Safe staffing: snowed-under ED now swamped with help

1 May 2012

Tauranga Hospital’s ‘busy’ emergency department used to often find itself at 150 per cent capacity on a daily basis. (See also "How Busy is Your Ward")

It would soldier on as more and more patients built up in the waiting room, the corridors, and even the ambulance bays. Responses to calls for help from the wider hospital were sometimes haphazard thanks to confusion over what overloaded actually meant …

In the past year, ED clinical nurse manager, Marama Tauranga, says she has been in the novel situation of turning away offers of help.

The introduction of the new variance and “hospital at a glance” tools has made the ED workload and triage surges visible to the whole hospital as never before.

Tauranga says while the VRM tool is no ‘magic pill’ – the department is still to reach the government’s target of 95% of ED patients turned around within six hours – it has “absolutely” made a difference and had an “amazing impact”.

“Prior to VRM, we had a state (where) we would often be 150 per cent occupied on a daily basis. That means people in corridors, people in our ambulance bay, and our ‘did not wait’ (DNW) figures were through the roof on a daily basis.”

Nowadays, she says it’s rare to have patients in the corridor and its DNW figures were at least 40 per cent better than they were.

Prior to the electronic variance tool, the department already had its own traffic light system and overload plan but it wasn’t well understood by the wider hospital, says Tauranga. An overloaded ED might report it had gone ‘yellow’, but that didn’t necessarily mean much to the duty manager.

“We didn’t feel like we were getting the response we required because we weren’t speaking the same language.”

When the SSHW unit came along and work began on a hospital-wide variance tool, things started to change. Now, every shift, Tauranga or the shift co-coordinator takes a ‘barometer reading’, in league with consultants on the floor. With the touch of a key, the ED’s status is visible on every computer in the hospital.

If the ‘hospital status in a glance’ tool and ED ‘worm’ shows a triage surge on the way, the team re-checks its variance colour and has “huddles” with its consultants every two hours to ensure it doesn’t flip into the next variance level.

The ED worm is a statistical tool hat that shows the ED attendance forecast for the day and then tracks it minute by minute against the actual patients registering at triage.

“One indicator we know that trips us over the edge is if we get more than eight patients at triage registered within an hour when the ED is already 75 per cent full. That can actually cause the ED to be over 100 per cent occupied.”

Tauranga says ED staff were surprised to find the ED didn’t descend into ‘red’ as often as expected, as process improvements have led to better patient flow hospital-wide.

“After midday, when we are already humming along and fairly much full, if you then get a couple of hours of patient surges coming, then you can flip into yellow.

“We don’t really get too fussed. We might not ask for help from the wider hospital as we might be able to ride that surge and use our own plan [including Tauranga and the nurse educator going onto the floor if necessary] and move back into green within a short space of time.”

Now the ED doesn’t even have to ask for help for the phone to start ringing. People are attuned to keeping an eye on the ‘ED worm’ and ED colour code.

“You aren’t in a silo any more. Someone might ring and say, ‘Noticed you’ve had two hours worth of surge. Are you guys okay? Is there anything we can do?’”

ED has even had the embarrassment of turning junior doctors away who turned up offering help on hearing about an ED surge. A text appeal now only goes out to junior doctors on the wards if okayed by the shift co-coordinator.

While VRM may not be the ‘magic pill’, it is helping ED step close to meeting the elusive 95% six hour target.

Tauranga says the department is now tracking in the “early 90s” and is making steady progress thanks to VRM, the new standard operating procedures (SOP), and the daily integrated operating centre or “state of the nation” meeting involving representatives of all staff from clinicians to security.