CORPORATE OFFICE
Level 1
32 Oxford Terrace
Telephone: 0064 3 364 4160
Christchurch Central
Fax: 0064 3 364 4165
CHRISTCHURCH 8011
[email address]
21 December 2017
Health Sector Workers Network
Email: [FYI request #6957 email];
Dear Health Sector Workers Network
RE Official information request CDHB 9756
I refer to your email dated 7 December 2017, requesting the following information under section 12 of
the Official Information Act from Canterbury DHB.
1. What are the percentages of patients presenting to the Emergency Departments that were
admitted, discharged or transferred within six hours of presentation for each month of the year
July 2016 to June 2017?
Please refer to
Table one (below) for the percentage of patients presenting to the Canterbury DHB
Emergency Departments that were admitted, discharged or transferred within six hours of presentation
for each month of the year July 2016 to June 2017.
Table one: Percentage and number of patients in Emergency Departments admitted, discharged or
transferred within six hours.
Ashburton Hospital ED
Christchurch Hospital ED
Total CDHB
Month / Year
%
Number of patients.
%
Number of patients.
%
Number of patients.
1/07/2016
95%
439
93%
7742
93%
8181
1/08/2016
91%
467
93%
7738
93%
8205
1/09/2016
90%
417
94%
7586
94%
8003
1/10/2016
94%
483
96%
7725
96%
8208
1/11/2016
92%
441
95%
7641
95%
8082
1/12/2016
93%
571
95%
7953
95%
8524
1/01/2017
90%
496
95%
7589
94%
8085
1/02/2017
92%
485
95%
7031
95%
7516
1/03/2017
93%
483
95%
7682
95%
8165
1/04/2017
94%
485
95%
7360
95%
7845
1/05/2017
93%
503
96%
7719
96%
8222
1/06/2017
96%
503
94%
7539
94%
8042
2. Please provide any DHB policy concerning guidelines and use of the ED observation unit? By “ED
observation unit”, we are referring to the usage defined by the Ministry Of Health in the paper
Streaming and the use of Emergency Department Observation Units and Inpatient Assessment
Units.
Please find attached as
Appendix 1, the Canterbury DHB Emergency Observation Guidelines.
3. What percentage of total ED presentations for each month of the year July 2016 to June 2017
utilised the ED Observation unit?
Please refer to
Table two (below) for the percentage of total Emergency Department presentations for
each month of the year July 2016 to June 2017 that utilised the Christchurch Hospital ED Observation
Unit.
Table two: Percentage and number of patients admitted to Christchurch Hospital ED Observation
Unit.
Month / Year
%
Number of patients admitted to ED Observation Unit.
1/07/2016
9%
723
1/08/2016
10%
752
1/09/2016
9%
717
1/10/2016
10%
808
1/11/2016
12%
880
1/12/2016
10%
822
1/01/2017
12%
875
1/02/2017
11%
779
1/03/2017
11%
855
1/04/2017
11%
812
1/05/2017
11%
876
1/06/2017
12%
872
4. What percentage of patients utilising the ED observation unit were discharged home from this
location for each month of the year July 2016 to June 2017?
Please note: Ashburton Hospital does not have an Emergency Department Observation Unit.
Please refer to
Table three (below) for the percentage of patients utilising the Emergency Department
Observation Unit who were discharged home from this location for each month of the year July 2016 to
June 2017.
Table three: Percentage and number of patients admitted to Christchurch Hospital ED Observation
Unit who were discharged from there.
Month / Year
%
Number of patients discharged from ED Observation Unit.
1/07/2016
85%
614
1/08/2016
86%
647
1/09/2016
82%
585
1/10/2016
86%
695
1/11/2016
87%
765
1/12/2016
87%
712
1/01/2017
86%
750
1/02/2017
85%
663
1/03/2017
86%
736
1/04/2017
83%
677
1/05/2017
82%
722
1/06/2017
82%
719
5. What is your DHB’s expected length of stay for the patients utilising the ED observation unit?
Our expectations for patients in ED Observation Ward, arriving between 0900 – 2259 is a Length of Stay
(LOS) <8hrs, and for those arriving between 23:00 and 08:59 a Length of Stay (LOS) <12hrs.
6. What percentage of patients for each month of the year July 2016 to June 2017 exceeding the
length of stay given in question 5?
Please refer to
Table four (below) for the percentage of patients for each month of the year July 2016 to
June 2017 exceeding the length of stay given in Question 5.
Table four: Percentage and number of patients ‘exceeding’ expected Length of Stay (LOS) in
Christchurch Hospital Emergency Department Observation Unit.
