Evaluation Framework for Nurse Delegated Emergency Care · NSW Agency for Clinical Innovation Nurse...

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NSW Agency for Clinical Innovation

Evaluation Framework for Nurse Delegated Emergency Care

Baseline Analysis

September 2014

NSW Agency for Clinical Innovation Nurse Delegated Emergency Care

Baseline Analysis - Final Report September 2014

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TABLE OF CONTENTS

1 Introduction ................................................................................................................................ 7

2 Background ............................................................................................................................... 8

2.1 Nurse Delegated Emergency Care .......................................................................... 8

2.2 Participating sites ....................................................................................................... 8

2.3 Key elements of the model of care .......................................................................... 9

2.4 Implementation context ............................................................................................. 9

2.5 Configuration of services required to deliver care ................................................. 10

3 Pre-implementation staff survey data ..................................................................................... 11

4 Pre-implementation patient survey data ................................................................................ 18

5 Pre-implementation clinical audit ............................................................................................ 21

6 Qualitative stakeholder data .................................................................................................... 36

6.1 The need for the NDEC model of care .................................................................... 36

6.2 Engagement ............................................................................................................... 37

6.3 Challenges with implementation .............................................................................. 37

6.4 Future considerations ................................................................................................ 40

7 ED presentation data................................................................................................................ 42

7.2 Time from triage to first seen clinician ..................................................................... 51

7.3 Time from triage to discharge .................................................................................. 55

7.4 Disposition status ....................................................................................................... 59

Index of Figures

Figure 3-1: Health District .............................................................................................................. 11

Figure 3-2: Professional staff group ............................................................................................... 11

Figure 3-3: Calls to medical officers off-site ................................................................................... 12

Figure 3-4: Calls received by medical officers ............................................................................... 12

Figure 3-5: Medical officer call-backs ............................................................................................ 13

Figure 3-6: Potential improvement in emergency care .................................................................. 13

Figure 3-7: Timeliness of emergency care..................................................................................... 14



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Figure 3-8: Quality of emergency care .......................................................................................... 14

Figure 3-9: New model of care ...................................................................................................... 15

Figure 3-10: Required resources ..................................................................................................... 15

Figure 3-11: Teamwork .................................................................................................................... 16

Figure 3-12: Education and training ................................................................................................. 16

Figure 3-13: Communication with patients / carers .......................................................................... 17

Figure 3-14: The local community ................................................................................................... 17

Figure 4-1: Patient confidence in staff ........................................................................................... 18

Figure 4-2: Communication regarding healthcare .......................................................................... 18

Figure 4-3: Decisions regarding healthcare ................................................................................... 19

Figure 4-4: Timeliness of healthcare ............................................................................................. 19

Figure 4-5: Information regarding next steps ................................................................................. 20

Figure 5-1: Proportion of files with triage time less than 10 minutes from arrival time ................... 24

Figure 5-2: Potential for inclusion in NDEC MoC ........................................................................... 25

Figure 5-3: Proportion of audited records with patients included in NDEC MoC ........................... 25

Figure 5-4: Patient re-presented within 48 hours with same condition .......................................... 26

Figure 5-5: Nursing history and assessment clearly documented ................................................. 26

Figure 5-6: Appropriate Paediatric Clinical Practice Guidelines used ............................................ 27

Figure 5-7: Minimum two (2) sets of general observations recorded ............................................. 27

Figure 5-8: Proportion of audited files with pulse recorded ............................................................ 28

Figure 5-9: Proportion of audited files with blood pressure recorded............................................. 28

Figure 5-10: Proportion of audited files with respiratory rate recorded ............................................ 29

Figure 5-11: Proportion of audited files with pulse oximetry (SpO2) recorded ................................. 29

Figure 5-12: Proportion of audited files with Temperature recorded ................................................ 30

Figure 5-13: Proportion of audited files with GCS/AVPU recorded .................................................. 30

Figure 5-14: Proportion of audited files with pain score recorded .................................................... 31



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Figure 5-15: Proportion of audited files with weight recorded .......................................................... 31

Figure 5-16: Proportion of audited files with Blood Glucose Level (BGL) recorded ......................... 32

Figure 5-17: Proportion of audited files with Hydration status recorded .......................................... 32

Figure 5-18: Proportion of audited files with neurovascular observations recorded ........................ 33

Figure 5-19: Proportion of audited files with Medications (Medication Standing Orders)

recorded ...................................................................................................................... 33

Figure 5-20: Proportion of audited files with discharge letter given to patient .................................. 34

Figure 7-1: Flow chart of case inclusion criteria, NDEC and comparator sites .............................. 44

Figure 7-2: Mean time from triage to first seen clinician: 0 to 4,999 ED visits – Inner

regional ........................................................................................................................ 52

Figure 7-3: Mean time from triage to first seen clinician: 0 to 4,999 ED visits – Outer

regional ........................................................................................................................ 53

Figure 7-4: Mean time from triage to first seen clinician: 5,000 to 9,999 ED visits – Outer

regional ........................................................................................................................ 54

Figure 7-5: Mean time from triage to first seen clinician 15,000 to 19,999 ED visits – Inner

regional ........................................................................................................................ 54

Figure 7-6 : Mean time from triage to first seen clinician: 25,000 to 25,999 ED visits - Inner

regional ........................................................................................................................ 55

Figure 7-7: Mean time from triage to discharge: 0 to 4,999 ED visits - Inner regional ................... 56

Figure 7-8: Mean time from triage to discharge: 0 to 4,999 ED visits – Outer regional ................. 57

Figure 7-9: Mean time from triage to discharge: 5,000 to 9,999 ED visits - Outer regional ........... 58

Figure 7-10: Mean time from triage to discharge: 15,000 to 19,999 ED visits - Inner regional ........ 58

Figure 7-11: Mean time from triage to discharge: 25,000 to 29,999 ED visits - Inner

Regional ...................................................................................................................... 59

Index of Tables

Table 5-1: Time period covered by NDEC pre-implementation audit t ......................................... 21

Table 5-2: Results of pre-implementation clinical audit ................................................................ 22

Table 5-3: Time of triage for audited ED attendances .................................................................. 23



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Table 5-4: Triage category of audited ED files ............................................................................. 23

Table 5-5: Range of injuries/illnesses in clinical audit .................................................................. 24

Table 5-6: Proportion of audited files with patient satisfaction survey given; follow-up

phone call undertaken; and discharge checklist completed ........................................ 35

