Faster transfers from the emergency department to the ward

1. Faster transfers from the emergency department to the ward Innovation Poster Session, HRT1215 – Innovation Awards Sydney - 11th and 12th Oct 2012 Auckland City Hospital Presenter: John McTaggart 1-1c_HRT1215-Session_McTAGGART_ADHB_NZ

2. The problem • The time taken to transfer patients from the Emergency Department to a ward, once a bed was available, was too long • It took an average of 70 minutes, and only 24% of patient transfers were completed within our target time of 30 minutes • This created a poor patient experience, created inefficiencies and impacted on the overall flow of acute patients • Some improvements had been developed and implemented that had made a shift in performance, but opportunities still existed to further improve.

3. The approach – Rapid Improvement Event (RIE) What is a RIE? A 3 to 5 day event that commences with a business problem and concludes with an approved, and in many cases, implemented solution. When to use it? When there is urgency associated with solving a problem Who’s involved? • A cross-functional team of people who understand the process, and • An approving panel of senior managers who are ready, willing and able to authorise the recommendations of the team • Key Success factors of a RIE • A Sponsor who wants to see things done • An Approving Panel who is prepared to support the work of the group • A problem that requires an immediate solution and that allows implementation of solutions within 1 day • Issues that can be broken down into manageable and realistic recommendations and action plans • Participants who represent a cross section of the impacted parties and who are willing to work openly and collaboratively • Clear accountability for the solutions • Realistic, clearly identified ‘no-go’ areas • Experienced facilitators who are passionate about improving the business

4. The week of the event • Day One – Focussed on understanding the current process and identifying areas of delay. Main tools used were a cross-functional process map and Failure Modes Effects Analysis (FMEA) • Day Two – Started to design the improved state, prototyping and piloting improvements • Day Three – Reviewed and refined improvements • Day Four – Prepared communication plans and completed implementation • Day Five – Documented improved processes and completed action plans for next 30, 60 and 90 days

5. The problems, and the solutions – fully implemented within 7 days The ED Staff Base now has a clearly marked, dedicated area for "Bed Requests and Discharges” • Flow Nurse, Orderly, and Clerical staff are co-located, and Flow Nurse to wear lime green scrubs to be easily identified (or Charge Nurse after hours) 1 Responsibilities and communications are unclear as to where and who to see to arrange transfer of a patient to a ward 2 Minimum standards set for documentation - A to D planner or 6 hour plan, IV Fluids, Meds charts. This has improved patient safety and toreduced follow up phone calls and rework Delays occur whilst waiting for documentation to be completed 3 Flow Nurse uses a 10-second checklist with the inpatient doctor to confirm the patient is ready for transfer and patient’s bed requirements (Flexi, isolation, side room, watch, etc.) Changing Bed Request requirements causes delays and rework ISOBAR procedure implemented for nurse-to-nurse handover – completed face-to-face for ED to APU transfers and escorted patients, and via ‘phone for ED to Ward transfers 4 Variation in patient handover procedures

6. The results AVG time Jan 2010 = 80 mins AVG time 2011/12 = 38 mins

7. Lessons Learnt The people who know the process know the solutions Creating urgency helps everyone to move to solutions faster Preparation is the key for a successful Rapid Improvement Event