Aim

The aim of this document is to describe the model of care for patients streamed to be assessed and treated via the Ambulatory Care stream of Bendigo Hospital Emergency Department.  It also aims to ensure consistency of practice amongst all clinicians working in this stream and to help orientate new clinical staff to the workflows of this area of the ED.

Medical Lead – Dr. Ye Min Swe (FACEM)

Nursing & Allied Health Lead – Rebecca Fawcett (CNC)

Reporting to – Dr. Simon Smith (Director of Emergency Medicine) & Jen Oxley (ED NUM)

Patient Exclusion Criteria for Ambulatory Care Stream

• Febrile infant < 3 months old (Temp 38c or above)
• Vital signs meeting MAC criteria (age adjusted)
• Abnormal GCS or behavioural disturbance
• Mental health presentations
• Accidental or Intentional OD of concern
• Severe dyspnoea or concern for potential airway compromise
• Severe abdominal pain or suspected acute abdomen – any age
• > 65yr with undifferentiated abdominal pain
• Limb injury with suspected arterial vascular compromise
• From aged care facility and non-ambulant
• Non-ambulant patients (especially consider elderly with lower limb injury/complaint)
• Suspected STROKE or acute neurological deficits
• Active Cardiac sounding Chest Pain/STEMI
• Trauma Call
• Patients needing active spinal precautions

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Ambulatory Care (AC) Treatment Areas

• AC Waiting Room – initial destination for all pts post triage and also for patients awaiting investigations post medical assessment (eg. awaiting imaging, pathology results etc).
• AC Chairs – these chairs are for patients awaiting imminent review or assessment by inpatient speciality teams. These chairs can also be used for admitted pts who are fit to sit whilst awaiting an inpatient bed and needing active treatment (eg. IV fluids / analgesia/antibiotics). Patient who are able to wait in the main waiting room should do so to keep flow within AC.
• AC Consult Room 6 – ED Consultant
• AC Consult Room 5 – ED Registrar
• AC Consult Room 4 – Nurse Practitioner (when rostered)
• AC Consult Room 3 – ED HMO/Resident
• AC Consult Room 2 – ED Intern
• AC Consult Room 1 – interview room/ admitted patients
• Allied Health Room – Primary Physio team
• Eye Room – eye assessments, patients should always be moved from this room once workup and assessment is completed.
• Plaster Room – Plastering/Bier’s Block reductions
• Paediatric Treatment Room – minor procedures and sedation for paediatric pts
• Adult Treatment room – This room can be utilised by the RN CIN/ AC nurse for a patients workup (ECG, IVC, etc). Patient should be able to moved from here once work up is complete
• Triage Assessment Rooms - early treatment and workup by CIN RN

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Ambulatory Care Clinical Staffing

Medical

• ED Consultant – AM & PM shift
• ED Registrar – AM & PM shift
• ED HMO/Intern – at least one junior on AM & PM shift
• Overnight – HMO/Intern with overnight ED registrar oversight

Nursing & Nurse Practitioner

• South ANUM – All shifts (phone 22016)
• RN AC Lead – AM & PM, NS (Phone 22016)
• RN AC/CIN – AM 09:30 – 18:00 & PM shift 17:30 – 02:00 (Phone 22015)
• Nurse Practitioner – AM or PM shift (when rostered)

Primary Physio Team

• AM & PM shift

AC Clerical Support Staff

• AM & PM shift

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Medical Staff Role Description

ED Consultant (FACEM)

• Ultimate oversight of the flow and safety of patients in AC each shift & Barnard
• Must be contactable on the AC Consultant phone 46024 at all times on shift
• Will update the staff board each shift (clerical and RN staff to assist)
• Works out of AC Consult Room 6
• Does a board round at the start of each shift (incoming and outgoing AC and Barnard team to attend). AC Consultant to also do board round with South ANUM in Collab room
• Takes handover of patients from outgoing medical staff (ED Reg may assist)
• Assist with early assessment and treatment of AC pts waiting to be seen (eg. chart analgesia, requests path/imaging, review ECGs etc)
• Uses EPR floor plan space to communicate/update plan for each patient
• Sees patients according to clinical urgency and waiting times and may delegate tasks to members of team
• Reviews and assists the junior medical staff with their patients as requested (including pts being seen by the Nurse Practitioner and the Primary Physio team)
• Will assist with procedures as needed (eg. minor paediatric procedural sedation, Bier’s block, fracture reductions)
• Must speak directly to the Mains ED Consultant 48104 if changing stream of a patient from AC to Main and vice versa (ie. Consultant in each area must approve change of stream either way)
• Will communicate regularly with the South ANUM in terms of flow of pts in AC

ED Registrar

• Attends the board round at start of each shift
• Assists the ED Consultant with taking handovers as needed
• Carries AC Registrar phone 46017
• Works out of AC Consult Room 5
• Sees patient according to clinical urgency and waiting times or as delegated by the Consultant
• Reviews and assists junior medical staff with their patients as needed or when requested by the Consultant
• Will perform and assist with procedures as needed
• Overnight ED registrar will have ultimate oversight of the running of the AC stream on the night shift