Table 7-1: ED activity data for NDEC sites, 2012/13 to 2013/14 .................................................. 42

Table 7-2: ED activity by peer group and ED level, NDEC vs other sites ..................................... 43

Table 7-3: Activity profile by ED size and ASGC remoteness area .............................................. 45

Table 7-4: Total ED activity by Comparator and NDEC sites ....................................................... 46

Table 7-5: List of ICD10 codes relevant to eligible NDEC injuries/illnesses ................................. 46

Table 7-6: Proportion of ED visits with ICD10 codes available ..................................................... 48

Table 7-7: Listing of NDEC injury/illness descriptors for NDEC and comparator sites ................. 48

Table 7-8: Age exclusion criteria for NDEC injury/illness categories ............................................ 49

Table 7-9: ED presentations by NDEC injury/illness type and age inclusion criteria .................... 49

Table 7-10: NDEC injury/illness presentations by triage category .................................................. 50

Table 7-11: Profile of eligible cases by comparator and NDEC sites ............................................. 51

Table 7-12: Mean time from triage to first seen clinician, NDEC sites by comparators .................. 51

Table 7-13: Mean time from triage to discharge, NDEC sites versus comparators by ED

size and location categories ........................................................................................ 55

Table 7-14: Patients admitted from ED........................................................................................... 60

Table 7-15: Patients who did not wait or left at own risk from ED .................................................. 60

Table 7-16: Patients who departed the ED and were transferred without being admitted .............. 61

Table 7-17: Patients who departed ED with treatment completed .................................................. 61



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List of Abbreviations

ACI Agency for Clinical Innovation

ASGC-RA Australian Standard Geographical Classification – Remoteness Areas

COSOPS Critical Operations Standard Operating Procedures

DRG Diagnosis Related Group

ECI Emergency Care Institute

ED Emergency Department

eMR Electronic Medical Record

GP General Practitioner

HIE Health Information Exchange

ICD International Classification of Disease

LHD Local Health District

MO Medical Officer

MoC Model of Care

MPS Multi-Purpose Service

NDEC Nurse Delegated Emergency Care

NMG Nursing Management Guidelines

NSW New South Wales

RCCT Rural Critical Care Taskforce

RN Registered Nurse

SNOMED Systematized Nomenclature of Medicine

SO Standing Orders

Disclaimer

Please note that, in accordance with our Company‟s policy, we are obliged to advise that neither the Company nor any employee nor sub-contractor undertakes responsibility in any way whatsoever to any person or organisation (other than the Agency for Clinical Innovation) in respect of information set out in this report, including any errors or omissions therein, arising through negligence or otherwise however caused.



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1 Introduction

This report presents the findings of the baseline analysis of the Nurse Delegated Emergency Care (NDEC) project. The NDEC model of care (MoC) has been developed by the Emergency Care Institute (ECI) to enable timely provision of care in ED settings by credentialed Registered Nurses (RNs) for low risk, low acuity presentations. It is designed for hospitals that do not have 24/7 medical officer (MO) coverage.

The MoC offers the potential to enable timely access to treatment for patients in rural and remote EDs with constrained access to local MOs. Additionally, the MoC supports MOs‟ work-life balance through enhancing the capacity of RNs to treat a common range of conditions that are within their scope of practice. NDEC is based on a collaborative MoC that involves clearly defined patient management and communication protocols with local MOs.

The focus of this baseline analysis is on the implementation process at the designated sites. The first section of the report describes the background to the development of the NDEC MoC and outlines its core components. This is followed by an analysis of the baseline data collected from NDEC implementation sites, specifically:

Pre-implementation staff surveys;

Pre-implementation patient surveys;

Pre- implementation clinical audits; and

Qualitative feedback gained through site stakeholder consultations.

In the final section, the report presents quantitative analysis of ED presentation data for NDEC sites relative to comparator sites, focusing on the period prior to the implementation of the NDEC MoC in relation to:

Service utilisation;

Time to treatment;

Time from triage to discharge; and

Discharge disposition.

Information provided in this report has been gathered and assessed during the pre-implementation phase of roll-out of the NDEC MOC and provides a baseline for future evaluation post-implementation.



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2 Background

2.1 Nurse Delegated Emergency Care

NDEC is a MoC that is being implemented in rural and remote Emergency Departments (EDs) across NSW, led by the Agency for Clinical Innovation (ACI) through the ECI. One of the key factors underpinning the initiative has been the challenge of providing access to emergency services in rural and remote settings within the constraints of available workforce. The majority of small rural and remote hospitals do not have full-time medical coverage and rely on local MO support for provision of medical care into the ED. However, the provision of 24/7 emergency service availability can place significant strains on the local MOs, particularly in relation to „call-ins‟ and after-hours „call-backs‟. This in turn creates challenges in medical workforce recruitment and retention.

In the majority of instances in small rural and remote hospital EDs, patients present with conditions of low clinical risk and low acuity. The NDEC MoC provides for a selected range of these clinical presentations to be managed within a defined treatment and medication regimen by RNs, under the delegation of the local MO. Defined clinical protocols for patient follow-up within 24 hours are a key component of the MoC to assure clinical review of patient conditions and medical input where required.

Effective and timely communication between nursing and medical staff, and with patients, is a core component of this collaborative MoC. For patients, the advantage of the MoC is that access to timely and appropriate clinical care is streamlined for low acuity, low risk conditions. Nurses who are designated as NDEC practitioners experience the benefits of operating within their recognised scope of practice in the management of minor injuries and illnesses. For local MOs, the principal advantage offered by NDEC is a more sustainable clinical workload and work-life balance.

2.2 Participating sites

Expressions of interest were sought by the ECI from Level 2 EDs interested in nominating for the first tranche of sites to implement NDEC. In total, 11 facilities completed the nomination forms and ultimately (in June 2013) seven sites were selected by the NDEC steering committee to take part in the initial roll-out phase. These sites comprised:

Bellingen River District Hospital Nimbin MPS

Coolah Multi-Purpose Service (MPS) Pambula District Hospital

Cooma District Hospital1 Wilcannia (MPS)

Milton Ulladulla Hospital

1. Cooma is a Level 3 ED, however, it was accepted into the Phase 1 implementation as there is no onsite medical presence overnight and the medical and nursing staff were very keen to implement the model.



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2.3 Key elements of the model of care

The NDEC MoC evolved directly from a model of care designed and implemented at Walcha MPS Hospital in the Hunter New England Local Health District in NSW in 2008. The NDEC MoC involves a collaborative approach between local MOs and RNs to enable the delegated management by RNs of a defined range of minor illnesses and injuries for patients presenting at rural and remote EDs which do not have 24/7 MO coverage.

