Consultation Paper The Acute Assessment Unit in the new RAH Medical Directorate Central Adelaide Local Health Network Issued: August 2016
TABLE OF CONTENTS TABLE OF CONTENTS 2 1. INTRODUCTION 3 1.1 Purpose of Document 3 1.2 Scope 3 2. CURRENT MODEL 3 3. RATIONALE FOR CHANGE 4 4. FUTURE MODEL 4 4.1 Design of new RAH Acute Assessment Unit space 4 4.2 Model of Care Guiding Principles 5 4.3 Model of Care The Patient Journey 6 4.3.1 AAU Admission Principles 6 4.3.2 AAU Admission Criteria 7 4.3.3 AAU Exclusion Criteria 7 4.3.4 AAU Discharge & Transfer Principles 7 4.4 Model of Care Workforce Considerations 7 4.5 Proposed Governance 8 4.6 Foundations for Governance 8 4.7 The Governance Structures: Acute Assessment Unit Committees 8 4.8 Proposed Structure 9 4.9 Partnerships 11 4.10 Benefits of the future model 12 4.11 Implementation of the future model 12 4.12 Related change processes 12 5. FEEDBACK 12 APPENDIX 1 SUMMARY OF PROPOSED ACUTE ASSESSMENT UNIT MODEL OF CARE 13 APPENDIX 2 MEMBERSHIP LIST AAU GOVERNANCE & OPERATIONAL MANAGEMENT COMMITTEES 14 Page 2 of 15
1. Introduction The Central Adelaide Local Health Network (Central Adelaide) is committed to delivering the highest quality health care and engaging in continuous review and improvement of its services. To this end, and consistent with the vision articulated in the SA Health Care Plan, Central Adelaide has embarked on a journey to change its approach to health care and the way health care services are delivered. This journey is based on the commitment to establish a Single Service, Multiple Site service model which is structured to deliver the right person, to the right place, the first time. The new Royal Adelaide Hospital (RAH) is a significant part of this journey. There is a significant work program in place to transition services to the new RAH to ensure readiness for the day the new hospital opens for service. The focus of this document is on the Acute Assessment Unit (AAU) at the new RAH as a key part in the link between the Emergency Department (ED) and inpatient teams. The new RAH AAU aims to deliver a model of care underpinned by Hospital Model of Care Planning Principles and new RAH Model of Care Principles. It forms one specific part of the steps towards preparation for commencing service delivery at the new RAH. 1.1 Purpose of Document The purpose of this document is to outline the proposed model of care and operational governance for the new RAH AAU. At this point there are no proposed changes to the Acute Medical Unit (AMU) at The Queen Elizabeth Hospital (TQEH). The development of the AAU model of care to date has been informed by: lessons learnt from the RAH AMU/ASU implementation; ongoing discussions with AAU Governance and Operational Management Committee members and stakeholders; extensive research of local, national and international AMUs; and analysis of data to project expected patient activity, patient volumes and diagnostic related groups from AMU, Acute Surgical Unit (ASU) and Emergency Extended Care Unit (EECU). As this model is further developed and components are trialled at the current RAH, further consultation may be required. 1.2 Scope The scope of the changes described in this paper is limited to: The AAU, associated services and all aspects of operations required to manage and deliver the full range of emergency services to be provided at the new RAH. All staff of Central Adelaide who will be working in the new RAH AAU. All visiting services and staff who provide services to the new RAH AAU. 2. Current Model Currently, acute medical and surgical assessment at RAH occurs in a number of locations and within different ward structures, such as 4 and 6 bed bays and a few single rooms. This is managed by discrete Directorates and sub-speciality teams including: AMU, ASU or EECU; inpatient General Medical or Surgical units; specialty medical and surgical consultative services to ED, AMU / ASU and inpatient units; Medicine has dedicated medical staff on AMU, but these staff also provide Medical Emergency Page 3 of 15
Response (MER) and consultative services to the rest of the hospital. Surgery has a daily take system with designated ASU junior medical staff. This structure results in numerous medical staff from multiple departments assessing patients in the ED. As a result, patients wait longer for inpatient treatment on an appropriate ward. Therefore KPIs such as NEAT and length of stay (LOS) are adversely affected, as well as potential discharge delays. There are few routinely implemented and monitored principles on how patient activity should be managed to cover their journey e.g. from ED to AMU/ASU/Home or to an inpatient ward. 3. Rationale for Change It is envisaged the future model will encourage and support a shared understanding of admission / discharge criteria. It is necessary for patients to have early access to senior clinical decision making (morning, noon and evening); inpatient team management; and improved access for patients from ED to inpatient beds. Furthering this mind set, the future model will support utilisation of criteria led pathways for high volume presentations. There are opportunities to further improve efficiency in surgical and medical inpatient units responding to ED referrals