FHED - Winter Demand Model of Care - Western Health Emergency Department

June 15, 2022

Overview

The standard Footscray Hospital Emergency Department (FHED) Model of Care is being altered to improve flow through the department during peak winter demand period.

This altered Model of Care (MOC) utilises the current ‘Blue Side’ cubicles to include the addition of three Triage Assessment Rooms and three Transit Cubicles. The altered MOC aims to:

Increase FHED capacity by six points of care
Improve flow through the department
Improve safety of patients in waiting room by commencing early interventions and investigations
Improve timely offload of patients waiting on an Ambulance Victoria stretcher
Improve patient experience

The six additional points of care will initially be operational between 0700hrs and 2130hrs.

Triage Assessment Rooms:

Flow through TARs

Maximising the benefit of TARs to the most patients requires flow through the TAR. Ideally, most if not all patients are returned to the waiting room after assessment.

Any patient unable to be transferred back to the waiting room due to clinical concerns must wait in the TAR until another cubicle is available.
Any patient seen in the TAR for whom a decision is made to admit (either to SSU or the ward) must have a bed-request made and wait in the TAR until another cubicle or SSU bed is available. During this time, they will be the responsibility of the TAR nurse.

If there is significant clinical concern about a waiting-room patient, it is suggested the TARs be used only if another solution cannot be found after collaboration with the NIC, and only for as long as is required for alternative space to be created.

Staffing

One Nurse (TAR Nurse) will oversee three TARs working closely with the Triage Nurse, Nurse in Charge and Yellow Emergency Physician to ensure patients are efficiently and safely streamed in and out of the TARs. The TAR Nurse works in close proximity with the Transit Cubicle Nurse sharing responsibility of the two areas.

The TAR Nurse is responsible for:

Assessment of patients in the waiting room – prioritising those who are most unwell (ie Cat 3s) or those who have exceeded the recommended ATS wait time
Initiation of investigations and simple treatments
Escalation of patients showing signs/symptoms of clinical deterioration

The third (Yellow) Emergency Physician will have oversight of the TARs and is responsible for:

Be the point of contact for the TAR Nurse
Identify patients in the waiting room for who a medical assessment may facilitate discharge or SSU admission
Provide rapid medical assessments with view to early discharge or SSU admission

When only two Emergency Physicians are rostered, the Emergency Physician in- charge will have oversight of this area.

TAR Assessment, Investigations and Treatment

Table One outlines the assessment, investigations and treatment that should be performed in the TAR where clinically indicated and determines suitability to be returned to the waiting room.

Table One: Triage Assessment Room Nursing Assessment, Investigation and Treatment

	Permitted for all patients	Only if clinically necessary
Assessment	· Nursing assessment · Vital Signs · Medical assessment
Investigations	· Bloods via venepuncture (IVCs should not be routinely inserted in TARs unless clinically necessary) · ECG · Nurse initiated xrays · Doctor initiated investigations	· IVC
Treatments	· Nurse initiated analgesia · Other oral medication (i.e. antiemetics, antihistamines, oxycodone*) as prescribed by senior MO (EP/registrar)	· IV fluids · IV medication infusions including antibiotics · Oral contrast
Return to waiting room	Patients can return to the waiting room after having the above interventions *Reassessment after oxycodone required before return to WR	Patients requiring the above interventions, or those determined to need admission should not return to the waiting room. These patients should remain in a TAR until a cubicle or ward is available

Documentation

The TAR Nurse will record all vital signs, patient assessment and interventions on EDIS or an Emergency Department Adult Flow Chart (AD51.2a)
The TAR Nurse will start an Emergency Department Adult Flow Chart (AD51.2a) for patients requiring admission to a ward or SSU (if bed immediately available – a chart can be commenced in SSU)
Medical assessments will be documented on EDIS

Transit Cubicles:

Flow through Transit Cubicles

The Transit Cubicles provide one directional flow from acute cubicles within the ED through to an inpatient ward. Patients awaiting an inpatient bed and who have been accepted for admission by an inpatient unit may be streamed to a Transit Cubicle, creating acute cubicle capacity for arriving patients. Once an inpatient bed becomes available, the patient should be transferred by the Transit Cubicle Nurse to the Ward.

Patients who meet the following exclusion criteria should not be streamed to a Transit Cubicle and should remain in an acute ED cubicle until a bed becomes available on the ward:

Clinically unstable (meets Urgent Clinical Review or Met Call criteria)
Requiring cardiac monitoring
Significant Beahaviours of Concern (BOC>1)

Staffing

One Nurse (Transit Cubicle Nurse) will oversee three Transit Cubicles working closely with the Nurse in Charge to ensure patients are efficiently and safely streamed through the area. The Transit Cubicle Nurse works in close proximity with the TAR Nurse sharing responsibility of the two areas.

The treating inpatient unit and assigned ED Medical Officer (as pre EDIS) will provide medical oversight in line with current practice.

Provision of Care in Transit Cubicles

The Transit Cubicle Nurse will be responsible for providing nursing care to patients in this area including but not limited to:

Identifying patients appropriate for streaming into a Transit Cubicle
Receiving clinical handover for patients arriving to a Transit Cubicle
Minimum of two hourly vital signs
Provision of hygiene and comfort measures
Administration of medications as per EMR
Implementation of relevant care plan as per interim admission order (4 hour plan) or admission notes
Completion of relevant risk assessments
Clinical handover (and escort if required) to admitting inpatient ward

Escalation of Deterioration

Patients whose clinical condition deteriorates whilst receiving care in a Transit Cubicle should:

Immediately be escalated to the Nurse in Charge and Emergency Physician in Charge
Further escalation in line with the Recognition and Management of the Deteriorating Patient in the Emergency Department PPG
If required, returned to a resuscitation bay or acute ED cubicle until a ward bed become available or condition stabilises

Documentation

The Transit Cubicle Nurse will record all vital signs, patient assessment and interventions on the Emergency Department Adult Flow Chart (AD51.2a) and the Electronic Medical Record as required

Operating Hours

The Triage Assessment Rooms and Transit cubicles will be operational between the hours of 0700 and 2130. In order to ensure the cubicles are decanted before 2130 the following should be considered:

Streaming to this area after 2000hrs should only occur if expected discharge by 2130 hrs
Any patient remaining in this area at 2000hrs and who is unlikely to be discharged at 2130hrs will require:
Return to waiting room if not admitted and appropriate
Admission to SSU
Acute cubicle in main ED

Supporting Documentation

Recognition and Management of the Deteriorating Patient in the Emergency Department (DP-GC4)

Clinical Handover (OP-GC1)

FHED – Transit Cubicle Nurse – Roles & Responsibilities

FHED – Triage Assessment Room (TAR) Nurse – Roles & Responsibilities

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