The patient target group for the NDEC MoC comprises patients attending EDs with low risk, low acuity and low complexity problems in triage category 4 or 5. Under the NDEC MoC, GPs formally delegate care to credentialed RNs to provide assessment, treatment and discharge of patients with these presenting problems. Defined RN interventions suitable for the MoC include a narrow scope of pharmacological agents.2

The care delegation allows the RN to further assess the patient and, if safe to do so, discharge the patient. The patient is given relevant discharge information and a discharge plan to follow-up with an MO within 24 hours. Once discharged, the patient receives a follow-up phone call from an ED RN within 24 hours of discharge to assess the patient‟s condition and follow-up compliance. If at any stage the patient‟s condition deteriorates and they are deemed no longer suitable for NDEC, the RN is required to revert to „usual care‟ and contact a MO for further patient review.

A comprehensive suite of support resources has been developed to enable implementation of the MoC. These include:

Implementation materials;

Full education package including on-line e-learning modules;

RN credentialing framework;

Patient care modules;

Auditing regime;

Governance structures;

Procedures for local and state review and updates; and

Optional full integration into the electronic Medical Record (eMR).

2.4 Implementation context

There were several requirements for each of the selected sites to complete in preparation for the rollout of the NDEC MoC, with local context adaptation encouraged. Tools and templates were provided by the ECI to support local facilities with implementation. The core components included (but were not limited to):

Pre-implementation education needs assessment;

2 There are 14 Medication Standing Orders in the model of care for the following medications: Amethocaine (eye drops);

Cephalexin; Chloramphenicol (eye drops); Fluorescein (eye drops); Ibuprofen; Lignocaine (1% solution); Loratadine; Metoclopramide; Ondansetron; Oral Rehydration Solution; Paracetamol; Paracetamol with codeine 8mg; Sodium citrotartrate; Tetanus Toxoid



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Nurse training and competency assessment for accreditation;

Review and local endorsement of Standing Orders (SO);

Review and local endorsement of Nurse Management Guidelines (NMG);

Endorsement by the Local Health District (LHD) Drug and Therapeutic Committee for the antibiotic administration / dispensing options included in the Patient Care documents;

Pre-implementation „Snapshot‟ audit of Emergency Department (ED) presentations pertinent to NDEC;

Pre-implementation staff survey;

Pre-implementation patient survey;

Establishment of a local governance structure; and

Adaption of the paper based NDEC documentation to Firstnet electronic medical record (eMR) if applicable.

2.5 Configuration of services required to deliver care

A suite of resources has been developed to facilitate implementation of the NDEC MoC, coordinated by the ECI. Key prerequisites for the implementation of the NDEC MoC include:

Support and cooperation of the local MOs, service/hospital managers, LHD and Medicare Local;

RN training and credentialing in the NDEC MoC nursing skills;

Completion of a pre-implementation audit covering existing clinical practice standards related to:

patient assessment;

patient symptom management;

disposition practices;

documentation; and

nursing staff competency and confidence with core nursing skills related to NDEC; and

Authorisation and communication of the NDEC “Go-live” decision.



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3 Pre-implementation staff survey data

As part of the process of developing the NDEC MoC, a pre-implementation survey was designed by the NDEC steering committee to gather feedback from staff on their experience of providing care in rural/remote EDs and multipurpose centres.

The results of the pre-implementation staff survey form a baseline for future evaluation post-implementation. The aggregated results of the pre-implementation staff surveys received from participating implementation sites are presented below. Comments are provided to highlight any results of significance.

Figure 3-1: Health District

Figure 3-2: Professional staff group

(N = 36)Percent of survey responses

Are

a o

f p

rim

ary

wo

rk

Please select the Local Health District you primarily work in

0% 10% 20% 30% 40% 50% 60% 70%

Far Western

Hunter New

England

Illawarra

Shoalhaven

Murrumbidgee

Mid North Coast

Northern New South

Wales

Southern New

South Wales

Western New South

Waltes

Metropolitan LHD

(N = 36)

1. My professional staff group is

Pro

fess

ion

al g

rou

p

Percent of survey responses

0% 20% 40% 60% 80% 100%

Allied Health

Enrolled Nurse

Medical Officer

Registered Nurse

Other



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Figure 3-3: Calls to medical officers off-site

A significantly higher number of respondents reported calling a medical officer between two and four times per shift.

Figure 3-4: Calls received by medical officers

(N = 27)

No

. of

calls

per

sh

ift

2. During a shift when there is not a medical officer on-site, I would usually call a medical officer


0% 20% 40% 60% 80% 100%

Once per shift

2 - 4 times per shift


10 or more times per

shift

(N = 7)

3. When I am not on-site in the ED, I would usually expect to receive a call from the ED

No

. of

tim

es p

er s

hif

t


0% 20% 40% 60% 80% 100%

Once per shift



10 or more times per

shift



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Figure 3-5: Medical officer call-backs

Figure 3-6: Potential improvement in emergency care

A significantly higher number of respondents agreed that their Emergency Department can improve the ways in which they care for their patients.

(N = 7)

No

. of

tim

es


4. When I am not on-site in the ED, I would usually expect to return to the ED to provide patient care

in person

0% 20% 40% 60% 80% 100%

Once or more in 24

hours

2 - 4 times a week

5 - 9 times a week

10 or more times a

week

(N = 36)

Per

cen

tag

e o

f su

rvey

res

po

nd

ents


5. The Emergency Department can improve the ways in which we care for patients

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Net Agree Net Disagree



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Figure 3-7: Timeliness of emergency care

A significantly higher number of respondents agreed that the emergency care provided in their department is done so in a timely manner.

Figure 3-8: Quality of emergency care

A significantly higher number of respondents agreed that patients presenting with minor injuries or complaints receive high quality, efficient care.


Per

cen

tag

e o

f su

rvey

res

po

nd

ents

6. Clinical care in my Emergency Department is provided in a timely manner

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



Per

cen

tag

e o

f su

rvey

res

po

nd

ents

7. Patients with minior injuries or complaints who present to the Emergency Department receive high

quality, efficent care

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%




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Figure 3-9: New model of care

The majority of respondents agreed that implementing a new MoC (Nurse Delegated Emergency Care) is a positive thing for staff and patients.

