In this part of the blog we aim to describe both how our new system has been designed to work and how we went about introducing this, frankly massive, test-of-change.
The primary aim of this test was to reduce time to first assessment but also to improve both staff and patient experience. We had previously had feedback from our patient group and had generated several hundred patient journeys over the preceding twelve months from a new medical student programme that had allowed us to identify that multiple handoffs, repetition of activity and excessive movement throughout the department was detrimental to everyone involved.
We decided to split our department into 5 separate teams or ‘Pods’. This was largely done as our department geographically aligned itself to this number as well as consultant day time numbers matching this number of pods. This created a Resus Pod, 3 Pods for Emergency Department patients and 1 Pod for the medical receiving (interface) team and other specialties. Each Pod would have 8-9 cubicles and our current numbers meant that we could aim to staff each Pod with the following:
- A senior doctor (Consultant or ST4+/Senior specialty doctor)
- Several junior doctors or ANPs (numbers increasing throughout the day to match attendances)
- 3 trained nurses
- 1 clinical support worker
We would also have 2 ‘Bernadette Nurses’* to perform a rapid triage. One Bernadette nurse would receive patients arriving by ambulance and one would receive patients who self presented to the department. The role of the Bernadette nurse is to receive patients and take a brief history or handover which would allow them to triage the patient and either send them to a Pod or redirect them to an alternative service such as the Minor Injuries Unit or Early Pregnancy Unit. To maintain flow through these areas it was decided that observations and other investigations would not be done at this point but would be done immediately on arrival in the Pod. The Bernadette nurse would decide which Pod to send each patient to by using the real time MedTrak computer system to see which Pod had the capacity, along with feedback from a Support nurse who would inform them if a particular Pod was stressed due to capacity or acuity. Patients would be transferred to individual Pods by a CSW or porter.
Each Pod would have a nurse designated as Safety Lead and, with the senior doctor, they would be responsible for ensuring that patients were being met and cared for in a timely fashion including ensuring that care rounds occurred, pain scoring and neuro obs were being done and being responded to. They would be supported by a Support Nurse who would be available to respond and react to individual Pod needs.
The design is for each patient to be received directly into a Pod in a cubicle by a nurse, junior doctor or ANP and the senior doctor. As a team they would perform observations, take an initial history and decide on and undertake necessary investigations or treatments and potential early admission or streaming to a particular specialty. The patient would remain the responsibility of that Pod for the duration of their stay in the ED to ensure continuity of care, although fit-to-sit was to be encouraged to maintain capacity in each Pod.
2 Pods were designated as Primary Pods and would remain open at all times (excluding the Resus Pod). The other Pods would be closed during times of reduced activity and staffing so that the teams were not spread too thinly. If required the bed spaces from the closed pods could be used by the 2 primary pods to maintain capacity.
We also took the opportunity to plan for mini-pod pauses. These would be brief multidisciplinary meetings in each pod to discuss any concerns, review actions and ensure staff wellbeing which could then be fed back into the main departmental pauses that occur 2 hourly with the senior staff for the department and management from the hospital.
‘Without data you are just another person with an opinion’
- W Edwards Deming
From the initial idea of this model we were set the challenging timeframe of delivery of 4 weeks. We put together a working group and initially discussed the very basics of how this model of care could be delivered. This was followed by a staffing exercise to ensure that we could adequately staff this model with our existing staff numbers 24 hours a day.
We then set about deciding on our data metrics. We agreed that this process was primarily about 1st assessment and this became our primary outcome measure. We decided on a range of process measures including time to triage, length of stay in the ED and staff and patient satisfaction measurements. Our primary balancing measure would be time to first investigation. ‘What matters to you’ Day allowed us the opportunity to gather some useful baseline data regarding staff experience. We worked with our data analyst team to develop these metrics as well as a real time data dashboard that would tell us what was happening in both the department and the individual Pods.
Our department has several hundred members of staff once all the nursing, medical, AHP and various vital support staff are calculated and ensuring that every team member knew what was happening, why it was happening and how it was going to affect them at the earliest opportunity was going to be key to any success. We needed a unifying brand and #PODSquad was born. The Narwhal was chosen as a logo (whales travel in Pods and the Narwhal is the unicorn of the sea, although we now know that a group of Narwhals is called a Blessing).
A small group of us sat and went through the plans adding in detail so that we could produce a standard operating procedure. This allowed us to try and consider, and plan, for a variety of contingencies such as increased activity or acuity. We used this detail to create the following video which we could then circulate around the staff and show at handovers to inform everyone of the test.
Prior to the launch of #PODSquad the video had been watched over 700 times.
We ran a Flowopoly exercise modelling an average day’s activity through the department with the #PODSquad model of care to identify any major problems and any areas of concern. Whilst the model worked well we did identify the following 3 issues as points of concern:
1. At times of peak business the Bernadette nurse for self presenting patients would be overwhelmed (estimated that they could triage 12 patients per hour) and would need support from the Nurse in Charge.
2. If patients were not directed to sit in the waiting room to await results if sufficiently well then maintaining capacity in the Pods would be difficult.
3. We needed to ensure flow out of the Pods by early decision making regarding admission or transfer to another area such as the observation unit when appropriate.
We developed roles and responsibilities for all staff members and developed templates for the mini-pauses and main departmental pauses. We also undertook the process of ensuring that each area of the department would have the right equipment, right medications and sufficient monitoring. Prior to this we had cohorted patients in different parts of the department depending on their acuity. Our plan was now to spread acuity out across the department and we needed all areas would be adequately equipped. Staffing was mapped and assigned for the full 2 week test.
Our eHealth department agreed to support us by producing a new layout for the system on MedTrak and we had new signs delivered for the department to create the sense of physical change as well as process change.
Throughout this time we spent as much time as possible simply talking to as many staff members as we could to talk them through the process and answer any questions that might arise. We included spreading this message to every other department in the hospital and to the ambulance service so that no one would be fazed on arrival in the department.
At 0700 on Monday the 17th of June we were ready and we started our test.
Results to follow soon......
*I do not know why it was decided that the triage nurses were to be called Bernadette nurses but like all good doctors in certain circumstances I just do what my nurses tell me to.....