for assessment and reducing the LOS a patient spends in ED. The AAU will view the clinical care arrangements as a team of health professional working very closely and collaboratively, supporting each other at times when one discipline is unable to immediately attend (e.g. in surgery). This method of working will promote the medical and surgical areas working cohesively to ensure the patient journey is safe and streamlined. In terms of how activity will be managed flowing from the ED, the utilisation of any vacant bed within the AAU will be encouraged, in times when a preference wing is fully occupied. This also promotes and aligns to the vision for increasing and improving nursing surgical and medical knowledge and skill sets, enabling them to manage any presentation. Patients will not be held in ED waiting for a specific bed in AAU. Rapid patient transfer will be routine. 4. Future Model 4.1 Design of new RAH Acute Assessment Unit space Located on level 2 in the new RAH, the design of the AAU supports forty four (44) beds in single rooms (including 1 bariatric room). The AAU has been introduced to facilitate early specialist assessment, rapid discharge and a location for safe patient care in the early part of a patient s admission 24 hours a day, 7 days a week. This concept of care is referred to as short, sort and safe. The space and geographical position of the AAU on level 2 will enable: the provision of urgent care in support of the ED with treatment co located on a single floor. the integration of the current AMU, ASU and part of the function of the EECU, creating a single governance model. the support of a direct first assessment process for selected patients from outpatients, community RAH teams, other hospitals and General Practice (direct admissions will be subject to a separate consultation process). the development of key relationships with the ED on Level 2 and predominantly General Medical and Surgical inpatient units. the provision of space for acute patient assessments, common investigations (i.e. exercise stress tests (EST)) and management. Page 4 of 15
the facilitation of rapid discharge and outpatient review (rapid assessment and review clinics) with priority access to support and diagnostic services. the provision of available space for multidisciplinary team function and patient / carer meetings. The floor plan below provides an understanding of the position of the AAU on level 2 of the new RAH, in relation to ED, and the wings location. The three wings (wings) in AAU are called preference wings. There will be a surgical preference wing, a medical preference wing and a mixed wing. The mixed wing will allow for either a surgical or medical patient presentation and enable a timely access to an inpatient bed from ED. However if there is a surgical patient needing admission and only a bed in medical preference pod available, the patient will be placed there. 4.2 Model of Care Guiding Principles The guiding principles for the AAU Model of Care are: Thorough clinical assessment including history, examination, diagnosis, specific investigations and a clear management plan are the foundations of good patient care. Early good quality clinical assessment is an important determinant of clinical outcomes. Rapid access to investigation, consultation and treatments are necessary to deliver efficient care. A high functioning clinical team aids in achieving good patient care and outcomes. Good quality and timely communication to the patient, family, carers and within the team is essential and expected. The main objectives of the AAU will be: - To manage short stay admissions (discharge or transfer patient where movement to another wing may not be efficient or timely in the overall patient stay). - To sort out (complete clinical assessment and management plan). - To provide a safe environment for patient care. Page 5 of 15
4.3 Model of Care The Patient Journey The AAU is only one part of the patient journey and should not be considered in isolation but in the context of the overall Model of Care and design features of the new RAH. For example an expedited admission process will be employed to transfer a patient from ED to AAU or an inpatient wing as per below: Between 8am and 8pm, an expedited admission process will be in place; this means that a full and detailed in-patient assessment will occur in the AAU after the patient has left ED. Referrals to the AAU will be by an ED consultant/senior registrar. The expedited admissions process will involve a collaborative discussion with inpatient areas, and will be subject to quality and review processes. Detailed protocols around the implementation of the expedited admissions process are in development. This was outlined in the ED Model of Care Consultation Paper and Addendum distributed in November 2015 and March 2016 respectively, and available on the Central Adelaide new RAH intranet page. Surgery emergency admission pathways will apply as follows: Patients with a clear diagnosis and a non-operative plan of management or where surgery will be delayed should be streamed to the inpatient wings. Patients with either an unclear diagnosis requiring further workup or whose plan of management is in evolution should be streamed to