Figure 3-10: Required resources

A significant number of respondents agreed the required resources are provided when changes or updates to clinical care are implemented.


Per

cen

tag

e o

f su

rvey

res

po

nd

ents

8. Implementing a new Model of Care in the Emergency Department is a positive thing for staff and

patients

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



Per

cen

tag

e o

f su

rvey

res

po

nd

ents

9. The required resources are provided when implementing changes or updates in clinical care

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%




16

Figure 3-11: Teamwork

Figure 3-12: Education and training

A significantly higher number of respondents agreed that they could easily access education and training opportunities in their role.

(N = 36)

Per

cen

tag

e o

f su

rvey

res

po

nd

ents


10. The level of team work amongst the staff in the Emergency Department is

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Excellent Good

(N = 36)

11. I can easily access education and training opportunities relevant to my clinical role

Per

cen

tag

e o

f su

rvey

res

po

nd

ents


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%




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Figure 3-13: Communication with patients / carers

A significantly higher number of respondents felt they were able to explain condition and treatment to most patients in a way that the patient or carer could understand.

Figure 3-14: The local community

A significantly higher number of respondents agreed that their local community collaborates positively with their hospital and Emergency Department.


Per

cen

tag

e o

f su

rvey

res

po

nd

ents

12. I can explain a patient's condition and treatment in a way the patient and / or carer can understand

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

All patients Most patients


Per

cen

tag

e o

f su

rvey

res

po

nd

ents

13. The local community collaborates positively with the hospital and the Emergency Department

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%




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4 Pre-implementation patient survey data

A pre-implementation survey was also designed by the NDEC steering committee to gather feedback from patients on their experience of receiving care in rural/remote Emergency Departments and MPS‟.

The results of the pre-implementation patient survey form a baseline for future evaluation post-implementation. The aggregated results of the pre-implementation patient surveys received from participating implementation sites are presented below. Comments are provided to highlight any results of significance.

Figure 4-1: Patient confidence in staff

All respondents agreed that they felt confident that staff knew how to look after their healthcare needs.

Figure 4-2: Communication regarding healthcare


Per

cen

tag

e o

f su

rvey

res

po

nd

ents

1. I feel confident that staff know how to look after my healthcare needs

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



2. I know who to ask if I have questions about my healthcare

Per

cen

tag

e o

f su

rvey

res

po

nd

ents

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%




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A significantly higher number of respondents agreed that they knew who to ask if they had questions about their healthcare.

Figure 4-3: Decisions regarding healthcare

A significantly higher number of respondents agreed that they were involved in decisions about their healthcare.

Figure 4-4: Timeliness of healthcare

A significantly higher number of respondents agreed that their healthcare was provided in a timely manner.


Per

cen

tag

e o

f su

rvey

res

po

nd

ents

3. I am involved in decisions about my healthcare

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


(N = 41)

4. My healthcare treatment is provided in a timely manner

Per

cen

tag

e o

f su

rvey

res

po

nd

ents


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%




20

Figure 4-5: Information regarding next steps

A significantly higher number of respondents agreed that they were kept informed regarding the next steps of their treatment.

(N = 41)

5. I am kept informed regarding the next step in my treatmentP

erce

nta

ge

of

surv

ey r

esp

on

den

ts


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%




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5 Pre-implementation clinical audit

Clinical audit guidelines and a pre-formatted data collection template in Excel were circulated to all NDEC implementation sites in October 2013. Sites were requested to select 10 to 15 sequential files of patients in ATS category 4 and 5 with a discharge disposition reported as „discharged from hospital‟. A proposed time-frame for file selection was the first week of the previous month. The audit was to be undertaken by a registered nurse other than the nurse involved in care of the patients.

Objectives of the audit were to enable each site to assess departmental „readiness‟ for NDEC implementation and highlight any practice improvement/s that need to be addressed. Additionally, the audit was designed to provide a baseline dataset for evaluation purposes.

The audit focused on the following areas:

Arrival date and time;

Time to triage;

Nursing history and assessment;

Minimum of 2 sets of observations including full “general” observations and relevant specific observations;

ATS category allocation;

Was the ATS category allocation agreed by the auditor;

Correct use of Clinical Practice Guideline (where available);

Medications administered and documented appropriately;

Discharge process documented including provision of discharge letter and follow-up instructions; and

Was the patient a possible suitable candidate for NDEC.

Five NDEC sites (de-identified in this report) completed the pre-implementation audit and 95 patient files were selected for the audit from the period September to November 2013 as summarised in Table 5-1.

Table 5-1: Time period covered by NDEC pre-implementation audit

NDEC SITE DATE OF AUDIT NO. OF FILES AUDITED

Hospital A 30 October 2013 to 13 November 2013 18

Hospital B Not stated 17

Hospital C 1 October 2013 to 2 October 2013 20

Hospital D 4 October 2013 to 9 October 2013 20

Hospital E 1 September 2013 to 9 September 2013 20

Total 95

A summary of the results of the audit is provided in Table 5-2.



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Table 5-2: Results of pre-implementation clinical audit

N/A No Yes Total N/A No Yes Total N/A No Yes Total N/A No Yes Total N/A No Yes Total N/A No Yes Total

Triage Time < 10 minutes from Arrival Time 0 1 17 18 0 0 17 17 0 4 16 20 0 9 11 20 0 1 19 20 0 15 80 95

Patient has potential for inclusion in ED MoC 0 3 15 18 0 12 5 17 0 6 14 20 0 3 17 20 0 14 6 20 0 38 57 95

Patient included in ED MoC 0 13 5 18 0 17 0 17 0 19 1 20 0 20 0 20 20 0 0 20 20 69 6 95

Patient represented within 48 hrs with same condition 0 16 2 18 0 16 1 17 0 20 0 20 0 19 1 20 0 19 1 20 0 90 5 95

Nursing history and assessment clearly documented 0 0 18 18 0 4 13 17 0 0 20 20 0 8 12 20 0 4 16 20 0 16 79 95

Appropriate Paediatric Clinical Practice Guidelines used 10 0 8 18 15 1 1 17 0 14 6 20 18 2 0 20 18 0 2 20 61 17 17 95

Minimum two (2) sets of general observations recorded 1 17 0 18 0 15 2 17 1 12 7 20 0 20 0 20 0 18 2 20 2 82 11 95

Pulse (heart rate) recorded 0 7 11 18 0 5 12 17 1 3 16 20 0 9 11 20 0 3 17 20 1 27 67 95

