Extended Scope of Physiotherapy
Emergency Department
Deborah Lenaghan
Extended Scope Physiotherapist
Dr Paul Bowe
Director ED Robina
Health Workforce Australia (HWA) Funded Project 2012-13
Purpose of this Presentation
Report on extended scope of practice as an emerging
model of care
Discuss the process of implementation
Key lessons learnt
Demonstrate the impact of this service on organisational
throughput and quality
Background HWA





National Health Workforce Innovation and Reform Strategic Framework for Action
2011-2015
National Partnership Agreement on Improving Public Hospital Services (the National
Partnership Agreement)
Whole of system change
Mandate to address known areas of workforce shortage in the Australian health
system
Expanding the scopes of practice of nurses and allied health professionals
National Emergency Access Target
(NEAT)
 Also known as the 4 hour rule.
 By 2015 90% all patients will leave the
emergency department within 4 hours.
 Overcrowding & LOS associated with
poorer outcomes for patients

Richardson 2006; Spivulis et al 2006; Forero et al 2010;Baggoley 2011; Geelhoed 2012
NEAT Targets to be phased in 2015
Jurisdiction
Baseline
2012
2013
2014
2015
NSW
61.8%
69%
76%
83%
90%
VIC
65.9%
72%
78%
84%
90%
QLD
63.8%
70%
77%
83%
90%
WA
71.3%
76%
81%
85%
90%
SA
59.4%
67%
75%
82%
90%
TAS
66.0%
72%
78%
84%
90%
ACT
55.8%
64%
73%
81%
90%
NT
66.2%
72%
78%
84%
90%
Project
 HWA nominated 2 lead sites Alfred and ACT Health
 Partnered each with 3 implementation
sites
 Two lead sites – have different education
pathways
 In-house competency vs in-house
competency + university qualification
Background: Robina ED
 Pre-project Staffing: 0.5 FTE
secondary contact Physiotherapist.
 Proposed Project model:
 1 Extended Scope Physiotherapist
 5 days week for 10 months
 7 day service for 4 months.
 0.5 Project manager
Objectives
Objectives

Primarily to successfully implement and evaluate a locally adapted model of the ESP
Physiotherapist working within the ED at Robina Hospital by Jan 2014.
Secondary objectives : demonstrate

Increased productivity by demonstrating a change in patient flow and waiting times as measured
against the National Access and flow Targets.

Workforce reform by measuring workflow impacts particularly for medical practitioners and cost
effectiveness of this model.

Transferability/Sustainability by developing and implementing (in partnership with Lead Sites) policy,
governance standards, resources and frameworks for training future ESP
Physiotherapists in ED.
Implementation
Steps taken to Implementation











Secure Funding
Develop project plan.
Staff Recruitment
Determine KPI’s Measurement Data- Establishment of Informatics and Data
Form Advisory Committee through invitation
Adaptation of Lead Organisation Model
Governance and Quality Assurance
Develop and communicate implementation, training ,competency frameworks and tool kits
Staff trainingCommunication Strategy:
Ethics approval.
Key Milestones
Key milestone
Date
Project commenced
July 2012 completed
Set-up completed- recruitment, training, model adaptation, baseline KPI’s gathered, ethicsOct 2012 completed
application, Advisory Committee formation.
Commence 5 day service (for 2-3 months)
Oct 2012
Commence 5 day service Sun-Thur (for 6-7 months) 8 hour days
Feb 2013 started
Commence 7 day service (for 3 months)???
July 2013 Unable to start due to
move to GCUH campus
Evaluation in conjunction with the Lead site and Evaluation Consultant
Dec 2013
Final Report with findings and recommendations to HWA
Dec 2013
Governance
Professional
District
Director of ED
Operational
HWA Program Manager
Advisory
UOW Evaluators
HWA Liaison Officer
Assistant
Director of ED
Robina
Delegated
Medical
Consultants
and Mentors
District
Director of
Physiotherapy
Lead Organisation
Project Manager
Local Project Advisory
Group
Local Project
Manager
ESP Physiotherapist
Recruitment Criteria
Qualifications/Professional registration/Other requirements
 >5 years experience in Musculoskeletal or Sports Physiotherapy or
Emergency Physiotherapy,
 Masters Qualification in MSK/Sports
 Be available to work a weekend roster
 Be available to undertake a training program in Extended Scope Physiotherapy.
Clinical Practice:
 Provide primary ‘first contact’ specialist musculoskeletal physiotherapy
service.
Communication / Team Participation
 Provide authoritative clinical counsel.
 Provide expert contribution to the professional body of knowledge.
Leadership / Service Development
 Provide leadership, direction and change management skills.
Training Pathways and Competencies

Lead Site (ACT Health) Model of training:

Formal Tertiary Training



University of Canberra- Graduate Diploma – Extended Scope of Physiotherapy.
Identified areas included:
 Pharmacology
 Radiology
 Injecting/aspirating
 Research/evaluation/management and leadership
Local Training:
 Weekly training with a Consultant Radiologist and Orthopaedic
Consultant.
 Daily input with the ED Consultants.
Extended Scope of Practice Activities
 Imaging interpretation
 Fracture management
 Direct referral to Specialist OPD
 Digital blocks-Joint relocation
 Medicine prescriptions
(simple analgesics)
Activities being
developed
Highlights
 (SOP) for Paracetamol and Ibuprofen
 Chief Health Officer sign off- S4
medications – Nitrous and Lignocaine
 Written instruction, possession, administration
and obtaining
Chief Health Officer
Health Professionals Prescribing Pathway: 8/11/13
 Ministers today approved the Health Professionals
Prescribing Pathway which will provide a way for health
professionals, other than medical practitioners, to
prescribe medications.
 The pathway sets out the steps required for a health
professional to achieve safe and competent prescribing
of medicines within their scope of practice
Patient Journeys
Patient Journey-1
Nursing input**
Patient
Presents
Triaged*
• Analgesia
• imaging
initiated
CIN Room
Evaluation
Analgesia
imaging
initiated
Seen by Dr or
NP
• Analgesia
• imaging
• investigations
• Review with
Consultant?
• Review with physio?
Orthopaedic technician
Allied Health***
Diagnosis
Management
plan
• Conservative
• Specialist
• GP
• Allied health – OPD
services
Discharged
Robina Emergency Department Advanced Scope Physio tracking
Patient 6 Wednesday 12th September, 2012
Dept Person
PATIENT 6
Patient
Process
System
Processes
Information
Flow
Dept Area
Triage Nurse
P
A
T
I
E
N
T
TEAM
Triage Nurse
Administration Officer
Clinical Nurse
Triage Nurse
Triage
Department
Triage
Department
TN
Triage Nurse takes patient
history, medications, allergies.
Patient has own crutches
6
Patient Triage through low window
slot.
Father shows that it was (aktiban)
Patient presents with Father, 2
Triage area.
11.31
Patient ankle injury & swelling. Patient
history is taken. Patient has own
crutches.
11.35
6th Patient female CAT 4
Patient presents with ankle injury &
swelling ; 11.31
Patient Triaged : 11.35
Patient goes to registration :11.39
Patient in waiting room in wheelchair:
11.39
Patient brought into Fast Track ;Room
1:13.37
Patient reviewed by Nursing Practitioner:
13.55
Patient out of room 1: 14.03
Patient meds administered ;14.06
Patient information re crutches, height
adjusting, walking ; 14.10
Patient awaiting discharge letter :14.13
Patient is discharged from Fast Track;
14.20
Patient
Process
Patient 6 Wednesday 12th September, 2012
Clinical Nurse
Nursing
Practitioner
Administration
Officer
Fast Track
↓
Room 1
Administration
Desk
Clinical Nurse
remains in room 1
Nursing
Practitioner
Fast Track
Medication area
↓
Procedure Room
↓
Room 1
Room 1
CN
NP
Patient goes to admin
for registration. Doctor
been before.
Nursing Practitioner
updates patient review
System
Processes
Information
Flow
Dept Area
Dept Person
Robina Emergency Department Advanced Scope Physio tracking
Collects medication ready for delivery.
Goes to Clinical Nurse Procedure Room to
check & they go to administer to patient,
comes back to Fast Track desk to collect
discharge, returns to pt room
Patient is brought into
Fast Track into Room
1, in wheelchair.
Patient goes to admin for
registration, then sits
down, then patient goes
out to have a smoke.
11.39
Goes to sit down, then
patient has gone out to
have a smoke.
1 hr & 2 min
Patient is brought into
Fast Track ? in
wheelchair waiting for ?
Patient review is updated by Nurse
Practitioner, / comes out to talk to
Nurse Practitioner, asks back pain,
elevate / have medication analgesia.
Patient ankle in boot.
13.37
13.55
Patient is administered
meds in room 1 awaiting
discharge letter from
Nurse Practitioner.
14.05 -14.06
Information
Flow
System
Processes
Patient
Process
Patient 6 Wednesday 12th September, 2012
Nurse Practitioner
Nurse Practitioner
Nurse Practitioner
Dept Area
Dept Person
Robina Emergency Department Advanced Scope Physio tracking
Fast Track
Desk
Clinical Nurse
NP
Room 1
Clinical Nurse
Clinical Nurse
Bed 1
Room 1
Room 1
CNP
Clinical Nurse
CNP
Nursing Practitioner returns
to update information
Needs to refer patient to #
OOPD
Clinical Nurse gets
patient standing with
crutches
.Adjusting height, talks
about walking.
EDIS
Patient
14.08
CNP
Patient is waiting for discharge
letter, from Nursing Practitioner/
Clinical Nurse
Patient talks with Clinical re
adjusting height, walking.
14.10
Q
Pt waits
14.13
Clinical Nurse adjusts
ankle boot
Clinical Nurse adjusts patients
ankle boot.
14.15
Fast Track phone ringing nobody answering.
Nurse comes round from main ED s she
couldn't get answer.
NP
Patient is discharged
from Fast Track.
14.20
ESP Patient Journey
Consultant
Orthopaedic registrar
Radiology
yes
ESP Suitable ?
Patient
presents
Triaged**
Patient
assessed
• Analgesia?
Imaging?
Nursing
Diagnosis
• Consultation
required?
no
Management
plan
• Conservative
• GP
• Specialist(direct
to Orthopaedics
Neurosurgery)
• Allied Health
(Community)
Discharged
Orthopaedic technician
Robina Emergency Department Advanced Scope Physio tracking Patient 7 Monday 9th September, 2013
Patient
Process
System
Processes
Information
Flow
Dept Area
Dept Person
PATIENT 7
ESP
ESP
ESP
ED Consultant
TEAM
ESP
E.D Consultant
SHO ED fast track
Orthopaedic Registrar
Orthopaedic technician
P
A
T
I
E
N
T
Patient 7
Child 10 years Female
Triaged 13:07
Waiting Room
↓
Fast Track
↓
Bed 7
Fast Track
Bed 7
↓
Procedure room
viewing box
ESP asks the patient
what has happened to
them. Mother and child
(patient)
7
Plan
Radial slab, CWMS post application
NAD
Referral to fracture clinicinformation given
Relevant information and exercise
sheet supplied
Referred to GP
Asks patient how they fell, and
whether they are right or left
handed.
Patient has private x-ray with
them.
Discuss patient x-rays
and plan including
medications
Gives handover to ED Consultant
for this patient. Reviews x-rays
and discusses what the ESP’s
plan is for the patient. Will get
Consultant to write up medication.
Orthopaedic technician contacted.
Then returns to patient.
Nurse leaves Fast
track to go to
lunch and gives
keys to ESP
Writes up patient notes
Continues write up of
patient information. Then
takes child to weigh
scales as weight
unknown
Continues to ask patient/
mother about whether the
child plays musical
instruments, are they