Month / Year
%
Number of patients exceeding LOS in ED Observation Unit.
1/07/2016
15%
108
1/08/2016
16%
121
1/09/2016
13%
96
1/10/2016
14%
116
1/11/2016
12%
107
1/12/2016
11%
88
1/01/2017
14%
120
1/02/2017
11%
84
1/03/2017
11%
91
1/04/2017
12%
97
1/05/2017
10%
90
1/06/2017
11%
91
I trust that this satisfies your interest in this matter.
Yours sincerely
Carolyn Gullery
General Manager
Planning, Funding & Decision Support
link to page 5 link to page 5 link to page 5 link to page 7 link to page 7 link to page 7 link to page 7 link to page 8 link to page 8 link to page 8 link to page 8 link to page 8 link to page 9 link to page 9 link to page 9 link to page 9 link to page 9 link to page 9 link to page 10 link to page 10 link to page 10 link to page 11 link to page 12 link to page 13 link to page 14
Emergency Department Location Manual
Emergency Observation Area (EO) guidelines
Emergency Observation (ED Obs) guidelines
Table of Contents
1
Standard ...................................................................................................................................... 2
2
Scope........................................................................................................................................... 2
3
Associated documents ................................................................................................................ 2
4
Indications for admission / placement into ED Obs ..................................................................... 4
5
Types of patients suitable for ED Obs ......................................................................................... 4
a. Head injury ........................................................................................................................... 4
b. Post procedural sedation ..................................................................................................... 4
c.
Alcohol intoxication .............................................................................................................. 5
d. Overdose .............................................................................................................................. 5
e. Crisis Resolution .................................................................................................................. 5
f.
Renal colic ............................................................................................................................ 5
g. Post-ictal............................................................................................................................... 5
h. Chest pain ............................................................................................................................ 6
i.
Patients pending discharge or transfer ................................................................................ 6
j.
Isolation ................................................................................................................................ 6
k.
Wound management ............................................................................................................ 6
l.
Back pain.............................................................................................................................. 6
m. Patients who primarily have social issues ............................................................................ 6
6
Staffing ........................................................................................................................................ 7
a. Nursing ................................................................................................................................. 7
b. Medical ................................................................................................................................. 7
7
Nursing team leader role and responsibilities ............................................................................. 8
8
Nursing team responsibilities .................................................................................................... 10
9
Medical team responsibilities .................................................................................................... 11
10
Hospital Aide team responsibilities ............................................................................................ 11
11
Clerical Officer team responsibilities ...........................................
Error! Bookmark not defined.
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Emergency Department Location Manual
Emergency Observation Area (EO) guidelines
1
Standard
ED Obs is an acute care area of the Emergency Department that provides
treatment, support and a period of observation, to patients who are expected to be
discharged home.
A plan from the medical staff for the patient is expected before admitting a patient to
ED Obs.
Patients may be admitted to ED Obs when the pandemic Red Zone Plan is
implemented.
ED Obs KPIs
Use of ED Obs: 10-15% of the total ED presentations
(Ministry target = < 20%)
Conversion from ED Obs to inpatient admissions: < 15%
(Ministry target = < 20%)
LOS: 90% to be discharged or admitted within 12 hours (longer if patient
admitted during the evening) (Ministry target = 80%)
2
Scope
ED and Casual Pool Nurses
ED Medical Officers
ED Hospital Aides
ED Clerical Officers
3
Associated documents
Ministry of Health (2014)
Suite of Quality Measures for the Emergency Department
Phase of Acute Patient Care in New Zealand. Wellington
Hospital HealthPathways
Volume 10 – Infection Control and Prevention
Volume 11: Clinical Policy and Procedure Manual
Transfer of patients policy
Transfer of patients to Christchurch Hospital from other CDHB and non