Blood pressure recorded 0 14 4 18 0 8 9 17 1 7 12 20 0 10 10 20 0 5 15 20 1 44 50 95

Respiratory rate recorded 0 7 11 18 0 8 9 17 1 4 15 20 0 8 12 20 0 3 17 20 1 30 64 95

Pulse oximetry (SpO2) recorded 0 7 11 18 0 8 9 17 1 9 10 20 0 9 11 20 0 3 17 20 1 36 58 95

Temperature recorded 0 9 9 18 0 8 9 17 1 11 8 20 0 8 12 20 0 3 17 20 1 39 55 95

GCS/AVPU recorded 2 13 3 18 0 17 0 17 0 15 5 20 0 18 2 20 0 13 7 20 2 76 17 95

Pain score recorded 0 0 18 18 0 17 0 17 1 16 3 20 0 5 15 20 4 16 0 20 5 54 36 95

Weight recorded 0 11 7 18 0 16 1 17 1 15 4 20 0 20 0 20 0 20 0 20 1 82 12 95

Blood Glucose Level (BGL) recorded 0 17 1 18 0 17 0 17 0 17 3 20 0 20 0 20 17 3 0 20 17 74 4 95

Hydration status recorded 2 11 5 18 10 7 0 17 1 17 2 20 19 1 0 20 17 3 0 20 49 39 7 95

Neurovascular observations recorded 6 8 4 18 0 17 0 17 1 15 4 20 17 3 0 20 15 5 0 20 39 48 8 95

Medications (Medication Standing Orders) recorded 12 2 4 18 0 17 0 17 1 18 1 20 15 1 4 20 13 0 7 20 41 38 16 95

Discharge letter given to patient 4 11 3 18 0 17 0 17 0 11 9 20 20 0 0 20 0 17 3 20 24 56 15 95

Patient Satisfaction Survey given to patient 0 16 2 18 0 17 0 17 20 0 0 20 20 0 0 20 0 20 0 20 40 53 2 95

Follow-Up phone call undertaken by RN 0 18 0 18 0 17 0 17 20 0 0 20 20 0 0 20 0 20 0 20 40 55 0 95

Discharge Checklist completed 0 13 5 18 0 17 0 17 20 0 0 20 20 0 0 20 0 20 0 20 40 50 5 95

Hospital E TotalAudit question

Hospital A Hospital B Hospital C Hospital D



23

5.1.1 TIME OF TRIAGE

The overwhelming majority (71%) of the audited files were for ED attendances with a triage time between the hours of 0800 and 1800, with 12% of ED attendances in the period 1800 to 0800. For 18% of files, time of triage was not reported in the audit template.

Table 5-3: Time of triage for audited ED attendances

NDEC SITE 0800 TO 1800 1800 TO 0800 NOT STATED TOTAL

Hospital A 13 5 - 18

Hospital B - - 17 17

Hospital C 20 - - 20

Hospital D 19 1 - 20

Hospital E 15 5 - 20

Total 67 11 17 95

The most frequent triage category was ATS 4 (50 files) followed by ATS 3 (15 files) and ATS 5 (12 files). Hospital B was the only hospital to have triage category 3 reported in the audit.

5.1.2 TRIAGE CATEGORY

Table 5-4: Triage category of audited ED files

NDEC SITE ATS 3 ATS 4 ATS 5 MISSING TOTAL

Hospital A - 16 2 - 18

Hospital B 15 1 1 - 17

Hospital C - 18 2 - 20

Hospital D - - 2 18 20

Hospital E - 15 5 - 20

Total 15 50 12 18 95

The four main illnesses/injuries that were recorded for ED attendances subject to the clinical audit were:

Limb injury (n=16);

Pain (n=13);

Wounds (n=10); and

Respiratory illness (n=6).

Remaining illnesses/injuries spanned the list of NDEC categories, as listed in Table 5-5, with 23 cases not directly aligned with NDEC illnesses/injuries.



24

Table 5-5: Range of injuries/illnesses in clinical audit

ILLNESS/INJUJRY HOSPITAL A HOSPITAL B HOSPITAL C HOSPITAL D HOSPITAL E TOTAL

Eye problems 3 2

5

Head injury (minor, mild) 1 1 1 3

Insect bites and stings 2

2

Limb injury 1 4 5 4 2 16

Minor burns 1

1

Other 3 7 2 4 7 23

Pain 1 3 4 2 3 13

Rash

3 1

4

Respiratory Illness 2

2 2 6

Tick bite

2 1 2 5

Urinary Symptom 1 1

1

3

Vomiting and Diarrhoea 1

1 1 1 4

Wounds 3

2 3 2 10

Total 18 17 20 20 20 95

5.1.3 TIME INTERVAL FROM ARRIVAL TO TRIAGE

For the vast majority (84%) of audited files, triage occurred within 10 minutes of arrival time, as shown in Figure 5-1.

Figure 5-1: Proportion of files with triage time less than 10 minutes from arrival time

Triage Time < 10 minutes from Arrival Time

N/A No Yes Total

0 15 80 95



25

5.1.4 POTENTIAL FOR PATIENT INCLUSION IN NDEC MOC

Of the audited files, 60% were deemed to be potentially suitable for inclusion in the NDEC MoC, as shown in Figure 5-2.

Figure 5-2: Potential for inclusion in NDEC MoC

Patient potential for inclusion in NDEC MoC

N/A No Yes Total

0 38 57 95

5.1.5 PATIENT INCLUDED IN NDEC MOC

As would be expected given the clinical audit was undertaken prior to the formal „go-live‟ date, there very few patients (6%) identified as being included in the NDEC MoC, as shown in Figure 5-3.

Figure 5-3: Proportion of audited records with patients included in NDEC MoC

Patient included in NDEC MoC

N/A No Yes Total

20 69 6 95



26

5.1.6 PATIENT RE-PRESENTED WITHIN 48 HRS WITH SAME CONDITION

The proportion of audited files which involved a patient re-presentation within 48 hours at the ED with the same condition was very low at 5%, as shown in Figure 5-4.

Figure 5-4: Patient re-presented within 48 hours with same condition

Patient re-presented w/in 48 hours with same condition

N/A No Yes Total

0 90 5 95

5.1.7 NURSING HISTORY AND ASSESSMENT CLEARLY DOCUMENTED

The majority of files audited had clear documentation of nursing history and assessment, as shown in Figure 5-5.

