A year of innovation in the ED. Part 2- Patient Pathways.

The Kaizen events pointed us towards areas we wished to improve and 'blue sky thinking' solutions. The real question was whether we could build these solutions into processes that would work for our patient population, our staffing and our space.

The biggest piece of work was around the patient pathway. The data made it clear that we have some work to do to consistently achieve the 95% 4 hour standard. You can argue about whether the 4 hour target is the best way to measure ED performance or not. Ultimately its evidence base is around improving patient outcomes....and it is how we, in Scotland, are measured.

The aim for the patient pathway work was to make our patient’s course through the ED as smooth and efficient as possible. Other work, done in the ED over the past few years, had also focused around this area. Major’s triage, an enhanced triage system run by our nursing staff for ambulatory patients, and the Minors RAT model run by our ENPs had already shown improved patient journeys. They showed reduced time to analgesia, ECG and recording of SEWS scores. We needed to build on those improvements and push them forward to ensure all patients received the same high quality care.

The One Patient Pathway brought together these 2 streams of triage. It increased the size of the triage team, added medical staff to the mix, and extended the system to include all patients presenting to the ED. The patients are met by the triage team and rapidly assessed by a senior clinician, usually an ED Consultant. They receive front load assessment in the triage area so initial blood tests and x-rays can be requested, analgesia administered and patients re-directed if they could be more appropriately managed in a different part of the healthcare system.

Clinician led triage is not a new concept. Many hospitals around the UK already run similar systems, with good results. We could have adopted the system without going through the Kaizen process. The strength of our system is in the methods we've used to get to this point. Every discipline has been involved in its design. Our system is designed in response to the evidence, collated and examined, during the kaizen events. Our system is designed to match our staffing levels and patient flows.

I would like to sit back and say that all the planning and design made the One Patient Pathway a breeze to introduce. I think it is fair to say that some parts have been easy to implement, other bits harder. Change is difficult. Not only have we changed our way of triaging patients, we have also changed the use of our floor space and the allocations of our staff. It has taken a bit of getting used to. The huge amount of support from all staff groups in implementing this process has been fantastic. Without the team working, resilience and perseverance of the ED staff we could not have achieved so much in so little time.

For me one of the hardest parts has been learning how to triage. As a clinician my desire when I meet a patient is to work out what is causing them to feel unwell and to cure it. An ideal, I accept. The concept of triage and rapid assessment takes away the mystery....I get to formulate a decision based on years of pattern recognition, request the tests, ease the pain....and someone else gets the answer. On the plus side the patients get a better deal...and as often as not I am on the side that has the answer (without having to request the tests myself!).

So how have we got on? On an almost daily basis I hear stories of patients whose journeys have been greatly shortened by early recognition and management of their medical complaints. Early US scans showing intra-abdominal pathology, pacemaker reports and adjustments available within an hour of patient arrival, head CT results available at time of care provider assessment. These are cheering stories and great for individual patients, but are we making a difference for the larger cohort? We are.

I'll spend time going through the results in more detail over the course of the next few blogs. For today, the bottom line; the One Patient Pathway has improved our compliance with the 95% 4 hour standard. More importantly the length of ED stay for patients is being reduced across the board. That's great news for patients, staff and the hospital. Thank you all for your hard work.