CDHB hospital policy
ED Location Manual:
7.01 Models of care
7.02 ED shift management standards – ED overload (EDOD)
7.05 Patients waiting referral to inpatients team
7.06 Requesting an inpatient bed
7.07 Transfers from ED and decision to escort
7.15 ED Obs patient returning to ED
7.19 Discharge planning
7.24 Red zone pandemic planning
7.24b Influenza pandemic – red zone assessment
7.26 Guidelines of ED nurse roles by treatment area
8.02 Imaging Guidelines
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Emergency Observation Area (EO) guidelines
8.03 Drug Guidelines
8.03c Adult antiemetic guidelines
8.08 Guidelines for care of the deceased patient in ED
8.29 Policy for care of the patient undergoing a procedural sedation
8.33 CT imaging overnight
Telephone Notification to ED (C21007)
ED Record (C110002)
Admission Form (Green Sheet) (C110001)
Smoking Cessation
online learning
Pathways:
Abdominal pain pathway (C240006)
Acute heart failure pathway (C240095)
Acute pyelonephritis pathway (C240078)
Adult asthma pathway (C240004)
Adult mild head injury pathway (C240092)
AF in ED pathway (TBC)
Aggression de-escalation pathway (TBC)
Alcohol intoxication pathway (C24008A)
Assessing Competence In Non-Consenting Patients Pathway (C240358)
Back pain pathway (C240091)
Cardiac chest pain pathway (C240005)
Community acquired pneumonia pathway (C240144)
COPD pathway (C240081)
Eating disorders patient pathway (C240303)
Epistaxis pathway (C240030)
Macroscopic haematuria pathway (C240329)
Mental health assessment pathway (C240093)
Palliative care interim care plan TB(C)
Palliative care pathway (with referral) T(BC)
Pelvic inflammatory disease pathway (C240141)
Probable peritonitis in CAPD patients pathway (C240145)
Procedural sedation clinical pathway (C270078)
PV bleeding pathway (C240143)
Renal colic pathway (C240080)
Suspected TIA pathway (C240034)
Testicular pain pathway (C240087)
Urinary retention pathway (C240083)
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4
Indications for admission / placement into ED Obs
Patients suitable for ED Obs should be identified as early as possible.
Suitable patients include those who have been seen by and remain under
the care of ED and are likely to be discharged following a period of
treatment and observation.
Junior medical staff need to consult with SMO about the suitability of patient for
ED Obs.
Senior nursing staff (ACNM) can direct junior medical staff to admit patients into
ED Obs.
A plan from the medical staff for the patient is expected before admitting to ED
Obs, including analgesia, antiemetic, IV fluid, x-ray as required, and other
requirements such as plan for observation, NBM status, and ability to mobilise.
Patients admitted generally need to be SMO cleared before discharge. This may
be after discussion with the RMO caring for the patient.
Patients waiting for speciality review may be placed in ED Obs while they await
for review in order to create capacity in other ED areas according to capacity
plan (not admitted into ED Obs to ensure transparency of use)
Children can be admitted to ED Obs at the discretion of SMO and ACNM.
All patients discharged from ED Obs require a discharge summary to be
completed by medical staff. Speciality patients who have been admitted into ED
Obs require a discharge summary to be completed by the speciality team.
5
Types of patients suitable for ED Obs
a.
Head injury
The patient is generally observed for four or more hours post injury
Complete the adult mild head injury pathway (start one if not already in place)
Complete a neuro observation sheet (this includes GCS, limb movement and
pupil monitoring). See adult mild head injury pathway for ongoing nursing care
including frequency of observations
Any abnormal signs need to be reported to the doctor looking after the patient or
the SMO
Prior to discharge give:
Head injury advice sheets
ACC
Prescription
Refer to Concussion Clinic as clinically indicated-back to the GP in the first
instance who can then refer on if needed. Most will settle down without
concussion clinic
b.
Post procedural sedation
The patient is to be monitored until fully awake
May eat and drink and be mobilised as condition allows (contact Physiotherapist
if clinically indicated e.g., after a hip relocation and if needed)
Review by medical staff before discharge
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Emergency Observation Area (EO) guidelines
Refer to Procedural Clinical Pathway
c.
Alcohol intoxication
Follow the alcohol intoxication pathway
Consider the need for Alcohol Withdrawal Scale and ensure medication is
charted as needed
This group is high risk for seizure, close observation and access to emergency
equipment is necessary
Follow-up should be arranged with Social Work team in the morning and is
mandatory for underage patients
d.
Overdose
Treatment and observation is dependent on the drug taken
Follow-up ECGs and / or blood levels may need to be taken, as well as regular
vital sign recording
Organise Static Guard watch, if required. Ensure the guard has the observation
form and understands the level of observation required (Security staff will also
ask that their request form is signed).Two patients may be able to be observed
by one security guard depending on the level of observation required.
All patients should have had Psychiatric Consult Liaison Team (PCLT)
assessment prior to admission
Follow up with CR must occur before discharge
Clothes and belongings should be labelled and securely stored away from
patient (locked in the drug room) until they are deemed safe to leave by CR
e.
Patients awaiting review by Crisis Resolution
Admit under Emergency Team even if the patient is medically clear whilst they
are waiting for review from CR.