normally healthy? What
weight is the child? Any
current drugs? Allergies?
Child (patient) with mother.
Patient/ mother explains what
happened to them.
13:25
Fast Track
Bed 7
↓
Weigh scales
↓
Fast track bed 7
13:28-13:30
13:31
EDIS,
HBCIS
eMR COW
7 Monday 9th September , 2013
ESP
ESP
Orthopaedic
technician
Fast Track
Bed 7
Patient
Process
System
Processes
Information
Flow
Dept Area
Dept Person
Robina Emergency Department Advanced Scope Physio tracking Patient
ED Consultant
Orthopaedic
technician
Orthopaedic
technician
Fast track
Nursing/ Dr
work station
Update patient notes
Orthopaedic technician
gets ready. Set up to
plaster child’s wrist/ arm.
ESP
ESP
Informs consultant of
patient’s weight and that
the child has no allergies.
Consultant will write the
script
SHO
Fast Track
Bed 7
Writes up patient notes
EDIS,
HBCIS
eMR COW
Orthopaedic technician
gets ready. Set up to
plaster child’s wrist/ arm.
Discuss with SHO about
administering the analgesia
medication as ESP is delayed
by the return of the nurse to
the Fast track and NP is not in
Fast track either. SHO not
keen to administer
Informs patient and mother
what is happening and how it
will be plastered. Asks the
patient how good she is at
sniffing? Informs child/ mother
that plaster cast will be on for
6 weeks.
13:34
Delay waiting for
nurse to draw up
and administer
analgesia
14:10
Dept Person
Robina Emergency Department Advanced Scope Physio tracking Patient
7 Monday 9th September , 2013
RN
ESP
RN
ESP
ESP
Orthopaedic
technician
ED Main area
↓
Fast Track
Bed 7
Patient
Process
System
Processes
Information
Flow
Dept Area
Fast Track
Bed 7
↓
ED main area
↓
Fast track
ESP goes in search of an RN to
administer the analgesia ‘fentanyl’. RN
arrives but FT RN has the drugs keys
and has taken a Fast track patient to
the ward
ED Main area
↓
Fast Track
Bed 7
Talks to patient about
how she will administer
medication
RN from main ED talks to
patient re medication. Comes
to administer to patient.
Patient just gone to toilet.
Patient goes to toilet
with her mother
14:11
RN from main ED comes back
to administer medication to
patient.
Discuss how medication will be
administered with patient and
gets the patient to practice
sniffing in preparation. Then
medication administered.
14:15
Orthopaedic
technician
Fast Track
Bed 7
Patient instructions re
care of plaster and what
patient should and
should not do
Orthopaedic technician
discusses positioning of arm.
Explains and demonstrates to
ESP. Gives mother
instructions re care of plaster
cast, contra-indications, pain.
Orthopaedic technician
demonstrates positioning of
child’s arm. Gives mother
instructions re does and do
not of plaster care, Contraindications to look for, pain.
14:20
Patient
Process
System
Processes
Information
Flow
Dept Area
Dept Person
Robina Emergency Department Advanced Scope Physio tracking Patient
ESP
Orthopaedic
technician
ESP
Fast Track
Bed 7
Writes up patient notes
Completes fracture
clinic referral
Mother given instructions re
medications after they leave
hospital.
14:22
ESP
ESP
Orthopaedic
technician
Fast Track
Bed 7
Discuss with mother the
medication post visit to
hospital.
7 Monday 9th September , 2013
Orthopaedic
technician
Fast Track
Bed 7
Completes fracture
clinic referral for patient
EDIS,
HBCIS
eMR
Prepare plastering equipment
and consumables. Position
arm ready for bandaging and
plastering.
Mother given referral and
instructions re fracture clinic
appointment.
14:24-14:30
Fast Track
Bed 7
Complete and
discharge patient.
Talks to Orthopaedic
technician and patient’s
mother about plaster heat.
Puts patient’s arm in sling.
Waiting to discharge patient
checks the plaster has cooled
down
Explain to patient about
cooling of plaster and
timeframe.
Patient waits for plaster to cool
then leave fast track with
mother.
14:31
14:34
EDIS,
HBCIS
eMR
Patient Flow
Presentations at Robina
6000
5000
4000
3000
robina
ESP
2000
fast track
1000
0
robina
ESP
fast track
1
2
3
4
5
6
7
8
9
10
11
12
13
4624
4612
4766
4875
4197
4882
4744
4881
4759
4904
5284
5198
5098
81
126
28
133
101
157
150
62
117
166
157
188
110
1641
1329
1619
1618
1338
1786
1679
1759
1686
1680
1892
1819
1747
Percentages of through put
Top 10 Oct12- Sep 2013
S93.40
S52.50
T00.2
S62.0
T00.3
S92.2
S63.50
S82.4
S62.6
148
100
60
58
56
54
50
48
39
Ankle- Sprain / Strain
Fractured Radius
Contusions Lower Limb
Fractured Scaphoid
Contusions Upper Limb
Fractured Lower Limb
Wrist -Sprain /Strain
Fractured Fibula
Fractured Finger
M24.2
38
Knee ligament or tendon
injury
Others
TOTAL
711
1362
Length of Stay (2/10/12-30/09/13)
Top 10 Diagnosis
Average LOS for patients seen by ESP
(651 patients)
1 hour 32 min
Average LOS for patients seen by others
(3490 patients)
3 hours 7 min
Average LOS combined
(4141 patients)
2 hours and 48 mins
Decrease in Aver LOS due to ESP role per
patient (4141 patients)
19 mins
Average Length of Stay for Top 10 ESP
Patient diagnosis per day of week.
•ESP- LOS n= 651
2 Oct- 30
Sept
2013
•≈ 2x LOS
Av LOS
1:34
1:29
1:26
1:28
1:33
1:29
1:41
•4141 patients in total
Av LOS
Excl ESP
3.25
3:13
3.25
2:43
2:58
2:47
3:19
Mon
Tues
Wed Thur
Fri
Sat
Sun
LOS for TOP 10 diag.
 Average LOS on
Sunday since Deb
has been working has
decreased by:
1hr 55mins
Pre Deb working
Sundays Av LOS
Post Deb working
Sundays
5.29 hours
3.38 hours
19 mins x 1311hrs,
4141
55 days
patients
90 mins
x8
patients
720mins
12 hrs
Clinical Quality Indicators - ED
Effectiveness of care
 1. Ambulatory care – no inappropriate admissions
 2. Unplanned re-attendance rate
 3. Total time spent in the A&E department- average 90mins
Patient experience
 4. Left without being seen rate- Robina trending to 6%
 5. Service experience- >95% satisfied or very satisfied
Patient safety
 6.Time to initial assessment – average 20mins
 7. Time to treatment 
8. Consultant sign-off – relates to higher acuity patients
October 2013 represents
1
Cellulitis - conflicting information given by GP patient concerned
2
Plaster review
3
Plaster review
4
Review from evening previous calf
5
LBP bladder retention patient - refused MRI self d/c
6
Review from evening previous
7
different injury
8
Plaster review DNW
9
Review from evening previous ankle
10
# managed - re-presented post ideation self harm
11
bronchitis 12/7 later
12
lady with Alzheimer's- fall in NH x2
13
LBP- incidental finding renal tumour
previous one d/c against medical advice security officer
ENABLERS
 The Districts focus on NEAT performance
 Austerity measures.
 State wide Ministerial Taskforce on
Expanded Scope of Practice underway.
 Networks
Challenges/Obstacles