AAU. Patients with a clear diagnosis that need emergency surgery and can be accommodated within a four hour to theatre timeframe should be streamed to the perioperative bays within the Technical Suite (the Technical Suite will be the subject of a separate consultation process). Clinical pathways for high volume patient group presentations are currently being developed by the AAU Operational Committee to facilitate a more timely movement of patients between ED, AAU and inpatient wings / discharge etc. Pathways include Cellulitis, Low Risk Chest Pain, Syncope, Abdominal Pain, Closed Head Injuries, Delirium / Dementia. Patients may be admitted to the AAU either via ED or they may be admitted as a direct admission from Outpatients Department, or from another hospital or GP referral (direct admissions will be subject to a separate consultation process). Multi-disciplinary clinical decision-making will occur at meetings and handover points. Patient care will be facilitated by three decision making times: morning, midday and early evening. This will facilitate a proactive approach to managing and detecting any deterioration or variances in care. The proposed AAU model of care is also summarised in a flowchart diagram in Appendix 1. 4.3.1 AAU Admission Principles Admission of a patient will occur 24 hours a day 7 days a week through a single point of referral. It is the intention that this single point of referral will be a collaborative of AAU Registrar and senior nursing. Patients will be triaged within 30 minutes of referral from the ED by the medical or surgical registrar representing the AAU. Patients will be referred through via taking Registrars, then admitted under the care of the Consultants either Medical or Surgical allocated on for AAU as per current practice. A consistent referral, notification and transfer system will be applicable for each patient. ED Registrar and Consultant staff should feel free to contact Consultant staff for AAU with any clinical or other concern about a patient. Patients with a clear management plan requiring ongoing specialist care will be streamed directly to the right bed within the hospital network (i.e. stroke, myocardial ischaemia, gastrointestinal bleeding, etc.). Page 6 of 15
4.3.2 AAU Admission Criteria Patient requires between 6 and 48 hours for refinement of diagnosis, management plan, plus observation and treatment (including discharge plan implementation). Patients who are hemodynamically stable and non-critical at time of referral where agreement has been made between ED and inpatient staff. Physiologically unstable patients may be admitted with a clear management plan and Rapid Deterioration and Response (RDR) modifications. Patients with a set of common presentations for which specific admission and exclusion criteria will be developed (i.e. abdominal pain, collapse, etc.). 4.3.3 AAU Exclusion Criteria Patients who are physiologically unstable and deemed critical. Patients for whom an existing clinical management protocol exists (i.e. stroke, chest pain). Patient disposition i.e. moved directly from ED to Operating Theatre. Patients likely to stay longer than 48 hours. Patients suitable for discharge from the ED straight to home, Hospital@Home, Health Care@Home, or a Residential Care Facility. 4.3.4 AAU Discharge & Transfer Principles Discharge planning commences upon admission. Discharge planning occurs collaboratively with the patient, carer, multi-disciplinary team to support timely and appropriate discharge. AAU will provide an effective fast turnaround service with emphasis on early identification of patient needs and discharge destination. Criteria led discharge is embedded into the routine discharge planning discussions and documentation. Options for discharge are home, with support services as required, or to inpatient wing. 4.4 Model of Care Workforce Considerations The new RAH AAU will change the way that staff work and the manner in which patients are cared for and managed. This will include different patient pathways / journeys and the bringing together of staff, who currently work in different locations and separate ways. All of these elements will need to be integrated in a coordinated and effective manner. The new AAU operational model requires the integration and coordination of various specialties, services, staffing models and supporting systems. Some of the changes for staff arising from the proposed AAU model will include the following: Administrative staff will need to understand system changes required for better patient outcomes for example, undertaking the administrative admission process in AAU for direct admissions (direct admissions and changes to administrative functions will be the subject of a separate consultation processes). Medicine and surgical medical staff will be required to work collaboratively in the same location, undertake a role in triaging of patients in ED and undertake full patient admission on a wing rather than in ED. Nursing staff will have the opportunity to improve their skillset and knowledge by working across the medical and surgical areas. All staff will be offered essential training before working in AAU for example, nurses who are not familiar with peri operative nursing care or have never cared for a patient needing telemetry will receive training in these areas accordingly. Training will be a mixture of online Moodle modules and face to face sessions. Pharmacy staff will work across surgical and medical areas in the AAU. Allied Health, Pharmacy, Nursing and Medical staff will work closely in a multi-disciplinary team. Page 7 of 15
