 2011 • Critical care patient total ED time > 4hrs • Time from referral from ED to assessment by mental health • Time to antibiotic in sepsis in infant • Paediatric asthma receiving salbutamol < 30 min • Discharge communication to primary care provider • Documented risk assessment prior to discharge patient > 65 years • Documented initial pain score • Documented pain reassessment score • Time to analgesia abdominal/limb pain • Did not waits (mental health/other)

  18. 1. Clinical Profile … Audit of procedural complications Audit of medical imaging/pathology (examples): • appropriateness • turnaround time • results checking * Joint College working parties ACEM - Radiology/ACEM - Pathology

  19. 1. Clinical Profile … Involvement in whole of hospital initiatives (examples): • hand washing • clinical handover • recognition of clinical deterioration • safety survey • procedure for patient identification and procedure matching

  20. 1. Clinical Profile … Participation in national registries, submission of data to jurisdictional / national registries relevant to hospital profile

  21. 2. Education and Training Profile • Departmental educational program - regular meetings, protected teaching time, evaluated • Departmental educational roles • Director of Emergency Medicine Training (DEMT) • Nurse Educator • Accredited training courses, e.g.: • APLS • EMST • instructors, staff who have completed competencies

  22. 2. Education and Training Profile • Medical student teaching and training • Credentialing of staff (e.g.): • ultrasound • procedural sedation • Participation in multidisciplinary, interdepartmental, and pre-hospital & retrieval education

  23. 3. Research Profile • Academic emergency appointments - professor, lecturer, fellow, post grad students • Research grants/awards/projects (internal and external to the department) • Research presentations at scientific meetings (including poster and oral presentations) • Publications by emergency department staff (e.g.): • book chapters • refereed journal articles

  24. 4. Administration Profile • A Designated Quality Team (staff as outlined earlier) • Regular audits (e.g.): • waiting times • death audit • trauma audit • complaints/patient satisfaction • Risk management (e.g.): • formal pathology and radiology results checking process • incident monitoring * with feedback to clinicians • Financial/Equipment/Workforce considerations * Proposal for ACEM- led Incident Monitoring project

  25. 5. Professional Profile … • Liaison with quality and accreditation organisations (e.g.): • Australian Council on Healthcare Standards (ACHS) • Australian Commission on Safety and Quality in Healthcare (ACSQHC) • Australian Institute of Health and Welfare (AIHW) • Participation in hospital committees

  26. Emergency Medicine Training In Australia/New Zealand

  27. Advanced Training 30 month ED 18 months non-ED Basic Training 2 PG Years Provisional Training 1 Year min, 6 month ED min Post Fellow-ship CPD Primary Examination Fellowship Examination Research

  28. ACEM “… recognisesthat a significant number of emergency departments and services, particularly in regional and ruralAustralia, are staffed by medical graduates who may not be specifically trained in emergency care. A commitment to providing more education and training and supervision for these doctors ...”

  29. Certificate/ Diploma of Emergency Medicine … further 12 months supervised clinical practice in approved ED + 3/12 ICU + 3/12 anaesthetics

  30. Continuous Professional Development

  31. Continuous Professional Development • Role of ACEM credentialing -currently 2. Move towards provision of training - future

  32. Research • Trainee requirement – research component • ACEM Research award • Government funding: • triage scale literature review • impact of 4 hour target • Director of Policy and Research • recently appointed • advocacy, external focus

  33. Conclusion • Time based targets – mandatory • New ACEM Quality Framework 2011 –”recommendations” • New ACHS ED Clinical Indicators 2011 –greater emphasis on quality, however non mandatory • Transition phase…..? move towards mandatory reporting of quality indicators alongside 4 hr target

  34. Finally, There are Challenges in How We Measure Quality in the Realities of ED … http://www.news.com.au/top-stories/heart-attacks-in-waiting-rooms/story-e6frfkp9-1111114514878 ACEM http://www.acem.org.au Dr Carmel Crock carmel.crock@eyeandear.org.au http://bluegumpictures.com.au/images/medium/04/04_14867.jpg

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