Governance – Credentialing
Staff cover
Data extraction delays
Access to finance and data managers
 Culture and fear of role replacement
 Communication to the multiple key stake-holders difficult
FUTURE SUSTAINABILITY
 Uncertainty - HH& S restructuring to
service line management model
 Funding
Acknowledgement









 Dr Tom Torpie- Emergency

 Dr Craig Buchan- Radiology

 Dr Haig Lennox- Orthopaedics

 Dr Michael Thomas- Orthopaedics

Dean Blond A/Director emergency
services (ecass)

Rod Ellem- A/director physio
Morven Gemmil- Allied health exec
director
Dr Paul Bowe- Director ED
Bruce Morton- NUM ED
Consultants
Brad Job -Director Radiography
Leonie Warren- BPIO
Lauren Patching-Pharmacy
Therese Kelley- DSS
Lynn Massey- Access & Flow
HWA
University of Wollongong

Cristina Thompson
ACT Health


Jo Morris
Katie Vine
Thank you
Skills required by staff

Knowledge, experience and confidence,




Demonstrated ability to interact and respond to others




practise proactively in a self-directed role with awareness of the role scope and boundaries
maintaining good communication with other ED team members.
balance of judgment and the assertiveness to seek assistance when required
personable and professional manner
takes into account unexpressed concerns.
requires well-developed listening and questioning skills and the ability to negotiate for desired outcomes.
Working knowledge