Figure 5-5: Nursing history and assessment clearly documented

Nursing history & assessment clearly documented

N/A No Yes Total

0 16 79 95



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5.1.8 APPROPRIATE PAEDIATRIC CLINICAL PRACTICE GUIDELINES USED

Paediatric patient clinical practice guidelines were not applicable for 61 files. Of the remaining 38 files, paediatric clinical practices guidelines were used in 50% of audited files.

Figure 5-6: Appropriate Paediatric Clinical Practice Guidelines used

Appropriate Paediatric Clinical Practice Guidelines used

N/A No Yes Total

61 17 17 95

5.1.9 MINIMUM TWO SETS OF GENERAL OBSERVATIONS RECORDED

In only 12% of audited files were a minimum of two sets of general observations recorded, with Hospital C having the highest recorded level at 37% as shown in Figure 5-7.

Figure 5-7: Minimum two (2) sets of general observations recorded

Minimum two (2) sets of general observations recorded

N/A No Yes Total

2 82 11 95



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5.1.10 PULSE (HEART RATE) RECORDED

Pulse was recorded in the majority (71%) of audited files, with some variation between sites evident from Figure 5-8.

Figure 5-8: Proportion of audited files with pulse recorded

Pulse (heart rate) recorded

N/A No Yes Total

1 27 67 95

5.1.11 BLOOD PRESSURE RECORDED

Blood pressure was recorded in just over one half (53%) of audited files, with divergent results apparent between sites, Hospital A having significantly a lower proportion (22%) than Hospital E (75%), with other sites in-between this range as shown in Figure 5-9.

Figure 5-9: Proportion of audited files with blood pressure recorded

Blood pressure recorded

N/A No Yes Total

1 44 50 95



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5.1.12 RESPIRATORY RATE RECORDED

Around two-thirds (68%) of audited files had respiratory rate recorded. Figure 5-10 shows some (not statistically significant) variation between sites.

Figure 5-10: Proportion of audited files with respiratory rate recorded

Respiratory rate recorded

N/A No Yes Total

1 30 64 95

5.1.13 PULSE OXIMETRY (SPO2) RECORDED

Pulse oximetry (SpO2) was recorded in 62% of audited files, with no significantly different results across sites as shown in Figure 5-11.

Figure 5-11: Proportion of audited files with pulse oximetry (SpO2) recorded

Pulse oximetry (SpO2) recorded

N/A No Yes Total

1 36 58 95



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5.1.14 TEMPERATURE RECORDED

At most sites the proportion of files with temperature recorded was in the range 50% to 60%, with a lower rate at Hospital C (42%) and a higher rate (85%) at Hospital E, as shown in Figure 5-12.

Figure 5-12: Proportion of audited files with Temperature recorded

Temperature recorded

N/A No Yes Total

1 39 55 95

5.1.15 GCS/AVPU RECORDED

GCS/AVPU scores were recorded for only a minority (18%) of audited files.

Figure 5-13: Proportion of audited files with GCS/AVPU recorded

GCS/AVPU recorded

N/A No Yes Total

2 76 17 95



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5.1.16 PAIN SCORE RECORDED

On average, 40% of audited files had pain scores recorded. Substantial variation is apparent between sites from Figure 5-14 with nil scores reported for Hospitals B and E as compared to high proportions for Hospital D (75%) and Hospital A (100%).

Figure 5-14: Proportion of audited files with pain score recorded

Pain score recorded

N/A No Yes Total

5 54 36 95

5.1.17 WEIGHT RECORDED

In only a minority (13%) of audited files was weight recorded, Hospital A having the highest proportion (39%) as shown in Figure 5-15.

Figure 5-15: Proportion of audited files with weight recorded

Weight recorded

N/A No Yes Total

1 82 12 95



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5.1.18 BLOOD GLUCOSE LEVEL (BGL) RECORDED

A very low proportion (5%) of audited files had Blood Glucose Level recorded, with nil reported instances at three sites as shown in Figure 5-16.

Figure 5-16: Proportion of audited files with Blood Glucose Level (BGL) recorded

Blood Glucose Level (BGL) recorded

N/A No Yes Total

17 74 4 95

5.1.19 HYDRATION STATUS RECORDED

There were low rates of recording of hydration status, with 15% overall. From Figure 5-17 it can be seen that only two sites reported hydration status: Hospital A (31%) and Hospital C (11%), with nil reported at other sites.

Figure 5-17: Proportion of audited files with Hydration status recorded

Hydration status recorded

N/A No Yes Total

49 39 7 95



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5.1.20 NEUROVASCULAR OBSERVATIONS RECORDED

Only two sites were found to have recorded neurovascular observations: Hospital A (33%) and Hospital C (21%).

Figure 5-18: Proportion of audited files with neurovascular observations recorded

Neurovascular observations recorded

N/A No Yes Total

39 48 8 95

5.1.21 MEDICATIONS (MEDICATION STANDING ORDERS) RECORDED

There was substantial variation in the proportion of files with medication recorded. Compared to the group average of 30%, rates were nil at Hospital B and very low at Hospital C (5%). Rates were at or above 67% for other NDEC sites as shown in Figure 5-19.

Figure 5-19: Proportion of audited files with Medications (Medication Standing

Orders) recorded

Medications (Medication Standing Orders) recorded

N/A No Yes Total

41 38 16 95



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5.1.22 DISCHARGE LETTER GIVEN TO PATIENT

In 21% of audited files there was evidence that a discharge letter had been given to a patient, with a higher proportion (45%) reported for Hospital C as compared to Hospital B (nil) or a very low proportion (15%) for Hospital E. All Hospital D files reported „N/A‟ on this questions.

Figure 5-20: Proportion of audited files with discharge letter given to patient

Discharge letter given to patient

N/A No Yes Total

24 56 15 95

5.1.23 PATIENT SATISFACTION SURVEY GIVEN; FOLLOW-UP PHONE CALL

UNDERTAKEN; AND DISCHARGE CHECKLIST COMPLETED

There were three remaining audit questions, each with very low proportions in the file audit:

Patient Satisfaction Survey given to patient (4%);

Follow-up phone call undertaken by RN (0%); and

Discharge Checklist completed (9%).

The low proportions are expected given the pre-implementation status of sites at the time the audit was undertaken.