4.5 Proposed Governance In order for new RAH AAU to be effective, safe and efficient, robust governance arrangements are required. It will be critical that such governance arrangements are in place, given the vast number of specialities, disciplines, services and staff that will interact with the new RAH AAU and the ED assessment and admission processes. 4.6 Foundations for Governance The new RAH AAU Service Delivery Model Committee developed principles which provide a foundation for how the new RAH AAU will function (outlined above). The principles must guide the application of all decision making processes associated with the AAU. The foundations for the governance include the following principles: A single system will be adopted for key processes in the new RAH AAU. These include patient assessment, admission, management plans and movement. All patient admissions and discharges via the new RAH AAU will be managed by a standardized approach. The available resources will be optimised by maximising the flexible use of space, equipment and workforce, ensuring best use of available funding and using standardised approaches and processes to service delivery. 4.7 The Governance Structures: Acute Assessment Unit Committees It will be necessary to ensure appropriate strategic leadership is in place in order to set, drive and monitor the performance of the new RAH AAU. Any governance structures established for the AAU must also support the Central Adelaide Single Service Multiple Site service model. For this reason an overarching Central Adelaide AAU Governance Committee is identified as the leadership body for AAU. This Committee will provide the strategic leadership and policy direction for the strategic management of the AAU across Central Adelaide, with an initial and specific focus on the establishment of the AAU service at the new RAH. The Governance Committee will be supported by a new RAH AAU Operational Management Committee which will oversee the day-to-day management and implementation of the new RAH AAU and ensure that the day to day operation reflects the strategic and policy directions for the new RAH AAU, as set by the Central Adelaide AAU Governance Committee. It is important to recognise that the transition to the new RAH will require specific attention in order to ensure the new site is ready to deliver services on the day it is opened to the public. To facilitate this, in the first instance, the new RAH AAU Operational Management Committee will be focused solely on the move to the new RAH AAU and ensuring that the required operational processes and workforce for the new RAH AAU are in place ready for day one. The diagram below depicts the committee structure for the new RAH AAU. Both Committees have been established and the respective membership lists are outlined in Appendix 2. Page 8 of 15
The following points should be noted in relation to the committee structure: The Central Adelaide AAU Governance Committee and the new RAH AAU Operational Management Committee are shown within the broader governance of Central Adelaide, reporting through the Medical Directorate to the Central Adelaide LHN Executive Management Team. It is intended that any matters requiring resolution would be escalated through the committee structure in the first instance, and then if unresolved via the Medical Directorate to the Executive Management Team where appropriate. The membership of the Central Adelaide AAU Governance Committee provides for representation from all key Directorates, and be chaired by the Medical Directorate. The new RAH AAU Operational Management Committee comprises more operational representation from all disciplines, key Directorates and services. 4.8 Proposed Structure Accountability for the day to day management of the performance and operation of the AAUs across Central Adelaide will rest with the Medical Directorate. In the first instance, this includes the Clinical Co-Director and Nursing Co-Director, Medical Directorate, Central Adelaide supported by the Medical Directorate, Central Adelaide. These are existing positions in Central Adelaide. In support of this, management accountability that will have delegated authority and responsibility to deliver the effective day to day management of the new RAH AAU is required. It is proposed this occurs through the Head of Acute Medicine (existing positon, currently vacant), and the existing Nursing Director Acute Medicine and Support Services reporting to the Clinical Co-Director and Nursing Co-Director, Medical Directorate respectively. The vacant medical position will be filled in accordance with the Central Adelaide LHN: HR Principles for Medical Managerial Appointments. It is proposed that the Head of Acute Medicine in collaboration with the Nursing Director Acute Medicine and Support Services will be responsible for: ensuring the smooth and efficient running of the new RAH AAU. the working environment, which will cover multiple workforces, a range of service providers, including visiting staff, and an array of general plus specific specialty services including investigational services (SA Pathology and SA Imaging) for emergency and urgent patient care. Page 9 of 15