local service delivery models
appropriate referral pathways.
Re-presentation rates
14
12
10
Representation rate % 7 days (1-15)
8
Representation rate % 28 days (1-15)
Linear (Representation rate % 7 days (115))
6
Linear (Representation rate % 28 days (115))
4
2
0
1
2
3
4
5
6
7
8
9
10
11
12
13
Embedding the Role
 Recognised and reported on at an Executive
Level.
 Supported verbally at a local level by the
Directors of ED. CEO and COO
 Continued positive feedback from ED staff and
Patients.
 Local and National Evaluation being undertaken.
Robina Emergency Department Advanced Scope Physio tracking
Patient 1 Monday 9th September, 2013
Patient
Process
System
Processes
Information
Flow
Dept Area
Dept Person
PATIENT 1
ESP
ESP
ESP
TEAM
ESP
Doctor
Registered Nurse
Registrar Orthopaedics
Radiologist
Triaged 08:26
Male 26 years
Pain Right knee fell off jet ski on
knee able to weight bear but painful
ESP review 08:44
Plan
RICE
Tubigrip (warning given and
understood)
CWMS post application NAD
Relevant information & exercise
sheets supplied
Refer to GP & physio
P
A
T
I
E
N
T
Waiting Room
↓
Bay 5
Bay 5
Retrieve patient record
from ED Dr
Updates patient record
Starts patient record for
episode of care.
Reviews patient on bed
Bay 5 – sitting.
08.44
What exactly
happened ?
EDIS,
HBCIS
eMR COW
EDIS,
HBCIS
eMR COW
EDIS,
HBCIS
eMR COW
1
Bay 5
Update patient
demographics,
Patient
Asked if they need a work
certificate – yes.
Gym, sports ? Live with ?
Any stairs at home ?
08.44
Update patient
information re general
health, presenting
complaint, previous
surgery?
Patient
Any other injuries?
Back a little sore.
Have you hurt knee before ?
Any other health issues.
Surgeries. Non smoker.
Taking any medications.
Robina Emergency Department Advanced Scope Physio tracking
Patient 1 Monday 9th September, 2013
Dept Person
PAP
Bed 5
Bed 5
Bed 5
Information
Flow
ESP
Asks about pain. It is a sprainray ordered.
Need to see Physio - haven’t
ruptured.
Physio / anti – inflammatory
should be back to normal.
System
Processes
Bed 5
ESP
Reviews patient asking
them to walk and then to
lie on the bed.
Discusses injury with patient and
informs it is a sprain and that she
has ordered an x-ray as well.
Discusses plan with patient saying
that it hasn’t ruptured
recommends he sees a
physiotherapist and antiinflammatories
Patient
Process
ESP
Dept Area
PATIENT 1
Patient walks and then
lies on bed.
08.48
Examines patient good
leg then the injured leg
checking neurovascular,
palpation, stress test.
Patient asked to carry
out certain movements
and resistance test.
- Good leg.
- injured leg.
08.49
Updates Patient‘s
record.
Updates plan re
Patient - Physiotherapy
& follow programme.
Patient receives
information about his
injury and proposed
plan.
08.49
EDIS,
HBCIS
eMR COW
08.51
Robina Emergency Department Advanced Scope Physio tracking
Patient 1 Monday 9th September, 2013
Radiologist
ESP
ESP
ESP
Bed 5
Bed 5
Patient has
sprained ligament.
Goes around to front of Admin
Station for level 1, level 2 knee
injuries – exercises & soft
tissues injury leaflet at other
side of Admin Station return to
patient & cow further update.
Patient
Process
Patient
Do you have a Physiotherapist?- no
She lets him know where there are
some sports – Physiotherapist near
his location. Need someone with Post
– Graduate qualifications.
08.55
08.55
Exercises and soft
injury leaflet.
Goes around to front of Admin
Station for level 1, level 2 knee
injuries – exercises & soft
tissues injury leaflet at other
side of Admin Station return to
patient & cow further update.
Patient
Do you have Health
Insurance ? No
Explains and gives patient
the leaflets on soft tissue
injury and exercises
08.55
Bed 5
↓
Medical Imaging
Department
GP letter and
physiotherapy referral.
EDIS,
HBCIS
eMR COW
EDIS,
HBCIS
eMR COW
EDIS,
HBCIS
eMR COW
Admin Station
Continue update
notes.
Continue updating
patient record
ESP
ESP
Bed 5
↓
Admin Station
System
Processes
Information
Flow
Dept Area
Dept Person
PATIENT 1
08.57
Radiologist arrives to
take patient for x-ray.
Altered x-ray form
manually.
Patient walked around to
Medical imaging.
08.59
Provisional diagnosis
at triage was # fibula
Robina Emergency Department Advanced Scope Physio tracking
Patient 1 Monday 9th September, 2013
Dept Person
Medical
Imaging
Department.
↓
Bed 5
Information
Flow
Medical Imaging
Department
Dept Area
PATIENT 1
Control Desk
↓
Plaster Area
Checks PACS system
re x-ray.
System
Processes
Patient
Process
ESP
Goes to Plaster area .
EDIS
Metal cage.
Cuts bandage & covers cage.
Places bandage over knee.
Physio tells him to ice the knee a lot today
& make an appointment for tomorrow.
Patient returns from xray.
09.02
Bandages patients knee.
Informs patient to ice the knee a lot
today & make an appointment with GP
for tomorrow then can organise
Physiotherapy & if required MRI
09.04
ESP
Fast track
administration
Printer
ESP
Bed 5
Work certificate for
patient 1 week. .
Gives letters to patient.
Advice Neurophen + can
take Panodol as well every
6hrs.
Patient advice
Medication - Neurophen + can take
Panodol as well every 6hrs.
Patient should start to fell better in
2 – 6 wks.
Advice that GP can write further
work certificate if required.
Discuss with patient
Method of walking.
Compression bandage, don't
wear to bed.
Don’t straighten out knee
completely
Patient receives guidance on
method of walking.
Compression bandage- don't
wear to bed.
Don’t straighten out knee
completely
Robina Emergency Department Advanced Scope Physio tracking
ESP
ESP
Bed 5
Information
Flow
