QUALITY IN THE RURAL SETTING
COROMANDEL PENINSULA
INTRODUCTION
Thames hospital and it’s emergency
department
 The quality framework team – what it’s been
like
 3 audit topics

THAMES HOSPITAL

Waikato DHB - 4 rural hospitals – Thames, Taumaraunui, Te
Kuiti, Tokoroa – the 4Ts

Variable skill base, resources and facilities
Neale Thornton January 2008
Catchment Thames Hospital
• Coromandel Peninsula from Waihi north and Hauraki Plains
• Drive Time: 90 minutes to base
• Population: 26000 year round Summer population 120900
• Presentations to ED: 15000 pa
• Seasonal fluctuations, same infrastructure
•
Retrieval for severe trauma
Neale Thornton February 2007
ED ATTENDANCES ANNUAL VARIATION
Facilities/Services-Thames Hospital
•48 bed IPU - Medical, Surgical, AT&R
•High Acuity Room (3 beds)
•Operating Theatres
•Emergency Department 15 beds
•Midwife-led Birthing Unit
•Radiology 08.00-18.00 then on call
•Laboratory 07.00-22.00 then on call
•Outpatients
MEDICAL STAFFING
ED mix MO and rural hospitalists – extended
role outside ED
 Physicians and surgeons based Thames
 Daylight SHOs, rural registrar training
 Visiting AT&R
 Many transfers – complexity, speciality,
destination, weekends and PH,

PATIENT TRANSPORT SERVICE
Developed a PTS service enabling a scheduled transfer of
patients between Thames and Waikato hospitals.
St John’s with skilled transfer nurse
Treatment en route
Two way
Neale Thornton January 2008
Application of the Quality Framework
• Quality Framework Team:
Clinical Lead (0.3FTE), CNM, 2IC (0.2FTE)
• Monthly meetings of team
• Feedback of results via M&M, ED business meetings,
and heads of departments
• Some support by request from IS and CASU.
Neale Thornton January 2008
DATA COLLECTION – DON’T REINVENT THE
WHEEL!

Use what already is available – eg LOS data,
time to be seen by decision making clinician
DATA COLLECTION

What goes in must come out – eg requesting
reports by specific discharge codes.
DATA COLLECTION
Getting into hot water – analysing complaints,
incidents and sentinel events
 Themes

DATA COLLECTION

Actively gathering feedback from patients and
staff
DATA COLLECTION
Number 8 wire – develop our own audit tools
from scratch
 Eg left before being seen – recoded, data
collected daily, patient contacted next day,
themes, safety.

DATA COLLECTION – TRYING TO SEE THE WOOD
FOR THE TREES!
Unplanned representation rates within 48 hours
of ED attendance
55 pages of raw data for 1 month
 After 3 hours sifting - 20 patients
 Several alternative reports available
 Filtering data to give useful reports.

ED LOS - 6 H TARGET – KPI 95%
Reasons for breach: July 2014 – 21 breaches
Cause of Breach
Number
Bed access block
7
Department in Overload
0
Awaiting Transfer
3
Awaiting Results (CT)
1
Lack of resource – telemetry, watch
2
Uncertain destination
5
Administration – patient not placed in
SSU/computer issue
2
Ongoing care – patient acuity
1
6 HOUR TARGET
Transfers
 CT
 Departmental overload, summer, inadequate
staffing
 Actions taken January 2015, re audit coming

MORTALITY RATES FOR #NECK OF FEMUR
July 2013 – June 2014
38 patients presented to Thames with
fractured neck of femur.

8/38 subsequently died within 30 days. 30
day mortality = 21% (expected rate = 10%)

11/38 died within 4 months. 4 month
mortality = 29% (expected rate = 20%)

12/38 died within one year. One year
mortality = 31.5% (expected rate = 30%)

WHY IS THIS?



Time from injury to surgery – longer for rural patients
Multiple delays in patient’s journey
Must be in base hospital to be put on surgical list
What can be done?
 Use of NoF clinical pathway
 Discussion with CD orthopaedics
 Discussion with St John re priority transfer
 Dissertation topic
TIME TO ANTIBIOTICS IN SEPSIS
July 2013 - June 2014

Total: 19 patients; 17 met criteria at triage, 2 had
received IV antibiotic prior to ED

Average time to first antibiotics: 2 hours 47
minutes

Deaths: 2/17 (11.7%)

Total no patients received 1st antibiotic dose
within 60 min (Sepsis 6 goal) 3/15 - 20%
TIME TO ANTIBIOTICS IN SEPSIS

After the initial audit, a sepsis treatment
pathway was implemented in Thames ED. This
pathway is based on the Waikato sepsis
pathway and follows international guidelines for
sepsis treatment in ED.
TIME TO ANTIBIOTICS IN SEPSIS

Re-audit: Oct 2014 to Feb 2015 (5/12 period)
 10 patients presented to Thames ED with “sepsis” diagnosis

9 patients met sepsis criteria

Average time to first antibiotics: 108 minutes (1 hour and 48
minutes)

Deaths: 1/9 = 11.1% mortality

Use of Sepsis Pathway: 2/9 = 22.2% use

Total no patients received 1st antibiotic dose within 60
minutes (Sepsis 6 goal) 1/9 = 11.1%
BENEFIT OF SEPSIS PATHWAY
Average time to antibiotic
– 2h 47m prior to pathway
-1h 48m after pathway.


Antibiotic within 60 min - 20% to 11%

Use of sepsis pathway 22.2%
TIME TO ANTIBIOTICS IN SEPSIS : ACTION
Promotion of use of sepsis pathway and
assessment tool
 Audit nursing documentation - use of
assessment tool
 Place pathway at triage to ensure that
paperwork is accessible
 Re-audit Sept 2015
 Better awareness among medical staff. Locums
too.

FUTURE DIRECTION
ISSUES SPECIFIC TO THAMES
Sometimes difficult to compare statistics
directly- due to transport and available
services.
 No IS service on site so getting specific data
can be delayed.
 Small team, time constraints
 Small team, ability to bring about change

LOST IN THE BUSH – WHEN TO ASK FOR HELP!
How to define ED overcrowding measures?
 Time to analgesia tool?

BENEFITS OF QUALITY FRAMEWORK
Quality is not geographical – it applies to rural
hospitals as much as metropolitan hospitals
 Unsuspected areas for improvement have been
unearthed (Thames is a goldmining town!)
 It is encouraging to align ourselves with
national framework and see how we compare

OVERVIEW OF AUDITS UNDERTAKEN
Patient journey time
stamp
ED LOS
Waiting time from triage until time seen by
decision making clinician
ED overcrowding
ED demographic
measures
ED occupancy >100%
UPRA
ED quality processes M&M
Sentinel events
Complaint review and response
Staff experience evaluations
Patient experience
Patient experience evaluations
measures
Left before seeing doctor or decision
making clinician
OVERVIEW
Clinical quality audits
Documentation and
communication
Performance of SSU
Education and training
profile
Departmental education
programme
Administration profile
Mortality rates for #NOF and STEMI
Time to thrombolysis
Time to adequate analgesia
Time to antibiotics in sepsis
Procedural sedation
Others – DVT, cellulitis, pneumonia, transfers
outside scheduled PTS
Nursing notes, medical notes, medication
Appropriate orientation with feedback
Designated quality team