Department management Flashcards
What is access block?
- Admitted patients filling ED assessment bays preventing further assessment
- An accepted measure of access block is the proportion of patients having waited >8hrs for an inpatient bed
What causes prolonged waiting time and extended lengths of stay (ELOS)
- Increase daily attendance
- Access block
- inappropriate ESS admissions
- Extended ramping time
- medical/nursing sick calls
How can you reduce ELOS for ESS units?
- ESS admissions approved by senior clinician
- Criteria led discharge (allows nurses to discharge prior to medical review)
- Dedicated ESS team with regular rounds
- Direct ESS admissions from triage if meeting certain criteria (ie kidney stones)
- Direct admission to wards for inpatient team expects
- optimise other points of flow ie path and radiology
What quality control checks can decrease the incidence and morbidity of transfusion reactions in the ED?
- Multiple point patient identity checks with blood bank and at the bedside
- Frequent obs post transfusion
- Remain in high visibility area during transfusion
- Strict controls regarding transport and storage of products
- Strict guidelines around delay to administration post ordering (ie sending back or designated fridges)
- Dont give blood products overnight unless patient unstable/very urgent
When meeting with a junior who is experiencing problems at work (ie recurrent sick days etc) how should this be approached?
- Establish confidential nature of the meeting
- Occur away from the clinical environment
- Explore the juniors understanding of why the meeting is occurring
- Explore factors contributing to their issues (ie excess sick leave)
- Establish expectations of employment
What are the risks on history for problem alcohol use?
- Drinking before work
- Drinking at work
- Impairment of other daily activities
- Drinking to the point of blacking out
- CAGE questions (cut down, annoyed, guilty, “eye opener”)
What actions should be taken regarding a junior doctor who is unfit to work due to substance abuse?
- Mandatory AHPRA reporting
- Stood down until situation resolved
- Referral to alcohol and drug service
- Referral for employee assistance whilst stood down
- Encourage engagement with own doctor and psychologist etc
What can lead to missed radiology diagnoses in a department?
- Medical error (lack of knowledge)
- Lack of senior oversight at the time
- Lack of processes to have seniors review radiology prior to discharge
- Lack of flagging by radiology regarding important results
- Delay to reporting
- Busy/understaffed departments
How should a missed diagnosis be managed when a patient complains?
- Arrange appropriate care for the patient
- Open disclosure including apology
- Assist patient with complaints process if they wish to make one
- Reassure patient it will be investigated, review notes, speak to those involved
- Notify patient of the results of the investigation if they wish
- Review departmental processes potentially leading to the situation (ie guidelines, oversight of juniors, staffing etc)
What are the problems with the Australian triage system? What are the problems with triage of the poisoned patient?
- Psych/AMS patients may give minimal information
- Lack of privacy for assessment
- May appear well if presents very quickly after certain OD’s
- Tox knowledge often too detailed for triage RN
- Difficult to appropriately triage without knowing exact type and dosing of tox agents
What are the features of the Australian triage system?
If a nurse or other staff member complains about a colleague, how should this be approached?
- Acknowledge their concerns
- Investigate details of incident(s)
- Debrief with the colleaaague
- Identify issues contributing ie well being, work like balance, lack of experience, ETOH use etc
- Develop a management plan
- If required alter the colleagues shifts so they have more senior support (ie no night shifts)
- Ensure the colleague has a mentor
If a junior staff member is being bullied how should this be approached?
- Acknowledge their concerns
- Document the discussion well
- Ensure the persons safety (ie not suicidal, has home supports)
- Escalate the case to appropriate department seniors ie director
- Arrange for them to have some time off work
- Arrange supports for them ie employee assistance program
What are the negative impacts of bullying?
Staff
- anxiety, depression, suicidality
- Substance abuse
- Failure of term
- Avoidant behaviours
- Increased sick leave
- Working unsupervised
- Dropping out of medicine
Patients
- Delays in care
- Reduced quality of care (ie from lack of supervision)
- Increase in patient complaints
- Distrust of medical staff advice
Emergency Department
- Poor reputation amongst juniors
- Recruitment issues/staff attrition and loss of staff due to long term sick leave/stress leave
- Poor culture/morale
- Loss of productivity
- Increased risk of litigation
- Loss of ACEM accreditation
What is the ACEM definition of overcrowding?