Dept Area
Dept Person
PATIENT 1
Bed 5
↓
Administration
Station
System
Processes
Patient record complete,
information provided.
Patient
Process
Completes notes on
patient.
Puts notes in out box.
Patient is discharged
09.10
09.11
Patient 1 Monday 9th September, 2013
SERVICE DETAILS
 Robina Hospital is an acute bed (360)
hospital and is part of the Gold Coast
Hospital and Health Service
 GCHHS had 125,745 ED presentations
12/13financial year,
 Southport 69,076 ( NEAT 64%)
 Robina 56,667 (NEAT 79%)
%
Robina DNW %
12
10
8
6
4
2
0
Sept
Aug-13
Jul-13
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Apr-13
May-13
Jun-13
Robina DNW's %
Performance against NEAT- Robina
100
90
80
70
60
50
District focus on Neat
40
30
20
ESP commenced
10
0
Percentage seen in clinically recommended time
Compliments
Comment from ED Business Improvement Officer
Patient Compliments
Completely professional, extremely efficient.
I was absolutely taken a back, by how quickly things were moving.
Having been to the Emergency Dept on a number of occasions and having to sit through very long
waits,
I found this new system to be a breath of fresh air.
I felt it important to pass on my positive feedback,
I would also like to emphasise the care that we received was
faultless. polite, friendly, efficient and very professional.
I would like to congratulate the Hospital for looking at ways to
improve their services.
This program can only be a good thing and I hope it will continue
indefinitely.
Influential Relationship Development
 Time
 Respect
 Flexibility
Key Change Processes
1. Identify key stakeholders/ influencers and
development of influential relationships
2. Very clear reporting of activity and
organisational impact to celebrate results
Communicate Success
 Identify the interest areas of your
stakeholder
 Capture data and report back on KPI’s in
these areas regularly
 Communicate regularly- “ I love this
meeting because people turn up and
things actually happen”- Advisory
Committee member
Robina Emergency Department Advanced Scope Physio tracking
Patient 2 Monday 9th September, 2013
Patient
Process
System
Processes
Information
Flow
Dept Area
Dept Person
PATIENT 2
Doctor
ESP
TEAM
ESP
Doctor
Registered Nurse
Administration Officer.
Triaged 09:09
Female 29 years
Pain lower back after lifting a box
able to walk but painful.
Representing to ED was here 3
weeks ago. had injection then
DNW.
ESP review 09:20
Plan
Refer to GP. Analgesia regime
and management required
P
A
T
I
E
N
T
2
Waiting Room
ESP
Consult Room
1
Commences patient
notes. You were here
before? Seen before?
ESP goes to speak with Dr.
Gives patient handover re patient
opinion re the medications.
Panadene 4 + Endone Diazepam
Cotorolac needs RN
Patient presents, in from waiting
room1
09.20
C.O.W,
EDIS,
HBCIS,
eMR
Patient presented 3wks ago hurt back
DNW. They gave injection / valium makes
her feel a bit better. Do you have a G.P?
No. ESP explains she needs to have a G.P
who can mange her back pain & plan
treatment. Patient needs to see a Physio
too. Had appointment with Chiropractor.
Patient supplies details Health History.
L/R handed R/H. Work? – in restaurant.
Student – studying Management. Do you go to
the Gym? Used to ride bike. Do you live
alone? Do you have stairs 3 – 4.
Injury lower back only? Yes. Pain in legs? Just
sometimes – pain to thigh area.
09.21
Robina Emergency Department Advanced Scope Physio tracking
Patient 2 Monday 9th September, 2013
Patient
Process
System
Processes
Information
Flow
Dept Area
Dept Person
PATIENT 2
Doctor
ESP
TEAM
ESP
Doctor
Registered Nurse
Administration Officer.
Triaged 09:09
Female 29 years
Pain lower back after lifting a box
able to walk but painful.
Representing to ED was here 3
weeks ago. had injection then
DNW.
ESP review 09:20
Plan
Refer to GP. Analgesia regime
and management required
P
A
T
I
E
N
T
2
Waiting Room
ESP
Consult Room
1
Commences patient
notes. You were here
before? Seen before?
ESP goes to speak with Dr.
Gives patient handover re patient
opinion re the medications.
Panadene 4 + Endone Diazepam
Cotorolac needs RN
Patient presents, in from waiting
room1
09.20
C.O.W,
EDIS,
HBCIS,
eMR
Patient presented 3wks ago hurt back
DNW. They gave injection / valium makes
her feel a bit better. Do you have a G.P?
No. ESP explains she needs to have a G.P
who can mange her back pain & plan
treatment. Patient needs to see a Physio
too. Had appointment with Chiropractor.
Patient supplies details Health History.
L/R handed R/H. Work? – in restaurant.
Student – studying Management. Do you go to
the Gym? Used to ride bike. Do you live
alone? Do you have stairs 3 – 4.
Injury lower back only? Yes. Pain in legs? Just
sometimes – pain to thigh area.
09.21
Patient
Process
System
Processes
Information
Flow
Dept Area
Dept Person
Robina Emergency Department Advanced Scope Physio tracking
ESP
Patient 2 Monday 9th September, 2013
ESP
Consult Room
1
Consult Room
1
Further patient
information. Updates
patient notes.
Take patient
demographics, general
health and medications
details. Updates patient
notes.
Reviews patient asks whether they
have Pins /Needles. Problems going to
bathroom - no incidents, when you want
to go but can’t ?
When did the pain start – 3 wks.
Was there an injury – heavy box up high
4 kgs ? Bend to get box then get strong
pain when stood up.
Patient responds to request for
information about their
demographics, health and how
they injured themselves.
C.O.W,
EDIS,
HBCIS,
eMR
C.O.W,
EDIS,
HBCIS,
eMR
Continues to review patient
