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International Emergency Medicine Perspectives on Quality and Implementation of Best Practice: PERSPECTIVE CEM/IFEM Symposium: Quality and Safety in Emergency Care Nov 15-16 London 2011 Dr Carmel Crock FACEM Director, Emergency Department, Royal Victorian Eye and Ear Hospital, Melbourne, Australia & Chair, ACEM Quality Subcommittee Outline 1. Emergency Medicine (EM) Background & Challenges in Australia & New Zealand 2. ACEM Quality Framework 2011 3. Training & Education 4. Research Population & Emergency Dept Visits Population • Australia ~ 22 Million - 2010 • New Zealand ~ 4 Million - 2010 Emergency Department visits • ~ 6 Million per year Australia • ~ 1 Million per year New Zealand Hospitals Approved for Emergency Department Training ACT NSW NT QLD SA TAS VIC WA AUSTRALIA NEW ZEALAND TOTAL 2 33 2 21 6 3 22 11 100 13 113 Australian Challenges http://www.ozanimals.com/image/albums/plants/OzPlant/Acacia-pycnanthaGolden-Wattle.jpg http://www.theodora.com/wfb/photos/australia/australia_photos_45.html Marine Challenges http://www.iscvid2011.com/images/uploads/snorkel_cairns_greeen_island_ great_barrier_reef.jpg http://picasaweb.google.com/lh/photo/yIzUrgSMNvTEbFaNdBidGg http://anakbawang.com/wp-content/uploads/2010/04/Box-Jellyfishattack.jpg Terrestrial Challenges http://australianmuseum.net.au/image/White-Lady-Spider-Catherine-Jubb http://www.idilium.com/spiders/redback%20spider%203.jpg http://images24.webshots.com/25/8/65/103786536xKBuGM_ph.jpg Everyday challenges City • Ambulance ramping • Access block • Increasing presentations • Access to primary care Country • Staffing rural/remote EDs • Rural/remote ambulance service Australasian Triage Scale (ATS) Triage Description Category 1 Immediately life-threatening, 2 3 4 5 Maximum Clinically Performance Appropriate Triage Time Benchmark Immediate simultaneous triage and treatment 100% Imminently life-threatening, or important time-critical Potentially life-threatening, potential adverse outcomes from delay > 30 min, or severe discomfort or distress Potentially serious, or potential adverse outcomes from delay > 60 min, or significant complexity or severity, or discomfort or distress 10 minutes 80% 30 minutes 75% 60 minutes 70% Less urgent, or dealing with administrative issues only 120 minutes 70% Emergency Presentations Waiting Time Statistics in Major Public Hospitals 2009-2010 • Proportion seen on time 70% • Median waiting time to service delivery 23 minutes • 90th percentile waiting time to service delivery 115 minutes • Proportion ending in admission 27% Policy on a Quality Framework for Emergency Departments “ACEM recommends all emergency departments should have a documented quality framework.” ACEM Recommends All Emergency Departments should have a Designated Quality Team with defined Roles Responsibility Reporting This Team should Include Staff who are Medical (must) Nursing (must) Clerical (may) Allied Health (may) ACEM Strongly Recommends Developing a Balanced Quality Program Policy for EDs 1. Clinical 2. Education & Training 3. Administration 5. Research 4. Professional 1. Clinical Profile ED should demonstrate... Regular clinical audits (examples): • high volume or high risk clinical conditions • documentation standards • clinical guideline compliance/variance • consultant sign-off for high risk patients • time to critical interventions • time to analgesia • written discharge instructions • unplanned returns to emergency department 1. Clinical Profile … • Participation in Clinical indicator collection • Australian Council on Healthcare Standards (ACHS) indicators • ACHS previously 9 for emergency medicine • ACHS increased to 21 in 2011 ACHS ED Indicators 2011 • • • • • • • • • • Critical care patient total ED time > 4hrs Time from referral from ED to assessment by mental health Time to antibiotic in sepsis in infant Paediatric asthma receiving salbutamol < 30 min Discharge communication to primary care provider Documented risk assessment prior to discharge patient > 65 years Documented initial pain score Documented pain reassessment score Time to analgesia abdominal/limb pain Did not waits (mental health/other) 1. Clinical Profile … Audit of procedural complications Audit of medical imaging/pathology (examples): – appropriateness – turnaround time – results checking * Joint College working parties ACEM - Radiology/ACEM Pathology 1. Clinical Profile … Involvement in whole of hospital initiatives (examples): – – – – – hand washing clinical handover recognition of clinical deterioration safety survey procedure for patient identification and procedure matching 1. Clinical Profile … Participation in national registries, submission of data to jurisdictional / national registries relevant to hospital profile 2. Education and Training Profile • Departmental educational program - regular meetings, protected teaching time, evaluated • Departmental educational roles – Director of Emergency Medicine Training (DEMT) – Nurse Educator • Accredited training courses, e.g.: – APLS – EMST – instructors, staff who have completed competencies 2. Education and Training Profile • Medical student teaching and training • Credentialing of staff (e.g.): – ultrasound – procedural sedation • Participation in multidisciplinary, interdepartmental, and prehospital & retrieval education 3. Research Profile • Academic emergency appointments - professor, lecturer, fellow, post grad students • Research grants/awards/projects (internal and external to the department) • Research presentations at scientific meetings (including poster and oral presentations) • Publications by emergency department staff (e.g.): – book chapters – refereed journal articles 4. Administration Profile • A Designated Quality Team (staff as outlined earlier) • Regular audits (e.g.): – waiting times – death audit – trauma audit – complaints/patient satisfaction • Risk management (e.g.): – formal pathology and radiology results checking process – incident monitoring * with feedback to clinicians • Financial/Equipment/Workforce considerations * Proposal for ACEM- led Incident Monitoring project 5. Professional Profile … • Liaison with quality and accreditation organisations (e.g.): – Australian Council on Healthcare Standards (ACHS) – Australian Commission on Safety and Quality in Healthcare (ACSQHC) – Australian Institute of Health and Welfare (AIHW) • Participation in hospital committees EMERGENCY MEDICINE TRAINING IN AUSTRALIA/NEW ZEALAND Basic Training 2 PG Years Provisional Training 1 Year min, 6 month ED min Primary Examination Advanced Training 30 month ED 18 months non-ED Fellowship Examination Research Post Fellow -ship CPD ACEM “… recognises that a significant number of emergency departments and services, particularly in regional and rural Australia, are staffed by medical graduates who may not be specifically trained in emergency care. A commitment to providing more education and training and supervision for these doctors ...” Certificate/ Diploma of Emergency Medicine … Based Certificate available from mid 2011 6 months supervised clinical practice in approved ED 46 enrolled, 200 supervisors trained Diploma available from 2012 further 12 months supervised clinical practice in approved ED + 3/12 ICU + 3/12 anaesthetics on current best Workplace practic Assessment e in educati Online Learning onal Modules researc e-Portfolio h Reflective Journaling Benchmarked with Best Practice Continuous Professional Development Mandatory Annual Online Reporting Continuing Research Medical Teaching Education Presentation Examinations Quality Improvement Skills Maintenance (incl Procedural Skills) Continuous Professional Development 1. Role of ACEM credentialing currently 2. Move towards provision of training - future Research • Trainee requirement – research component • ACEM Research award • Government funding: – triage scale literature review – impact of 4 hour target • Director of Policy and Research – recently appointed – advocacy, external focus Conclusion • Time based targets – mandatory • New ACEM Quality Framework 2011 – ”recommendations” • New ACHS ED Clinical Indicators 2011 –greater emphasis on quality, however non mandatory • Transition phase…..? move towards mandatory reporting of quality indicators alongside 4 hr target Finally, There are Challenges in How We Measure Quality in the Realities of ED … http://www.news.com.au/top-stories/heart-attacks-in-waiting-rooms/storye6frfkp9-1111114514878 ACEM http://www.acem.org.au Dr Carmel Crock [email protected] http://bluegumpictures.com.au/images/medium/04/04_14867.jpg