- Where the emergency department function is impeded primarily by the excessive number of patients needing or receiving care
- The single most important factor contributing to overcrowding is the availability if inpatient beds (ie access block)
What is ED Surge, Surge Capacity and Surge Capability?
Surge: A sudden increase in the patient care demands on the health system
Surge capacity: The ability of the health care system to respond to a higher number of presentations
Surge Capability: The ability of the healthcare system to respond to more higher specialised medical needs (ie severe burns, pandemic) than normal
If a critical incident occurs in the department (ie drug misadministration) how should this be approached?
- Open disclosure to patient/family
- Investigation (examine records, interview staff)
- Report the incident (electronic incident system, medicolegal)
- Education including M&M
- Feedback
- Give recommendations
What system factors contribute to medications errors?
- Lack of mandatory reporting of patient allergies
- Lack of alert systems
- Shift work and roster patterns
- Inadequate supervision
- Overcrowding
- Overworked
- Fatigue
What is the SMART methodology for constructing goals?
Specific
Measurable
Achievable
Realistic
Timely
What are the barriers to change in the workplace?
- Poor organisational culture
- Poor communication between different departments
- Tribalism
- Leadership instability
- Competing demands
- Magnitude of change
- Scarce resources
- Stakeholder resistance
What is the basic management of a critical incident?
- Open disclosure
- Investigate
- Report (ie medicolegal, AHPRA, electronic incident system)
- Education (ie M&M)
- Feedback (staff and patient/family)
- Recommendations
What elements of a new ED design create an older person friendly environment?
- Good lighting
- Good way finding/navigation ie clearly labelled toilets
- Privacy within cubicles
- Noise reducing strategies
- Hearing loop technology
- Supported surfaces such as reclining chairs
- Falls risk reduction ie trolleys that lower, less slippery floors
- Visible wall clocks
- Functional/accessible call bells
- Temporal orientation cues
- Appropriate food/fluids ie thickened fluids
- Access to physical/functional aids
- Family rooms
- White communication boards
What is the definition of ambulance ramping and what are its consequences?
Definition
- When ambulance officers and paramedics are unable to transfer care of a patient to the ED within an appropriate time frame
Consequences
- Delays to ambulance response times with knock on effects (worse patient outcomes)
- Adverse publicity
- Increase patient morbidity/mortality
- Increase stress and conflict between staff, patients and paramedics
- Financial penalties to hospitals and ED for not meeting KPI’s
- Poor patient experience
- Increased patient complaints
What should be measured when determining the prevalence and impact of ambulance ramping?
- Ambulance arrival time in ED
- ED notification time
- Patient triage time
- Patient entry to ED time
- Clinical handover time
- Ambulance crew preparation time
- Ambulance egress time out of ED
What are the causes of overcrowding?
- Access block number 1
- Sick calls
- Lack of future planning ie new people moving to a region
- Diversion of patients from another hospital
What are the broad recommendations from ACEM for dealing with Access Block?
Demand reduction
- Easier referral pathways
- More access to outpatient clinics
Removing barriers to flow
- Pull to full
- Minimize investigations in ED
Reducing hospital occupancy
- Improved discharge planning
- HITH
- Outpatient options on discharge
How should an emergency department prepare at the start of a pendamic?
- Institute measures to decrease demand and increase capacity
- Establish safe areas for both tirage and treatment (ie isolation rooms)
- Establish safety measures and protocols for staff and patients ie PPE, donning/doffing stations
- Upgrade staffing skills ie for mass casualty, PPE, NIV, intubation etc
- Co-ordinate between hospital and pre-hospital services to ensure safe and unified response
What important equipment and supplies should be ordered at the start of a pandemic?
- PPE
- Ventilators, masks, tubing etc
- Enough 02
- Diagnostic tests
- Antiseptic/cleaning solutions
