Patient Flow & The 4 hour rule 

This is a key concept to make the department work.

It is also mandated by the Australian Government in the form of NEAT (National Emergency Access Targets) - "the 4 hour rule"

90% of patients are expected to be admitted to the ward or discharged within 4 hours.

The model of “getting the tests back and then waiting for the med reg” is not feasible and not acceptable.

Rapid flow of patients through the emergency department is essential for good patient care, allows ambulances not to be “ramped” waiting to unload instead of responding to emergencies in the community, and allows undifferentiated patients in the waiting room to be seen and assessed within an appropriate time.

Basic Approach to Flow

To enhance flow, discuss a plan for admission or discharge within 30 minutes of seeing the patient with the duty consultant.  Most admission decisions can be made easily within this period.  A bed will be requested for the patient at this time by notifying the duty consultant and ANUM.

All investigations should be ordered early in the consultation to reduce lag time.

Once a bed is available, you should flag this to the consultant so, if appropriate, the patient is sent to the ward on interim orders where the patient will be admitted by the inpatient unit.

Interim Orders

If an inpatient bed has been allocated but the patient is not clerked by the inpatient unit, the patient will be sent to the ward if they are stable and not immediately for theatre. There should be no resistance to this process from inpatient registrars unless there are specific concerns which the ED consultant will assess and liaise with the appropriate inpatient consultant.

There is an interim order form in the EPR under ED Medical or Paper forms are still available at present which must be completed.  If this is not completed and all the boxes at the bottom of the form not ticked, the patient cannot go to the ward.  Write which ED consultant interims orders have been discussed with on the form.

The inpatient unit must be aware that the patient is being sent to the ward.

Only drugs/fluids required for immediate management are required to be charted.

Nurse Navigator Role (Ext: 46025)

This Role is staffed from 08:00-16:30, 7days a week. They are responisble for patient flow within ED, with the main focus of the position being coordination of non-admitted patient flow withinn the ED from Triage to Discharge guided by NEAT targets.

The areas they may be able to help would include (but not limited to):

• Movement of patients to ward
• Movement of patients to Short Stay
• Movement of patients to St John of God (SJOG)
• Assist with discharge of patients home eg. Discharge lounge awaiting transport, organising transport for patients etc.
• Assist with movement of patient in the department and ambulance offloads

 

They are a fantastic resource, so please utilise them while on the floor, at the same time they will approach you regarding ongoing disposition plans for your patients. If disposition at this time is still unclear please use this as an oppurtunity to get a plan into place, or if unsure discuss with the Senior Medical Staff for advice