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Improving care in the ED – one department’s response to the Francis report

This article discusses the efforts of a department in the Royal Devon & Exeter Hospital to improve care in the emergency department, focusing on the basics of care, achievements, ongoing plans, aspirations, failures, challenges, and measuring care. The article highlights the importance of championing care in the ED and provides context for the hospital and its patient population.

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Improving care in the ED – one department’s response to the Francis report

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  1. Improving care in the ED – one department’s response to the Francis report Gavin Lloyd Consultant Emergency Physician and ED Patient Champion Royal Devon & Exeter Hospital

  2. “Care”: the basics • Smiling face to welcome me • Reassurance that I’ll be looked after • How about some quality pain relief? • Keep me informed (on my patient journey) • Keep me fed and watered if I'm here for ages • Respect and dignity

  3. Gold standard Care: Look after me as if I were one of your own Basic Care: Look after me “Are we providing a safe, committed, compassionate and caring service?”

  4. Fluid Oxygen Aspirin Early abx Propofol Sux Bipap Electricity Enlightenme modules Sedation Driving better care Time Shopfloor quality assurance Clopidogrel for potential ACS?? Omeprazole for resus room haematemsis?? Basic care!

  5. Overview of talk One department’s drive towards better “care”: • Achievements • Plans in progress • Aspirations • Failures • Challenges • Measuring care • Resources

  6. Go and champion care in your ED!

  7. Context • Royal Devon & Exeter Hospital • 320 patients a day, 20% children • Trauma unit • 10 consultants 8am-10pm+, 365 days a year • Full MG rota, 10 WTEs • Nights: 1 MG, 3 juniors • Ethnically not diverse

  8. Prior work • Appointments for bereaved relatives with a senor clinician • 2014 CQC patient summary

  9. Achievements • The (senior) meet and greet • Essential first part of the RAT • Patients +/- relative(s)/friend/carer • Plan B – dovetail with a MG • Plan C – majors triage nurse

  10. Achievements • Care rounds • Selected patients • “Permission” • Introduction • “How have we as a department care for you today?” • Hot feedback • Written feedback to team via email and newsletter

  11. Achievements • Care round checklist (for patient +/- relatives) • How have we as a team cared for you today? • Kept you informed? • Pain relief? • Fed and watered? • What do you think we could have done better?

  12. Achievements • Skin Care • Ambulance triage skin assessment • Mattress toppers for ?#NOFs • Otherwise directly on to a bed for vulnerable patients

  13. Other achievements • Letter regarding ‘care’ issued to all new staff including agency • ‘Care’ focus in induction of new doctors • Privacy in reception for those patients presenting with personal complaints • Letter issued to all doctors involved in a complaint, offering second victim support from a senior clinician • Trainer of the year award to promote good education • Productive care initiatives from junior doctor cohorts’ feedback • Regularly updated foreign language speakers list • Written confirmation of regular cleaning displayed in the toilets

  14. Other achievements • Partitioning of a previously open minors are to improve dignity

  15. Other achievements • Monthly ED newsletter with a ‘care corner’

  16. Care initiatives in development • Comfort rounding • Targeting all staff • Volunteers! • Medical students

  17. Care initiatives in development • Nominated champions for pain/# NOF/urinary retention Problem: poor performance guaranteed by • Taking your eye of the ball/inertia • Staff turnover Solution: • Champions! • Standardised bimonthly reminders on audit issues

  18. Care initiatives in development • Bespoke management plans for frequent attenders: • 28 patients with >100 attendances • 2 patients per consultant/1 per supervised MG • Signed off at ….. • RCEM suggest those with >30 attendances in last 12 months JH (DOB, Hospital Number.....)  Background – frequent attender with physical DSH; very amicable and compliant. Clive Urdaibay’s suggestion – secure a theatre grade staple gun and close her wounds under the influence of standard entonox. Offer crisis input, but in Clive’s experience this is unlikely to be taken up.

  19. Care initiatives 4.The waiting room (and other waiting areas) • Telly - 24hr BBC news channel with subtitles • Free Wi-Fi access • Charity bookstall • Magazines top ups in all waiting areas • Some rearranging

  20. Other care initiatives in development • OOH eye presentation that can safely be deferred to normal hours and return for eye nurse practitioner assessment in normal hours • A welcome (and explanatory) leaflet for those patients attending with DSH • Spotlight: a written letter highlighting the contribution of a staff member and sent to their home address • Copies of all complaints sent to ED patient champion with monthly feedback via newsletter • Provision of pillows! • Looking after/welcoming specialty team in ED • Ensuring staff take their breaks • Independent senior nurse observations

  21. Failures • Patient passports ref. Newstead et al EMJ 2013 • Written information for patients regarding their journey – whiteboards/cards • Elderly name badging • New faces board

  22. Aspirations • Communication skills training • Better information for the waiting room regarding time to be seen

  23. Tapping in to junior doctor thinking Please consider some initiatives that could improve “care” in our ED. Consider for example: • An “off legs” 88 year old female found on her floor by her carers • A 3 month old boy with mum with poor feeding, crying and +/- temperature • And all the rest of minors/majors/resus

  24. Efficiency suggestions from the juniors • Stocking up of blood trolleys three times a day • Oral rehydration therapy for pre-school children and babies initiated at triage • Paramedics bloods! • Computer access

  25. Computer access

  26. Efficiency suggestions from the juniors • Stocking up of blood trolleys three times a day • Oral rehydration therapy for pre-school children and babies initiated at triage • Paramedics bloods! • Computer access • Stack of chairs for relatives • More stools for staff

  27. Challenges • Exit block/ignoring the prescription • Patients who shouldn’t be in ED in the first place • Excessive work load/gaps in staff rotas • IT problems • Competing interests • More challenging patients: alcohol excess/DSH/the delirious/deaf/learning difficulties

  28. Measuring Care

  29. Measuring care

  30. Governance (from a CQC perspective) • NICE compliant guidelines • Safeguarding children/domestic violence • Incident reporting and learning from them • Learning from audits

  31. Resources QEC Best Practice Guidelines: Management of Domestic abuse End of life care for Adults in the ED Chaperones in the ED Suffering in the ED Body et al. EMJ March 2015 March 2015 March 2015 January 2015

  32. Francis Report

  33. Go and champion care in your ED!

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