30 March 2007 - Auckland

1. The Clinical Initiatives Nurse in the Emergency DepartmentPresenter: Cathy MillerHospital: Apollo 30 March 2007 - Auckland

2. KEY PROBLEM Overview • Increased demand for Emergency Services leading to lengthy delays for emergency care. • Lyell McEwin ED • 49,000 presentations per annum • 150 adult beds available for admission • 15% increase in presentations each year for last 3 years • Other LMH Initiatives • 23 Hour Ward • Nurse Practitioner (4) lead ‘See and Treat’ • Medical Assessment Unit • Patient Streaming A, B, C • Mental Health Streaming Initiative

3. AIM OF THIS PROJECT • Improve quality of care in ED • Decrease time to treatment and length of stay in ED • Increase level of patient safety • Assist in overcoming the effects of access block

4. KEY CHANGES IMPLEMENTED Action Plan – Stage 1 • Identify project aims • Formulate a basic process for operations • Identify additional resource requirements • Develop Clinical Pathways and Education Plan • Select staff with appropriate skills

5. KEY CHANGES IMPLEMENTED Action Plan – Stage 2 • Distribute information to candidates • Begin Education/Information sessions • Precept in initial stages of role and provide ongoing support Action Plan – Stage 3 • Evaluation (3 months) • Further Development

6. KEY CHANGES IMPLEMENTED CIN Clinical Operations • CIN role targeted at the groups of patients that experienced the longest waiting times • CIN intervention limited to assessment and commencement of treatment and investigations • Initiate treatment utilising Standing Drug Orders and Clinical Pathways

7. OUTCOMES AT 3 MONTHS • In the initial 3 month period 1 x CIN was introduced as an additional nursing member on the evening shift • 66% shifts attended by CIN • Targeted Patients • 92% of patients were priority 3 and 4 • 77% of patients were abdominal or trauma presentations • CLINICAL PATHWAYS • Chest Pain • Collapse • Abdo Pain • Headache • Limb Injury • Hip Injury • Flank pain • PR Bleed • PV Bleed • TMC • Eye Injury • Dyspnoea • Urine Retention • D and V • Wounds • Febrile Child • 3

8. OUTCOMES AT 3 MONTHS • 708 patients • 58% of all patients seen by the CIN have assessment and treatment commenced within the triage threshold time • Patients seen 78 minutes prior to intervention from a medical officer or nurse practitioner • Represents 39.6 days of waiting time in the first 3 months • Results often at hand by the time of MO attendance • Treatment underway and evaluated • Low numbers of additional tests ordered by MO indicated clinical pathways development has been accurate • Time to discharge reduced 20.5minutes • Time with patient is 20 minutes

9. PROJECT EVALUATION • CIN success have been offset by a continuing rise in ED presentations • The CIN role has been well received by patients and ED staff • Faster turn around has been noted • Now have 11 CIN trained staff Level 1 RN’s • Plans to further extend this number to include all Senior ED nurses • Services to be extended to include peak period extending into night shift

10. CONCLUSIONS • Results during this initial period clearly show that suitably trained nursing staff utilising problem specific clinical guidelines can have a positive impact on time to treatment and length of stay for many ED presentations.