Improving care in the ED

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Improving care in the ED one departments
response to the Francis report

• Gavin Lloyd
• Consultant Emergency Physician and ED Patient
  Champion
• Royal Devon Exeter Hospital

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Care the basics

• Smiling face to welcome me

• Reassurance that Ill 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

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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?
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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!
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Overview of talk

• One departments drive towards better care

• Achievements
• Plans in progress
• Aspirations
• Failures

• Challenges
• Measuring care
• Resources

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• Go and champion care in your ED!

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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

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Prior work

• Appointments for bereaved relatives with a senor
  clinician
• 2014 CQC patient summary

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Achievements

1. 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

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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

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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?

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Achievements

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

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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

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Other achievements

• Partitioning of a previously open minors are to
  improve dignity

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Other achievements

• Monthly ED newsletter with a care corner

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Care initiatives in development

• Comfort rounding

• Targeting all staff
• Volunteers!
• Medical students

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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

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Care initiatives in development

• Bespoke management plans for frequent attenders
• 28 patients with gt100 attendances
• 2 patients per consultant/1 per supervised MG
• Signed off at ..
• RCEM suggest those with gt30 attendances in last
  12 months
• JH (DOB, Hospital Number.....) 
• Background frequent attender with physical DSH
  very amicable and compliant.
• Clive Urdaibays suggestion secure a theatre
  grade staple gun and close her wounds under the
  influence of standard entonox. Offer crisis
  input, but in Clives experience this is unlikely
  to be taken up.

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• 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

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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

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Failures

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

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Aspirations

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

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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

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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

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Computer access
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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

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Challenges

• Exit block/ignoring the prescription
• Patients who shouldnt 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

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Measuring Care
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Measuring care
Caring Caring Inadequate Outstanding
By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect. Feedback High or rising level of complaints re care Substantial numbers of letters of praise
By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect. Interview Indifference or disdain demonstrated by more than 1 senior member of staff Evidence of widespread engagement in promoting patient welfare and outcomes
By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect. Family and Friends No participation or return rate lt 10 Return rate gt 30
By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect. Environment Lack of privacy reported or observed on a regular basis Provision of privacy for all patients in the majors/ resus at all times
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Governance (from a CQC perspective)

• NICE compliant guidelines
• Safeguarding children/domestic violence
• Incident reporting and learning from them
• Learning from audits

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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
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Francis Report
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• Go and champion care in your ED!