The Head of Acute Medicine and Nursing Director Acute Medicine and Support Services will be required to drive new ways of working through innovation by linking positive changes in efficiency, productivity and quality of care to create improvements in the performance and operation of the AAU. The Nursing Director Acute Medicine and Support Services will maintain responsibility for Medicine nursing staff and take on management of Surgery nursing staff within the AAU. The flowchart below illustrates the management and partnership structure, and staff reporting lines. The only change to reporting lines from the current structure is highlighted by the red box/line indicating both medicine and surgery nursing staff will report to the Nursing Director Acute Medicine and Support Services. This is not currently the case for surgery nursing staff. All staff working within the new RAH AAU service area will abide by consistent policies and procedures that govern the new RAH AAU, which will be developed by the Medical Directorate through the Governance Committee and Operational Management Committee. Staff will be required to work in an integrated manner to support the safe and effective delivery of emergency and urgent care for all patients. In relation to the above: Nursing Staff will report to one central governance structure, the Medical Directorate (in particular the acute medicine stream) (as indicated in red in the above diagram). Staff currently working in Surgical Directorate, excluding the Nursing Director and Nurse Management Facilitator, will all report to the acute medicine stream. Allied Health and Pharmacy Staff will remain under Allied Health and SA Pharmacy governance respectively for professional and operational reporting and work as part of the broader team. Page 10 of 15
Medical Staff reporting lines will remain unchanged and will work as part of the broader hospital team. Head of Unit AAU The Head of Unit AAU (currently vacant) will undertake an active clinical role within the unit and also be involved in many of the following duties: Line management responsibilities and/or supervision of staff. Monitoring in-patient and/or out-patient workload activity. AAU Cost Centre management; including, budget preparation, management of allocated funds, preparation of capital works proposals. Contributing to the overall efficiency and effective operation of the AAU as a member of the management team. Policy development and planning and for the AAU, in the context of the unit, hospital and CALHN Management of operational strategies. Meeting teaching commitments. Co-ordination and fostering of research. The vacant Head of Unit position will be filled in accordance with the Central Adelaide LHN: HR Principles for Medical Managerial Appointments. Administration Staff currently reporting to Surgical Directorate in ASU will report to the Medical Directorate (this change will not affect the business support team). 4.9 Partnerships The governance committees and management and accountability structure for the new RAH AAU detailed above will require the fostering of effective inter-relationships and partnerships with all Directorates and service areas from across Central Adelaide who have a direct relationship with the new RAH AAU in order to ensure the AAU operate as efficiently and effectively as possible. Regardless of whether a person or service is provided by another area of Central Adelaide or by an external provider, all persons who work within the new RAH AAU will be expected to abide by the new RAH AAU governance, service delivery principles and operational documentation and any agreements that may be formalised for the delivery of services. It should be noted that each service, clinical service and directorate, including Allied Health and Pharmacy, that operate within the AAU but sit outside of the direct reporting lines of the Medical Directorate, will maintain accountability and responsibility for their performance and operation of their particular areas or services. The Head of Acute Medicine and Nursing Director Acute Medicine and Support Services will need to ensure appropriate communication is in place with the Facility Operator to ensure effective service provision and performance by Spotless services and to ensure that these issues are appropriately addressed through the contract management process. Establishing and maintaining effective inter-relations and partnerships with all service providers to the new RAH AAU will be an essential aspect of the role of the Head of Acute Medicine and Nursing Director Acute Medicine and Support Services. Page 11 of 15
