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
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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
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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
carmel.crock@eyeandear.org.au
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