Have you hurt your back before? Yes some years ago.
Has it been ok? Health problems – had kidney stones, they came out naturally.
Any fever, shakes? Only once.
Weight stable? Yes
Surgery? – yes appendix when 25yr old
Smoke? -yes 2 a day
Allergies? Amoxicillin. what happens? Rash. Medication review including
dosage. Patient tried neurophen, was not helping and physio cream,
Patient responds to request for
information including if she would
like pain relief now- yes
Is asked how she got here today –
friend dropped her off..
09.21
09.30
9 mins
Doctor
ESP
Dept Area
Administration
Station
Information
Flow
ESP goes to speak
with Dr.
Gives handover re patient. Opinion
re the medications Panadene forte +
Endone Diazepam needs RN – ( not
here at the moment)
ESP washes
hands
ESP
Consult Room
1
Plaster /
medicine Area.
Patient
Process
Updates notes.
Leaves E.D clipboard on the
medication area for RN to dispense
medication request.
Registered Nurse has to administer
Cotorolac.
Patient is asked to walk a little.
Sits back down on bed –
examines patient.
09.37
Patient 2 Monday 9th September, 2013
RN
ESP
System
Processes
Dept Person
Robina Emergency Department Advanced Scope Physio tracking
Two patient’s in
department
One with ESP
One with Nursing
Practitioner.
09.40
Leaves E.D clipboard on the
plaster / medicine area.
Registered Nurse has to administer
Cotorolac.
Explains about inflammation & why
it causes pain. Explains why patient
needs to take anti inflammatory and
that she needs to get up every 20
mins. That she should lie flat not
propped up, pillow between knees
when she sleeps.
Patient listens to ESP information.
Delay
Waiting
for RN
Nurse Practitioner &
Registered Nurse
meeting? both nurses
away at the same time.
09.42
Patient 2 Monday 9th September, 2013
Dept Person
Robina Emergency Department Advanced Scope Physio tracking
RN
Dept Area
ESP goes to get a list
of G.P’s for Varsity
Area from Front Desk.
Patient
Process
System
Processes
ED waiting
room front
Desk Area
Information
Flow
ESP
ESP
Front Desk
Area
09.46
ESP
Front Desk
Area
ESP goes to speak to
Registered Nurse .Re:
administering – still no
RN
ESP goes to see earlier
patient was boy (this
patient arrived before the
tracking started)
Gives details to Patient
i.e. G.P’s
Nurse Practitioner
R
N
RN
Bed 1
Bed 1
R
E
T
U
R
N
S
Medication script
F
R
O
M
ESP can’t find anyone to
administer injection.
Delayed.
B
R
E
A
K
RN dispenses
medication and goes to
administer injection.
Patient.
RN administers
injection.
Earlier patient.
09.46
RN
09.46
Nurse Practitioner returns. Asking
ESP – has his patient come back for
x-ray? No -patient was for # Clinic
09.58
10.00
Administer
injection
Patient
RN completed
injection.
10.04
Patient
Process
System
Processes
Information
Flow
Dept Area
Dept Person
Robina Emergency Department Advanced Scope Physio tracking
Patient 2 Monday 9th September, 2013
Administrative
Officer
ESP
ESP
ESP
Fast track
administration
Station
↓
Bed 1
Fast track
administration
Station
Bed 1
GP letter
Back pain &
exercise
information
Bed 1
GP letter
ESP updates
patient notes.
Administration prints off
letters for patient,
Collates information
Back pain to give to
patient.
C.O.W,
EDIS,
HBCIS,
eMR
Back pain &
exercise
information
Sends to printer – goes
to collect.
Patient
Lifting & getting up
exercises. Shows how to
get in / out bed without
straining back.
10.04
ESP
ESP returns to patient
gives letter. Any
questions ?
10.07
10.09
Discharge patient and
completes patient
documentation/
discharge.
Patient discharged.
ESP asks patient to see
a G.P & see a Physio to
manage condition.
10.11
Patient
Process
System
Processes
Information
Flow
Dept Area
Dept Person
Robina Emergency Department Advanced Scope Physio tracking
Patient 3 Monday 9th September, 2013
ESP
TEAM
ESP
Radiologist
Imaging Department
Triage Nurse
Orthopaedic Registrar (new)
Senior Orthopaedic Registrar.
Triage 09:55
Patient 29yrs Male
Fall from MBA 5/7 days ago
deformity to right 5th finger ?
Metacarpal fracture.
ESP review 10:14
Plan (approval from Orthopaedic
Registrar)
Pull to length
Posi slab applied
CWMS post application NAD
Post reduction x-ray good position
Refer to # clinic Information given
Refer to GP
Relevant information re exercises
ESP
Waiting Room
↓
Bed 6
ESP updating patient‘s
notes.
Reviews Demographics, general health?
employment? R/L handed?- Right
What fitness activities does he do?
Any stairs at home?
Had any surgery?– yes arm but not sure
what they did.
Any problem with anaesthetics?
Smoke? Drug allergies?
Any regular medication?
Patient is examined.
What happened ?
Hand got squished last Thurs. Had
been camping. May have ruptured
tendon ?
Medical history taken.
10.14
Bed 6
EDIS,
HBCIS,
eMR
C.O.W.
ESP updates patient ‘s
notes.
Examine patient again.
Asks patient when did you last
eat / drink? ESP believes they may
need surgery.
Patient is examined again.
When did you last eat / drink ?
10:20
EDIS,
HBCIS,
eMR
C.O.W.
ESP goes to
check with
Radiology ?
Patient 3 Monday 9th September, 2013
ESP
Radiologist
ESP
ESP
Dept Area
Dept Person
Robina Emergency Department Advanced Scope Physio tracking
Bed 6
Information
Flow
Bed 6
Bed 6
System
Processes
ESP updating
patient record
Radiologist comes
to collect patient
Patient
Process
Goes to check
with Radiology?
To ask them
Patient collected by
Radiologist.
Delay
Radiology x-ray form. Triage 10.25
Nurse wanting to complete x-ray
form causing delay in waiting room
when there are empty beds in fast
track
EDIS,
HBCIS,
eMR
C.O.W.
PACS.
ESP reviews x-ray
PACS.
