Emergency Department Flow

Treatment of the Sickest Patient First

This step requires that Health Boards agree and implement a service model which supports the principle of treatment of the sickest patient first and provides appropriately accessible acute emergency services at designated centres, with 24/7 access to acute medical service/senior clinical decision makers, and 24/7 access to surgical opinion.
 
The intended outcome here is that patients are made safe and assessed by Emergency Departments (ED) quickly with prompt handover from ambulance crews and speedy handover to the most appropriate place and clinician for treatment.

Front Door, Acute Hospital Services

Service Model

Generic filtering of potentially immediately life threatening conditions for resuscitation/ stabilisation, triage of higher risk patients and signposting of low risk patients e.g. to minor injury or GP led services is equally applicable to acute hospital services.
 
A consultant led, rapid assessment/ immediate treatment (e.g. pain relief) model fits well with this; while an aligned Clinical Decision Unit ensures that the initial assessment is followed up, within the Front Door, with an adequate clerking, initial set of investigations and a signed-off treatment plan based on the patient’s particular needs.
 
Early specialist review (particularly for Cardiology and Respiratory Medicine) within the Front Door will help minimise unnecessary admission. This means that the patient will then be safe for:
  • Discharge (to home or community services)
  • Receipt by a co-located 24 hour stay unit; or
  • Receipt by a hospital ward

It is acknowledged that risk generally increases at interfaces; so in all cases the treatment plan will be agreed by a suitably senior individual. At hand-over, there should be clear communication of the treatment plan itself including clear agreement on who is the senior responsible owner.

Specific access-time sensitive condition pathways (e.g. stroke) and direct speciality-based, admission processes will need to be detailed in order to avoid unnecessary delays while ensuring passage to the relevant specialist team is done safely.

Generally speaking, a change of decision making perspective and language (from, ‘Does this patient need to be admitted?’ to ‘Can this patient be better served by community services’ will help to gradually re-balance both culture and system. Clearly the correct services need to be in place to achieve this and, as indicated previously, Intermediate Care Teams/ Community Response Teams including individuals with Therapies and Social Care skills, will need to be physically available within the Front Door; as will appropriate imaging, diagnostic and Pharmacy services.

The Front Door team (and other Hospital teams) will be an integral part of the senior decision making capacity for the 999 Clinical Contact Centres, the Communication Hubs and Community services. Able to provide telephone advice and assessment supported by technology (e.g. telemetry) where appropriate.

A study was undertaken by the Primary Care Foundationof GPs working with or alongside emergency departments. Approximately half of the emergency departments reviewed had primary care clinician links/staff and an estimated ten to thirty percent of patients presented with clinical conditions that are normally dealt with in Primary Care.

The Foundation found three main models with Primary Care units

  1. Situated alongside the ED running separate reception and operational processes
  2. Situated alongside the ED running common reception and separate operational processes
  3. Fully integrated with common reception and operational processes.

Workforce Model

Having appropriate Mental Health and Substance Misuse skills within, or rapidly available to, the Front Door has been raised by clinicians as a particular issue. The possibilities of cross-training to avoid duplicative, onward specialty referrals to relatively junior staff and the value of GPs, who as generalists and can manage a significant level of paediatric and mental health problems, deserves serious consideration.

The Clinical Decision Unit model relies on appropriate pooling of junior ED, medical and surgical clinicians. Clearly, when patient flows are high (e.g. during times of high volume direct GP admissions) the ED / trauma and Clinical Decision Unit ends of the Front Door spectrum will need to be independently appropriately staffed. At times of low volume input, co-located teams provide synergy and efficiency while at all times virtual integration (and free flow of support between ED and Acute Physician consultants) is essential to provide safe, high quality services.

The challenges inherent in this are clearly greater where infrastructure is inadequate but, while this is being improved, opportunities for virtual integration need not be delayed. This is most easily facilitated by discussion within, and between, front-line teams on how to provide the best possible services to patients within the resource envelope.

Clinical information and IM&T systems need to reflect the need for a balance between local needs and limited unnecessary variance. ED consultants have explained that this is a particular priority for them, but the need for connectivity within the USC system, and the availability of an appropriate clinical record during USC encounters has been repeatedly highlighted by clinicians across the system.

Wider USC Workforce Issues

Currently, there is a relative emphasis on USC workforce planning within acute hospital services. This is important and, for instance with doctors. It is vital that they are exposed to adequate training in USC, but from a whole system Primary, Intermediate and Secondary Care perspective.

This is of particular importance following the impact of Working Time Directive, shift work and the increased rate of team-to-team patient handovers. Looking forward, USC workforce planning will need to encompass the whole system and ensure that those practicing more office-based clinical services are regularly updated in the necessary USC skills via CPD, appraisal and job rotation opportunities.

The philosophy should be to first define the clinical service required and match that up with the person who has an appropriate skill set; rather than fitting the service into a traditional workforce model that is already in place.