4.10 Benefits of the future model The change in work location and work practices will bring multiple benefits to both consumers and staff. These include: improved patient flows; focused patient assessments; expedited patient investigations; defined patient pathways for the top 10 common DRGs i.e. chest pain (in progress); patient safety; continuity of patient care; timely specialist review for patients; rapid follow up care (especially for short stay patients); opportunity to increase efficiency of patient care for both the ED and inpatient teams; enhanced utilisation of staff through upskilling and increased knowledge across the AAU e.g. telemetry. 4.11 Implementation of the future model The model described in this paper will start at the new RAH on day one. For this to occur work needs to commence now to refine the model and determine more of the detail which will ensure patient safety and timely access to services. To help us achieve this it will be useful to implement some aspects in the current RAH, although the physical design and available technology may limit how much can be tested. Following this consultation process, it is intended to start with trialling components of the model for example, commonly presenting patient pathways, with a view to implementing a more complete model later in the year. In relation to Central Adelaide LHN s Single Service, Multiple Site service model, the impact of the new RAH AAU on TQEH is unclear at this stage. Further consultation will be undertaken in relation to any proposed changes at TQEH as soon as they become evident. The new RAH AAU model of care will undergo continuous improvement through the transition period and after the move to the new RAH. 4.12 Related change processes Each Directorate within CALHN is working on projects related to transition to new RAH, and a number of these will have an impact on the AAU. These include models of care in ED and Outpatients, direct access/admissions, the implementation of the administration review and EPAS for day one at the new RAH. These matters will be subject to separate consultation processes as required. 5. Feedback This proposal provides more detail in relation to how the AAU will operate in the new RAH. There are still details that need to be determined and your feedback, suggestions and questions will assist in further refining the AAU model. Feedback can be provided via survey monkey at https://www.surveymonkey.com/r/newrahaaumoc or in writing to Workforce Workstream, new RAH Program, Level 8, Emergency Block, Royal Adelaide Hospital, SA 5000. Feedback is due by 2 September 2016. Page 12 of 15
Appendix 1 Summary of Proposed Acute Assessment Unit Model of Care Page 13 of 15
Appendix 2 Membership List AAU Governance & Operational Management Committees The membership of the RAH Acute Assessment Unit Committee is reflective of the following key clinical, business and administrative representation: AAU GOVERNANCE COMMITTEE Clinical Director, Acute Medicine, Medical Directorate (Co-Chair) Director of Nursing, TQEH and Nursing Co-Director, Medical Directorate Nursing Director, Acute Medicine and Support Services, Medical Directorate (Co-Chair / Executive Officer) Manager, Business Operations, Medical Directorate New RAH Commissioning Manager, Medical Directorate Clinical Director / Head of Unit, Surgical Directorate Director of Nursing RAH, Nursing Director, Surgical Directorate Acting Network Director, CALHN Emergency Services Nursing Director, Emergency Department, Critical Care Services Directorate Clinical Toxicologist, Emergency Department, Critical Care Services Directorate Acting Site Director, RAH Emergency Department, Critical Care Services Directorate Director, Exercise Physiology & Physiotherapy, Allied Health Directorate Head of Unit, Cardiology, Medical Directorate Nursing Director, Cardiovascular, Medical Directorate Clinical Director, Medical Specialties, Medical Directorate Nursing Co-Director, Cancer Directorate Clinical Director, Cancer Directorate Clinical Operations Lead, Outpatients Head of Unit, Geriatric Medicine RAH, Medical Directorate Head of Unit, Post Graduate Medical Education & Endocrine Service Clinical Director, Renal Directorate Executive Director, Mental Health Directorate Nursing Director, Patient Flow Medical Director, Transition, new RAH Registrars Medical & Surgical EPAS / IT Representative Transition Manager, new RAH, Medical Directorate Representatives - SA Pathology, SA Imaging, SA Pharmacy General Practitioner Representative, Primary Care Consumer Representative AAU OPERATIONAL MANAGEMENT COMMITTEE Business Consultant, Medical Directorate Transitional Manager, NRAH Nursing Director, Emergency Department Nursing Director, Acute Medical & Support Services Consultant, Geriatric Services Consultant, Chemical Pathology, SA Pathology Pharmacy Representative Manager, Campus Operations, SA Imaging Clinical Practice Consultant, Acute Assessment Area Consultant, General Surgery Acting Network Director, Emergency Services CALHN Acting Nursing Director, Medical Directorate Chief Project Officer, Transforming Health (CALHN) Clinical Head of Unit, Acute Medicine Consultant, General Medicine Clinical Practice Consultant, Hospital@Home Page 14 of 15
Administrative Officer, Emergency Department Representative, Spotless Nursing Director, Surgical Directorate Physiotherapist, Acute Assessment Area Acting Director, Patient Flow Acting Site Director, RAH Emergency Dept Nursing Director, Cardiology Consultant, Acute Medical Unit Clinical Services Consultants, Acute Medical & Acute Surgical Units Page 15 of 15