35

Table 5-6: Proportion of audited files with patient satisfaction survey given; follow-

up phone call undertaken; and discharge checklist completed

Patient Satisfaction Survey given to patient

N/A No Yes Total

40 53 2 95

Follow-Up phone call undertaken by RN

N/A No Yes Total

40 55 0 95

Discharge Checklist completed

N/A No Yes Total

40 50 5 95



36

6 Qualitative stakeholder data

The seven sites nominated and selected to participate in Phase 1 of the NDEC implementation were contacted by the evaluation consultants to seek their perspectives on the pre-implementation stage, including the planning processes employed and any operational issues identified relevant to local implementation. A discussion guide was prepared to facilitate these interviews and is provided as Appendix 1. Experiences of staff at each of the implementation sites have been summarised into common themes and are presented below.

It should be noted that one of the seven Phase 1 implementation sites, Wilcannia MPS, has delayed progressing implementation of the NDEC MoC due to competing local priorities. Pre-implementation feedback from this site has been excluded from the qualitative analysis.

6.1 The need for the NDEC model of care

Of the sites consulted, there was a unanimous view that the NDEC MoC would benefit the local hospital, with widespread praise for the model and the opportunity for nursing staff to entirely manage low acuity presentations. There was a general consensus that the model would fit local needs.

“This model would be perfect for us. We are on COSOPS3 every night of the year as we only have medical coverage from 7am to 10pm”.

“We have no GP in our ED – she is available on a call-in basis only”.

One site felt that the NDEC MoC offered a legal framework for the work that their nurses were essentially already doing. Another emphasised the positive aspect of nurse empowerment that the model would promote through greater autonomy.

“The model is brilliant. It’s a sensible, sustainable model that allows RNs to undertake nursing diagnosis. It gives us the backbone to do our role”.

Interviewees also commented that patients would benefit from the model, with greater options for receiving treatment and reduced waiting times, which meant that overall, the whole community would benefit.

The NDEC MoC was also considered advantageous in supporting EDs to provide out of hours coverage to patients.

“After hours and on weekends is the time when there is a particular need for additional support – this is the main advantage of NDEC. It will allow nurses more autonomy and more

choice for patients.”

3. COSOPS refers to Critical Operations Standard Operating Procedures and identifies the emergency management arrangements necessary for the coordination of medical services at State level when HEALTHPLAN – Medical Services Supporting Plan (NSW Functional Area Disaster Plan) is activated.



37

Initial enthusiasm for implementation of the NDEC was clearly conveyed by all of the individual stakeholders consulted.

6.2 Engagement

All stakeholders reported initial engagement of most of their nursing staff and local GPs, with the majority in fact being very supportive of the MoC.

“The local GP in town was supportive of the model of care.”

“Our GP was fine with the NDEC concept and very supportive.”

“The GP VMOs appear to be very happy with NDEC guidelines.”

One site commented that the model has proved to be empowering for staff and has been embraced positively by the doctors at the health service.

“There has been lots of enthusiasm”. One site expressed some difficulty engaging their full nursing workforce.

“There was significant resistance from one of the registered nurses who refused to undertake the training required”.

Another site reported trouble gaining approval from their LHD Drug and Therapeutic Committee for the antibiotic administration and dispensing options.

“We had no response at all from the XXX Drug and Therapeutic Committee despite numerous attempts to gain their approval”.

The level of reported Executive Support also varied from site to site, with one site noting that their LHD Executive were not overly involved in the project at all.

There was a mixed response regarding engagement of the community with the MoC. One site which reported high levels of support from local GPs described how the local GP presented key features of the MoC, including the NMGs and the SOs, to the Medicare Local. It was reported that these had been very well received.

Conversely, respondents from another site said that they were purposefully choosing not to „advertise‟ the MoC as they were worried about increasing the expectations of the community in regard to accessibility of treatment. With only 1 RN per shift, interviewees from this site were worried about being unable to cope with the potential workload.

6.3 Challenges with implementation

Of all the Phase 1 implementation sites consulted, none of the sites had officially commenced operating the NDEC MoC, although one site reported taking an incremental approach and introducing one new protocol each week. The relevant components of the NMG were then included on a laminated poster and displayed in a high visibility site within the ED as part of a communication strategy to nurses.

“We started with things that are of most interest and use to staff – for example stings and bites and isolated limb injuries.”



38

There were several reasons reported for the delay in implementation, many of them common to more than one site. Some of the major challenges are summarised below.

6.3.1 PROJECT SUPPORT AND TOOLS

A commonly reported problem related to the workload of the person given responsibility to implement the NDEC MoC, which in most cases was either the NUM or the Clinical Nurse Consultant (CNC) or equivalent role. Given that there was no additional EFT provided for project support at any of the Phase 1 implementation sites, respondents commented that they were trying to manage the project on top of their already busy roles.

“We would have liked more support, there was no project support provided. The project was given to the NUM and the CNC who already have fulltime roles”.

The fragility of the workforce was also another factor that had an impact on implementation at a couple of the sites. The comment was made that in a very small workforce, one person leaving can have a big impact on the rest of the staff and can easily derail any momentum that may have been created.

“There was a hiatus in the implementation due to…changes to senior managers…”

Notwithstanding the challenges with project support at a local level, the majority of the sites consulted felt that the tools and templates provided by the ACI/ECI were generally helpful.

“The matrix for assessment on the ACI site is great and it is good to have scenarios for each of the guidelines..”

“We are very happy with the information and materials provided by the ACI and their website is very user friendly. eMR is very helpful and there has been good support from ACI.”

“The NDEC requirements are very clear. The final test for self-assessment was an area that could be improved in terms of functionality. Nurses couldn’t scroll backwards to review or

revise answers”.

However, one site expressed considerable frustration with the tools provided by the ECI, in particular the inability for a site to amend or make changes to the fact sheets locally.

“The number one frustration for us was not being able to make changes to the fact sheets. We would like uniform fact sheets for each presentation. ACI are planning to make changes to the fact sheets at the end of 2014. We don’t feel we can implement (the NDEC model of

care) until the fact sheets are changed”.

One site also reported that the age ranges stipulated for medication management in the ECI guidelines conflicted with those in the Rural Paediatric Emergency Clinical Guidelines and the Rural Adult Emergency Clinical Guidelines, however, this issue was subsequently resolved with the ECI.

Another site identified medication issues to be problematic.

“When a patient is given medication, say at midnight, and will need medication again 6 hours later, then they either have to wait, or come back.”



39

Some sites felt that support received from the ECI was good at the beginning but waned over time.

“We haven’t had any constructive contact with the ACI or ECI for a long time”.

“We would have liked more central support from the ACI / ECI to try and work through our barriers to implementation”.