Organise Static Guard watch, if required. Ensure the guard has the observation
form and understands the level of observation required (Security staff will also
ask that their request form is signed).Two patients may be able to be observed
by one security guard depending on the level of observation required
The CR patient is to remain in a hospital gown
Clothes and belongings should be labelled and securely stored away from
patient (locked in the drug room) until they are deemed safe to leave by CR
f.
Renal colic
Ensure regular / PRN analgesia charted prior to admission and give as charted
Encourage oral fluids or give IV fluids if vomiting
Check CT scan appointment – patients who have stayed overnight can usually
go to radiology at 0700 for CT.
Follow up CT results
Complete renal colic pathway
The Urology Registrar should review these patients at 0900h (document if this
does not occur)
g.
Post-ictal
Hourly vital sign recordings and neuro observations required
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Emergency Observation Area (EO) guidelines
Be prepared for further seizure activity and have resuscitation equipment
available. (Know where airway, ambu-bag, suction, anticonvulsant medications
etc. are stored)
Check area for hazards
h.
Chest pain
Patients identified as suitable according to the Low Risk Cardiac Chest Pain
Pathway need to follow pathway for follow up blood tests and exercise tolerance
test (ETT)
i.
Patients pending discharge or transfer
Discharged patients
Some patients from other areas of ED who are waiting for a ride home may sit in
ED Obs to be collected.
These patients will not be admitted to ED Obs but have ED Obs in loop 17 of
the computer screen
Patients who are waiting for an ambulance transfer
These include patients who sometimes wait an extended time for an ambulance
and may require nursing input and should be admitted into ED Obs.
Patients who need to be admitted under an inpatient team following ED review:
General Medical team: contact the AMAU ACNM who will arrange a bed
Other teams: order the bed through the duty manager
then ring the ward
to inform them of the transfer and provide handover
The green sheet is amended, the patient is then transferred to the new ward,
and on the computer they are transferred to the new ward)
j.
Isolation
EO6 and EO7 can be used as the first choice for isolation patients. Other
cubicles can be used, with curtains around, as isolation rooms
There are two Isolation toilets available to EO patients. Place signs on the doors
to identify them if they are in use for isolation
Ensure Personal Protective Equipment (PPE) is outside door and use it
Display open Isolation Flip Chart on door (or curtain)
Use red linen trolley with dissolvable liner and yellow rubbish bag, as necessary
Order Terminal Clean through operator or page OCS and fill out maintenance
request book
k.
Wound management
Patients requiring wound care can have their wound care undertaken and
managed in ED Obs
l.
Back pain
Sinister causes have been considered-see pathway
Usually patients with mechanical back pain who require analgesia and
mobilisation
m.
Patients who primarily have social issues
Ensure early Social Work / MDT referral
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6
Staffing
a.
Nursing
x3 RNs per shift* comprised of 1 Team Leader and 2 nurses
x1 hospital aid working between ED Obs and WU
*Night shift - the third RN will commence the shift in WU and remain there until
0300 or when it closes (whichever is the earlier time), then go to ED Obs
b.
Medical
SMO/RMO – responsible clinician
c.
Clerical
Clerical cover 0915-2300
d. Hospital Aid
x1 HA morning and afternoon working across WU and ED Obs
x1 HA night shift working across whole of ED
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7
Nursing team leader role and responsibilities
Step
Action / expectations
1.
Patient load
The Team Leader on the morning and afternoon shifts does not have a patient load. On the
night shift the team leader will share the patient load until the 3rd RN joins the team .Patient
flow, support and supervision are the key responsibilities of the Team leader.
2.
Start of shift
Receive handover from departing nurses
Check the allocation, staff skill-mix and allocate the patients. On night shift locate the
3rd nurse and liaise with them.
Know which doctors have responsibly for the patients in ED Obs
If there are concerns about skill mix or staffing, then discuss this with the ACNM
Check nurses allocated to bay/equipment checks
Identify the order in which patients should be reviewed by the SMO to facilitate early
discharge of patients who are ready to go quickly
3.
Patient Flow
Patient flow is a key role of the team leader in ED Obs. This is facilitated through:
Inflow of patients from Resus Monitored, Work Up and Ambulatory:
Use the Bed Management Screen to ‘pull’ patients
Use ED Queue Screen to identify patients suitable for ED Obs
Liaising with Resus Triage nurse, WU and Ambulatory Team leaders to identify
suitable patients for ED Obs.
Liaising with medical staff regarding all patients who have been seen and remain
under the care of ED and are likely to be discharged as to their suitability for ED
Obs.
Seek handover from nurses re patients coming to ED Obs and arrange transfer
Using the dashboards to assist with patient flow management
Consider the patients being admitted to ED Obs in the early evening to ensure
there will be capacity overnight.
