Managing Patient Flow and KPI's in the Emergency Department - ANUM Roles and Responsibilities
The role of the Associate Nurse Unit Manager (ANUM) in the emergency department is pivotal to the successful management of emergency department KPIs and providing timely, quality care. ANUMs are required to have a thorough understanding of all emergency department KPIs (see “guidelines for understanding emergency department KPIs” attached). There must also be a thorough understanding of all data entry requirements and barriers to patient flow internal and external to the emergency department. The ANUM and duty consultant must work together as a team and assist each other to meet KPI targets.
FLOW CONCEPTS/PULLING AND PUSHING
The primary focus of the ANUM with regard to KPIs and patient flow is to ‘get the patients in’. Concurrently, the primary focus of the emergency department duty consultant is to ‘get the patients out’. The ANUM and duty consultant must at all times consult with each other and work closely to ensure this process happens. Pulling and pushing patients in to and out of the department must be a constant to maintain patient flow and ensure KPIs can be managed.
It is expected the ANUM remain on the flight deck where possible and ensure Patient Flow is kept up to date with patient plans, disposition, bed requests and nursing allocations and be the central point of contact for the Department. The ANUM should direct the nurse or doctor allocated to bring the patient into the cubicle and commence the treatment pathway. If the ANUM brings the patient in then it is expected he or she will commence the treatment pathway. This should not be the preferred option as the ANUM should where possible, remain on the flight deck to ensure consistency of patient flow and maintain a ‘helicopter’ view of the department at all times.
The ANUM will be responsible for entering the patients allocated nurses details on the ‘Nurse Int. of PM’ tab on iPM as soon as the treatment pathway is commenced (if this has not already been done at triage) this will ensure accurate and timely data entry.
The ANUM will liaise closely with the triage and clinical initiatives nurse to ensure a treatment pathway is commenced at triage if necessary. The ANUM will respond to all ‘category 1 and 2’ presentations and ensure the patient is allocated to a cubicle and treatment is commenced.
The ANUM will be responsible for monitoring the occupancy of the waiting room and cubicles and act to streamline flow through the appropriate ‘stream’ within the department. This, in conjunction with the Short Stay Unit ANUM, will include identifying patients suitable for the SSOU and facilitating admission to the unit.
The ANUM will identify (in consultation with the Patient flow coordinator (PFC)/After hours manager (AHM)) when it is necessary to open the ‘escalation cubicles’ in times of significant inpatient access block. The ANUM will then source a nurse to staff this zone. During weekdays this can be with the Clinical Nurse Specialist (CNC) or Nurse Unit Manager (NUM) for the morning shift. If required in the evening then pool staff, part time ED staff or casual bank staff can be requested to staff the escalation cubicles.
HOURLY BOARD ROUNDS
Together with the duty consultant the ANUM will attend to hourly board rounds. This process will enable the continual review of the patient treatment pathway and ensure all aspects of the treatment plan (clinical/admission/discharge) are appropriate and up to date. Hourly board rounds should aim to identify any actual or potential barriers to patient flow, such as inpatient access block, delayed response from admitting unit registrars, unreasonable resistance from inpatient unit ANUMs and staffing shortfalls.
All barriers to flow should be firstly escalated to the PFC or AHM and if an inadequate response received, escalated to the NUM, Deputy Director of Patient Access and Demand or the Director of Nursing for Acute Health.
The following points will be considered during each board round:
- How long has the patient been in the department?
- What is the current status of the patient’s treatment pathway and what is their plan?
- Does the patient fit a short stay pathway?
- Will the patient require inpatient admission?
- Has an inpatient bed been booked?
- Has the inpatient unit registrar been notified and responded?
- Has an inpatient bed been allocated and available?
- Are interim orders appropriate?
- What is the status of the waiting room?
EMERGENCY DEPARTMENT KPIS
It is a mandatory requirement of all emergency department ANUMs to have a thorough understanding of emergency department and hospital wide KPIs. Following is an outline of emergency department KPIs:
Patients seen and discharged within 4 hours of presentation (KPI 80%): The length of stay (LOS) for all patients seen, treatedand discharged from the emergency departmentshould not exceed 4 hours. Patients for discharge should be identified at the earliest possible time and plans for discharge before 4 hours should be discussed at each hourly board round.
Time to treatment (KPI 80%): Time to treatment KPI is measured against triage categories for each patient presenting to the Emergency Department. Patients are triaged according to the Australasian Triage Scale (ATS). The time from when the patient is triaged to when “treatment commenced” is the time measured. “Treatment commences” when the patient is first seen by the doctor OR when the nurse sees the patient and commences an established treatment pathways (i.e. vital signs, IV cannulation, ECG, nurse initiated medications, etc.). Treatment pathways may commence at triage therefore should be entered at triage where appropriate.
Ambulance off stretcher within 40 minutes (KPI 90%)
The ambulance ‘off stretcher’ KPI is a Department of Health set KPI. This indicator dictates that 90% off all patients who arrive via ambulance road service or non-emergency patient transport must be triaged, offloaded and handed over to a Bendigo Health, health professional in less than 40min after ambulance arrival.
LOS greater than 24 hours in the emergency department (KPI 0%) The number of patients spending greater than 24 hours in the emergency department should equal zero. Patients with a length of stay exceeding 12 hours should have barriers to discharge identified and escalated to the PFC/AHM, ED NUM, DDON of Patient Access and Demand of DON for Acute Health to avoid a 24 hour admission to the emergency department.
The key to managing and meeting emergency department KPIs is continuous surveillance of patient flow within each stream of the Department. It is the emergency department ANUMs primary responsibility to ensure patient flow continues through out each shift and remains constant. The ANUM is responsible for directing nursing staff to ensure all care is up to date and ensure patients are “ward” or “discharge ready” as appropriate. Communication between the ANUM and duty consultant is paramount at all times when discussing and managing flow.
The ANUM must ensure that all data entry requirements with regard to “time to treatment” and ‘ambulance off stretcher’ KPIs are up to date and accurately reflect the department’s performance. Barriers to meeting KPIs must be identified and where appropriate escalated so systems such as hospital wide escalation can be initiated.