System Flashcards
Discuss triage
Doing the greatest good for the greatest number of people
In the ED urgency is distinct from severity, prognosis, complexity and case mix, although correlations do exist.
Some urgent problems (for example upper airway obstruction) have a poor outcome without rapid intervention but are not severe in the sense of requiring long term care, other severe problems such as life threatening malignancy may not require treatment in the ED time frame.
Discuss the Australian triage scale
ATS 1 - immediately -100% PIT ATS 2- 10 minutes - 80% PIT ATS 3- 30 minutes 75% PIT ATS 4- 60 minutes 70%PIT ATS 5 120 minutes 70% PIT
PIT=performance indicator threshold
Discuss structure and function of a triage system
The exact requirement for triage vary but effective systems share a number of important features
- a single point in the ED near the entrance where traige is undertaken
- appropriate facilities for undertaking a brief assessment and limited treatment.
- A balance between competing conerns of accessibility, confidentiality and securuity
- A computerized information system to bother record assessment and triage cats
Discuss emergency short stay units
- Discrete wards with 4-20 beds located adjacent to or in close proximity to the main body of the ED
- Designed for short term observation or stay <24 hours
- staffed and run by ED personnel
- specific admission and discharge criteria and policies
Discuss benefits of short stay units
-Allowing patients to access investigations prior to leaving the ED ensuring accurate diagnosis and formualtion of a discharge plan
-admission to the correct inpatient service once an accurate diagnosis has been made
-provides an alternative to inaptient hospital admission as a way to improve efficiency, clinical care and patient satisfaction while minimizing cost
-reducing inpatient admissions
-temporary accomodation for patients where immediate discharge especially after hours would place the patient at risk
safegaurd for junior medical staff who require assistance
Discuss admission and discharge criteria to a SSU
Emergency doctor should have admission rights to the unit and admission criteria need to be clear
1) patient should have an expected length of stay of no more than 24 hours and at the time of admission to the observation ward ahve a well defined reson for observation.
2) Should include
- immediate treatment goals
- expected outcomes/response
- clear instructions surrounding monitoring food and flud intake
- medications charted
- ancillary allied health service review
Documentation include dsicharge letters should be completed.
Discuss causes of overcrowding
1) Access block - inability of patient rearguing inpatient admission to access appropriate beds in a timely fashion
- caused by both absolute number of beds and staff shortage
2) increase in demand on EDs in both number and complexity of patients - resulting from a growing ageing populaiton
3) Growth in diagnositc and therapetuci choices and changing expectations of medical availability and service
4) this has not been matched by growth in other serviceses especially outside of office hours.
ED overcrowding is best seen as a marker of whole-of-hospital dysfunction which requires a whole of hospital response
Define overcrowding in the ED
EDs can be considered as overcrowded when nornal pathways of clinical care cannot be followed due to total patient load that is the treatment rate is reduced or the treatment quality suffers,
ACEM defines ED overcrowding as the situation where ED function is impeded primarily becuase the number of patients waiting to be seen undergoing assessment and treatment or waiting for departure exceeds either the physical or the staffing capacity of the ED
Discuss exclusions criteria to the SSU
Patient who clearly require >24 hours admission
- patient who have more than one or complex medical problems especially the elderly
- patient without clearly defined treatment plans
- patient who require intensive nursing care
- patient who are a heavy nursing load
- patient who are violent psyhcotic or disurptive
Discuss consequences of overcrowding
Multiple studies in different centres have found an associated between overcrowding and
1) reduced access to care
2) decreased quality measures
3) lesser outcome including
- increased subseuent inpatient length of hospital stay
4) excess patient mortality
Discuss strategies to deal with overcrowding
System wide
- NEAT target
- Executive leadership
- hospital wide co-ordination
- data-driven management
- performance accountability
- Hospital enforced overcapacity protocols
Staff -Increases in the number of seniority of ED staff is associated with improvement in process measures -early seniour intervention Triage nursing ordering of IX -Nurse practitioners
Area
- streaming of selected patietn to rapid assessment
- dedicated fast track areas
Discuss rapid response system
The term RRS describes an entire system
- afferent limbs to detect clinical deterioration
- efferent limb is the responding team
- Audit and governance limbs
Discuss methods to improve health care for indigenous patients in the ED
1) Increase cultural compentancy of their staff
2) ensuring that barriers for indigenous patients accessing health care are miniised
3) environement are culturally appropraite
4) employ indigenous staff including indigenous health workers and liason officers
5) develop a network within the indigenous health service
Discuss cultural compentency in regards ot indigenous australians
While indigenous cultures are diverse themes such as
- the importantce of customary law
- the extended family and kinship obligations
- the notion of reciprocity and a differing worlview
Staff need to understand and acknowledge the existence of racism and how it has affected the health of indigenous people.
Cultural competnece is a set of behaviours and attitudes and a culture within a business or system that respects and takes into account the person cultural backgroung, belief and thir values and incorporates them in the way health care is deliveried.
Cultural saftey is a way of practicing - it is importantly measured from the patients perspective and is when the health professional undertakes a process of reflection on their own cultural identity and recognises the impact of that culture on their professional practice
Discuss ACEM stance on utrasound
US exam and interpretation should be available in a timely manner 24 hours a day for ED patients
ACEM supports
- emergency physicians providing focused US should possess appropriate training and hand on experience to perform and interpret imaging
- ED physicians encouraged to be competent in at least the “core”areas- AAA,EFAST, procedural guidance, lung and echo
CREDENTIALING
- complete an appropraite accredited educational program/coruse
- perform and record requisite number of accurate proctored ED ultrasounds
- pass summative assessment
- meet ongoing maintenance requirement (e.g undertake 3 hours US training per year and perform 25 EFAST scans over a 2 year cycle or as set out be credentially body)
- Documentation