Patient back from x-ray.
Q
10.28
Pt.’ s wait line up in
waiting room.
Empty beds.
10.40
Patient
Process
System
Processes
Information
Flow
Dept Area
Dept Person
Robina Emergency Department Advanced Scope Physio tracking
Patient 3 Monday 9th September, 2013
Senior Ortho
Registrar
ESP
Ortho Registrar
Ortho Registrar
Senior Ortho
Registrar
Bed 6
↓
Phone call
ESP calls to speak to
Orthopaedic Registrar on
call. Informs patient re
what is happening
Request Orthopaedic
review.
Inform patient of process
Bed 6
↓
Phone call
Fast track
Clinician
Station
Orthopaedic Registrar and
Senior Orthopaedic
Registrar discuss who is
the on call Consultant?
Orthopaedic Registrar
speak to Senior
Orthopaedic Registrar
re earlier patient ‘s
Consult room 3.
Ortho Registrar gives
handover for patient 3.
Registrar looking up
PACS to see x -rays.
Looked x-rays
Reviews another
patient.
PACS.
Set in motion the
operation for another
patient.
Informs patient re what is
happening.
10.41
10.45
11.00
11.04
Dept Person
Robina Emergency Department Advanced Scope Physio tracking
Patient 3 Monday 9th September, 2013
Orthopaedic
Registrar
Dept Area
Ortho Registrar
Bed 2
Senior Ortho
Registrar
Ortho Registrar
Information
Flow
System
Processes
Patient
Process
Another Patient
Ortho reviews on PACS –
(Ankle)
Ortho Registrar complete
review.
Patient in bed 2
Ortho reviews (Ankle)
Goes in to see them in
Bed 2
Patient review completed.
11.04
11.07
Senior Orthopaedic Registrar
phones on call for Orthopaedic
Consultant for Robina. Leaves
message.
Orthopaedic Registrar discusses
patient injury with Senior
Orthopaedic Registrar
3
Senior Orthopaedic
Registrar
Administration
Station
↓
Phone call
Bed 6
Bed 2
P
a
ti
e
n
t
PACS.
Senior Registrar does
some training with
new Registrar.
Orthopaedic
Consultant on call
Robina
PACS.
Ortho Registrar goes to
next patient (patient 3)
Reviewing x-rays PACS.
Orthopaedic Registrar
and Senior Orthopaedic
Registrar
Review patient.
11.08
11.08
8 mins
ESP
Senior Ortho
Registrar
Patient 3 Monday 9th September, 2013
Orthopaedic
Registrar (new)
Orthopaedic
technician
ESP
ESP
Senior Ortho
Registrar
RN
Bed 6
Bed 6
Bed 6
Discusses patient 3
with Consultant.
Discuss re decision
System
Processes
Information
Flow
Dept Area
Dept Person
Robina Emergency Department Advanced Scope Physio tracking
Updates patient
temporary record.
Patient
Process
ESP + Senior Ortho Registrar +
New Registrar review patient.
And tell patient the plan, they are
going to splint / strap.
Patient may go to Orthopaedic
Outpatient Clinic for procedure.
11.19
PACS.
Review xrays
Nurse taking patient Obs.
Gas delivered to patient
bedside
ESP + Senior Ortho Registrar +
New Registrar review patient.
They are going to splint / strap.
11.17
Bed 6
ESP returns to patient to
confirm what the plan is for
them.
11.27
11.27
11:45
Dept Person
Robina Emergency Department Advanced Scope Physio tracking Patient 3 Monday 9th September, 2013
Dept Area
Orthopaedic
technician
Orthopaedic
technician
Information
Flow
Bed 6
Orthopaedic
technician
Orthopaedic
Registrar
Bed 6
System
Processes
Orthopaedic technician
speaks to Orthopaedic
Registrar re pain relief
Prepare plaster trolley
Nurse Practitioner
Orthopaedic
Registrar
Bed 6
Orthopaedic Registrar talks
to Nurse Practitioner re gas
dose.
Move plaster trolley to
bedside. Commences
bandage
Patient
Process
Nitrous
oxide
Nurse Practitioner instructs
patient on use of gas.
11:47
11:51
11:55
11:57
ESP
Nurse Practitioner
Orthopaedic
technician
Orthopaedic
technician
ESP
ESP
Bed 6
Bed 6
Orthopaedic
technician
SHO
Bed 6
Orthopaedic
technician
Bed 6
Patient
Process
System
Processes
Information
Flow
Dept Area
Dept Person
Robina Emergency Department Advanced Scope Physio tracking Patient 3 Monday 9th September, 2013
Orthopaedic technician
applies traction to patients
hand. Then ESP arrives
and continues traction on
hand for Orthopaedic
Technician
Orthopaedic Technician
applies fibreglass plaster.
Nurse Practitioner holds
hand in traction then ESP
takes over.
11:58
ESP speaks to SHO re
pain relief. Orthopaedic
Technician continues with
plaster
Patient on gas until 12:20
12:07
12:15-12:20
Orthopaedic Technician
completes plaster and
tidies up.
Patient plaster completed
12:21
Patient receives oral pain
relief
12:25
ESP
Work station
↓
Medical Imaging
↓
Work station
ESP completes xray request form
Place x-ray request with
Medical Imaging.
Collates care of plaster
information
Patient
Process
System
Processes
Information
Flow
Dept Area
Dept Person
Robina Emergency Department Advanced Scope Physio tracking
ESP
Radiographer
Administration
Station
↓
Bed 6
Medical Imaging
↓
Bed 6
↓
Medical Imaging
Radiographer
Medical Imaging
↓
Bed 6
Care of plaster
information
Place x-ray request with
Medical Imaging.
Collates care of plaster
information
Patient receives
information re care of
plaster and explanation
12:26
Patient 3 Monday 9th September, 2013
12:33
Collects patient and takes
to Medical Imaging
Patient transferred to
Medical Imaging for x-ray
post plaster
12:40
Patient returns after x-ray
12:42
ESP
ESP
Patient 3 Monday 9th September, 2013
ESP
Fast Track
Work station
Tries to
review x-ray
waits for
them to be
on line
System
Processes
Information
Flow
Dept Area
Dept Person
Robina Emergency Department Advanced Scope Physio tracking
PACS.
Returns to patient to
discuss x-ray. Remind
patient of limb observations
and OPD appointment
Patient
Process
Informs patient alignment is
good and that they can be
discharged.
12:44-12:46
12:46
Patient discharged
Patient leaves department
12:47