ED HMO/Intern

• Sees patients according to clinical urgency and waiting times or as delegated by the Consultant or Registrar
• Performs and assists with minor procedures as needed
• Will assist the Consultant or registrar when requested with specific tasks

AC Registered Nurse (RN)

• AC RN Lead may attend board the round with consultant and South ANUM at start of each medical shifts at 08:00, 14:00
• Must be contactable on nurse lead phone 22016 or on 22015 at all times on shift
• Ensure that the nursing team staff board in AC is up to date each shift
• Ensure there is nursing cover in AC during breaks
• Ensure that patient locations in AC are up to date (medical and clerical staff to assist)
• Work closely with the AC Consultant and South ANUM and escalate any clinical concerns to the Consultant or registrar early
• Perform and administer early interventions for patients waiting to be seen (administer analgesia, perform ECGs, pathology etc) – self initiate or as directed by the Consultant/Registrar
• Assist with the ongoing care of the patients once medically assessed (administering analgesia, antibiotics, assisting with procedures etc)
• If a patient is being admitted - facilitate flow of the patient through the department (either to SSOU/ward/or needing a mains cubicle etc)
• If flow of admitted patients is unable to be accommodated, ensure care for patients is maintained
• Keep floor plan of each patient updated on EPR – with the aid of medical staff and ensure communication is maintained with the South ANUM

Nurse Practitioner

• Will see and manage patients within the scope of practice
• Will be assisted and guided by the ED Consultant or registrar as requested
• Assist the ED Consultant as able with tasks that are within the scope of practice
• Will perform and assist with minor procedures as able

Primary Physio Team

• Will see and manage patients within the scope of practice
• Ensue that patient are moved and discharged from ePR in a timely manor
• Will be assisted and guided by the ED Consultant or registrar as requested
• Assist the ED Consultant and the medical staff with tasks that are within the scope of practice as able
• Will assist other areas of the department as able with talks that are within the scope of practice (gait assessments for discharge planning, joint/fracture reductions etc)

Clerical Staff

• Assist with ensuring that the AC Medical and Nursing staff board is updated at the start of each shift
• Assist with ensuring that each patient location is accurate and updated on the EPR – with the help of medical and nursing staff
• Ensuring that patients are discharged off EPR in real time with the assistance of medical and nursing staff
• Assist the AC team with task within the scope of practice – communication and IT

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Patient Flow Process in Ambulatory Care

Triage

• Patients to be streamed to AC according to clinical need and not patient load (AC vs Mains patient load)
• Triage categories assigned according to ATS and taking note of exclusion criteria
• If ATS Cat 2 is given to an AC patient – should notify and discuss with AC Consultant to ensure AC is the appropriate stream for that patient and to alert the AC team (examples include possible testicular torsion and acute eye emergencies)
• Once triaged, all AC patients will wait in the main waiting room (WR) with the other Mains patients awaiting a cubicle inside.
• Patients will only be taken into the AC treatment area once the AC team (clinician or RN) are ready to assess them
• ‘Flipping’ of patients from one stream to the other will only be done with the knowledge and approval of consultants of both streams (AC & Main) and in consultation with the Triage nurse. 

CIN nurse

Insert job description here.

Assessment by the AC team

• AC RN/CIN can administer and perform early assessment and treatment of AC patients in either the triage assessment rooms or in the eye room – pts are then returned to the main WR
• AC RN or medical staff will bring patients into AC assessment rooms for formal assessments and workup (may use medical students or MAOs to perform this role)
• Formal assessment and management plan takes place in the allocated treatment room for each AC clinician
• Procedures will be performed either in the assessment room or in dedicated treatment spaces in AC (eye room, palter room etc)

Disposition of AC patients

• If likely for discharge but awaiting investigations – patients will return to the main waiting room (WR) to await such investigations/results
• If appropriate for SSOU admission – AC team will discuss with the SSOU Consultant on 49152 who will facilitate flow of these patients up to SSU. These patients are to wait in the AC Chairs until such time when ready for transfer to SSOU
• AC RN will undertake the relevant handover
• If needing inpatient unit review or admission – appropriate referrals and bed request will be made by the AC team. These patients will wait in the AC Chairs for this to occur.
• AC patients needing admission and care needs exceeding scope in AC (patients needing to lie down for prolonged periods, non-ambulant, needing continuous monitoring) – RN AC Lead or AC Clinician will notify NORTH ANUM to allocate a mains cubicle.
• AC clinician may continue to look after these patients or handover care to Mains team according to workload of both areas
• Patients needing emergent procedures or resuscitation will be immediately facilitated into an appropriate resuscitation bay after alerting the Complex Consultant and NORTH ANUM

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Measures of success

• Success in the care and flow of patients in the AC stream relies upon excellent teamwork and communication amongst the AC team and with other areas of the department (triage team/ED ANUM/Mains Consultant)
• Surrogate measures of success include time to treatment of these patients
• Proportion of patients seen within ATS wait times
• AC 4hr discharge NEAT
• Time until ready for admission for AC patients
• AC patients who left without been seen
• Qualitative surveys of patient and staff experience in AC stream