Outflow
Discharged from ED Obs
Create bed capacity by organising discharging patients into chairs
Ensuring patients have a discharge letter on leaving ED Obs
Assisting with transport options-liaise with and arrange ambulance/taxi/family
member/ rest home
Transfers to IP wards
Ensuring DNM phoned with bed request.
Ensuring ward rung with handover once bed allocated.
Communication
Liaise with and keep ACNM and SMO informed of ED Obs activity and capacity
Supervision and clinical oversight
Provide support and clinical expertise to the RNs working in ED Obs.
Follow up on treatment plan and medication prescribing
Update the computer as necessary
Relieve meal breaks
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Step
Action / expectations
4.
Drug check
Undertake drug check at the end of each shift
5.
Observation /Specialiing (Mental Health)
Review the observation/specialising requirements of patients
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8
Nursing team responsibilities
Step Action / expectations
1.
Patient care considerations
Organise patients for CT to go up to x-ray by 0700 (weekdays) 0800
(weekends)
Ensure analgesia / medications have been given for morning assessments
Check that follow up ECG and or blood tests have been done if required
Liaise with and organise list for OT, Physio, PES, Social Worker ,Maori Health
worker requirements for patients
Complete risk assessment forms
Provide hydration and nutrition
Communication with a multidisciplinary team
Follow up organised in the community as clinically indicated
2.
Safety checks –
EACH shift
Check that you know where alarms are located
Ensure the area is stocked and prepared for the shift ahead: check nurses
allocated to equipment checks are aware of their responsibility:
The defibrillator should be checked daily as per check list and signed off,
including that it is plugged into red essential switch power outlet, so that it
remains charged in an electrical failure
There are two other ambu-bags and assorted airways
Check other safety equipment located in ED Obs
Check each cubicle that there is O2 and connectors and suction equipment that
is working
Check fire exits are clear of obstruction
3.
Medications
Ensure regular and adequate analgesia is given to post injury patients,
especially before mobilisation with physiotherapist, and even though patients
may feel pain free at rest
Ensure usual medications are given as indicated – especially Parkinson’s
medications prior to mobility assessments
4.
Smoking cessation
All patients admitted to ED Obs are to have the smoking cessation section of
the nursing risk form or the smoking cessation on the discharge note completed.
The Ministry of Health requirement is that an intervention is offered to the
patient who smokes. This can simply be giving the patient a smoke free pack of
information (without the prescription) to view at a later date.
All nursing staff can do the online course, and earn education hours, about
smoking cessation and be deemed suitable to prescribe nicotine replacement
gum, lozenges’ and patches.
5.
Meals
Ten meal boxes supplied three times a day plus some boxed sandwiches. Order
more as required.
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9
Medical team responsibilities
Step
Action / expectations
1.
Admissions
The following documents should be completed by the admitting doctor, prior to
admission to EO:
Plan of care – all patients
Drugs charted – as clinically indicated
Pathway commenced – as clinically indicated
Imaging requests – as clinically indicated
2.
Discharges
The following documents should be completed by the discharging doctor, prior to
discharge from EO:
Discharge summary – all patients
ACC – as clinically indicated
Advice sheet(s) – as clinically indicated
Prescription – as clinically indicated
Referrals – as clinically indicated
10 Hospital Aide team responsibilities
Step
Action / expectations
1
Cleaning and stocking
From 06.30h to 08.30h the hospital aides’ time is dedicated to cleaning and
stocking the EO or Work Up equipment. Restock and clean as required at other
times
Check CR interview rooms
2
Care provision
At other times the hospital aides may assist the nurses to provide personal or
nursing cares.
Transfer patients to ED Obs as requested.
11 Clerical team responsibilities
Step
Action / expectations
CLERICAL COVER 9.15AM – 11PM
General duties
Telephone enquires
Assist Team Leader
Update screens
Restock printers
Keep all patients documentation in tidy order
Assist Dr/Nurse with data entry
Fax referral
Fax any Discharge documentation
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Step
Action / expectations
Track Clinical Record
Transfer patients on PMS to wards and ensure all paperwork is collated and
send with the patient
Put any incomplete HCS notes in the Duty Room for the doctor to complete
Discharge
Discharge patients on PMS
Prepare discharge documentation
Fax to GP any relevant information
Track Clinical Record
Order Orderlies
Order transport for ambulance patients
Photocopy all notes for Hillmorton patients
ACC – check complete
Organise OCS to do terminal cleans
Check filing baskets complete/incomplete
2.45pm – move to assist Resus “high chair” person with entering change of
nurse codes
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Document Outline