Dr Lisa Niklaus
Consultant Emergency Medicine
Dr Tony Joy
ST5 Emergency Medicine
October 2012
QUEUE FOR TRIAGE,
BANK HOLIDAY JUBOLYMPICS
THE SOLUTION?
Majors –
Ambulance
handover
Triage –
initial
assessment
Majors –
Cubicle
assessment
Investigations
Dr Review
Treatment
Majors –
Ambulance
handover
Triage –
initial
assessment
Dr Review
Investigations
Treatment
 Two
triage nurses for walk in patients
 Nurse coordinator taking ambulance handover
 ‘Recipe book’ of investigations to be requested
 Intermittent nurse requesting of x-rays
 HCA for blood tests / ECGs
 5.5
WTE Consultants (two per day)
 16 Middle Grades
 12 FY2
 One Consultant 0900-1700
 One Consultant 1400-1900
 Roles:
• Ward rounds at 0900, 1400 and 1800
• Covering majors, paeds, resus, clinical decision unit
•
•
•
•
•
•
(CDU)
Reviewing patients
Reviewing cards in the queue
Clerking patients
Review clinic
Supervision & training of juniors
Managing the shift
 Pilot…
 Consultant
12-16, Middle Grade 16-20
 [Locum MG 12-20 – support for additional consultant]
 Nurse
 HCA
 RAT mobile…
RAT 1 – Dr & Nurse for walk-in patients
RAT 2 – Dr & Nurse for ambulance patients
 Brief
history from patient / paramedic
 Focused examination if required
• RAT two team go with patient into cubicle
 Request
blood tests / urinalysis / ECGs
 Request imaging
 Initiate treatments
 Stream: to specialties or other providers
 ‘See & Treat’ simple conditions
 Juggle
Pre-RAT
Post-RAT
Time to initial assessment 38% < 30 mins
69% < 30 mins
Time to treatment
20% < one hour
55% < two hours
30% < one hour
70% <twohours
Consultant sign off
10%
44%
Time to ECG
55% < one hour
92% < one hour
Time to blood tests
42% < one hour
68% < one hour
Time to x-ray request
31% < one hour
46% < one hour
Time to analgesia
53% < one hour
73% < one hour






Time critical treatments that make a
difference to quality of care
Ordering scans early
Starting simple treatments that could
enable discharge within four hours
Reducing unnecessary investigations
Streaming to specialties
See & treat




‘its not a good use of my
skills as a consultant’

You do more than you think

Are you doing this already, in
a less structured way?

Same work, done differently

Do you need a designated
area?
‘we don’t have enough
doctors’
‘we don’t have enough
nursing staff’
‘we don’t have any space’
 RAT team disappeared
• ‘Incentive money’ discontinued
• Changing ways of working within nursing team?
 Out of hours
• Middle grades struggle to keep system going
 Rapid
assessment may lead to overinvestigating
working – can feel like only person
seeing patients
 Intense