The importance of IT enablers was reiterated by one site:

“The IT system is essential for implementation otherwise would miss people and they would fall through the gaps. Needs to be fully integrated with existing EMR to ensure requisite

follow up with GP and patient.”

„Initially the paper system was difficult to implement but following negotiation to use EMR it has been easier and better.”

Another site that does not have eMR systems considered the manual paperwork an implementation challenge.

“Other places that have implemented have managed to do so because they use the eMR.”

6.3.2 ACCESS TO EDUCATION AND TRAINING

Sites reported significant difficulty in accessing and completing the required education and training. The reasons for this varied, from a reported lack of educator resources, to problems with the online components and the difficulty of getting everyone together to undertake training at the same time, due to geographic location and 24 hour rosters.

“Training in general was the most significant barrier to implementing the model of care. Our clinical nurse consultant is located over 100 km away and has a huge workload”.

“There is very little access to face to face education and it is not possible to get all staff together at once to do the training because of the nature of the shifts”.

“We had problems with the e-learning site. The Nurse Management Guidelines are on the ITIM website, not the ACI website, and you need a logon for the ITIM website. There are a

lot of bugs in the system”.

6.3.3 MEDICAL WORKFORCE ISSUES

As in many regional areas across the country, availability of medical practitioners is often difficult. This in turn presents difficulties for proper engagement and support for nursing staff in these communities.

“The GP is the only GP in the town. She works every second weekend and doesn’t work Mondays at all. When she is not on, they “fly by their tail”. They have videoconferencing

facilities in their ED and access to remote consult by phone.”

“The last GP, who was also a sole practitioner in the town, burnt himself out. The current GP has a bit more balance with every Monday and every second weekend off.”



40

It is these circumstances that are best served by the NDEC model which provides a clear framework within which nurses can operate.

Additionally, the ECI acknowledged that NDEC may be perceived to impact the fee for service arrangements that a medical officer has with a specific health facility.

This has proven to be a problem at one site in particular, creating a barrier to implementation until it can be resolved.

“There is an issue with the medical staff. They are not currently on-call after-hours so they don’t get paid. The NDEC model would require them to sign-off on patients that were treated through the night in the NDEC model. For this they require time during their day to read the

notes and history - and for this they want to be paid”.

6.3.4 PRE-IMPLEMENTATION CLINICAL AUDIT

Feedback on the pre-implementation clinical audit was neutral to positive. For some, the audit was regarded as a necessary milestone to be completed and no specific actions were undertaken following the audit. One site used the opportunity of the results from the audit to modify ED protocols in relation to nurses doing two checks and to implement paediatric guidelines. For this site, the implementation of NDEC has reinforced the importance of nurses taking accountability for clinical assessment and patient management (within the RN scope of practice).

“NDEC helps us no end. Since we’ve been using NDEC, accountability is now a bigger focus for our nurses. We are more thorough and we give greater attention to assessment

skills. All of this takes confidence.

Another site implemented documentation changes to ensure accurate reporting of triage times.

6.4 Future considerations

The combined impact of the abovementioned challenges has affected progress with implementation of the MoC.

“(The model) has completely lost momentum. If it was attempted to be revived it would basically have to start all over again”.

“All doctors except one were supportive of the MoC in the beginning. The issues and delayed implementation means that we have now lost some of those who were initially

supportive…. We need to get our medical staff back on-board”.

When sites were asked what would need to be done differently to mitigate some of these barriers if they were starting implementation afresh, responses included:

Provision of dedicated project support in the form of a project officer;

Greater support and direction from the ACI / ECI;

Improved accessibility to training; and



41

Capability for local sites to amend documentation, such as fact sheets, with any changes ultimately approved by the ECI before being finalised.

NDEC was clearly received as an innovative and valuable model of care for rural and remote EDs when introduced to the first tranche of sites. For the most part, negativity associated with the MoC at these sites was associated with the inability to fully implement, or frustration at not being able to progress at a pace that sites would have like to have achieved, due to the variety of reasons detailed above.

Accordingly, the feedback gained from the Phase 1 implementation sites, in particular the barriers to implementation that were encountered, provides valuable insight into issues that require consideration prior to the continued rollout of the MoC across the NSW health system.



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7 ED presentation data

This section presents a baseline analysis of ED presentation data for NDEC implementation sites and comparator EDs. The baseline analysis involved de-identified, patient-level data extracted from the NSW Health Information Exchange (HIE) by the ACI comprising ED presentations to Level 1, 2 and 3 EDs for the period July 2012 to 31 March 2014.

Table 7-1 provides a summary of the profile of NDEC implementation sites in terms of peer group, ED role, ED activity levels and geographic remoteness based on the Australian Standard Geographical Classification – Remoteness Areas (ASGC-RA).4 The sites for which HIE data is available comprise three separate peer groups (C2, D1a, and F3) and two separate ED role levels (level 2 and 3). There is substantial variation in relation to volume of ED presentations, which ranges from 3,303 at Bellinger River District Hospital to 27,110 at Milton and Ulladulla Hospital (HIE data was not available for Coolah MPS and Wilcannia MPS).

Table 7-1: ED activity data for NDEC sites, 2012/13 to 2013/14

FACILITY NAME HIE DATA AVAILABLE

PEER GROUP

ED ROLE NO. OF ED VISITS

ASGC REMOTENESS AREA

Milton and Ulladulla Hospital Yes C2 2 27,110 RA2 - Inner Regional

Bellinger River District Hospital Yes C2 2 3,303 RA3 - Outer Regional

Cooma Health Service Yes C2 3 16,880 RA2 - Inner Regional

Pambula District Hospital Yes D1a 2 6,063 RA3 - Outer Regional

Coolah Multi-Purpose Service No F3 1 n/a RA3 - Outer Regional

Wilcannia Multi-Purpose Service No F3 2 n/a RA5 - Very Remote

Nimbin Multi-Purpose Service Yes F3 2 4,790 RA2 - Inner Regional

It is apparent that NDEC sites vary in terms of geographic remoteness, with three sites in „RA2 - Inner Regional‟ areas, two in „RA3 – Outer Regional‟ and Coolah MPS in the most remote category, „RA5 – Very Remote‟. Geographic remoteness categories was chosen as a basis for matching comparator sites with NDEC sites as a way of selecting comparator EDs with similar levels of access to service centres of comparable population size.5

Taking into account these attributes of NDEC sites (for which HIE data was available), the following approach was taken to select comparator sites:

Include peer groups C2, D1a, and F3;

Include EDs with role levels of 2 and 3;

4 The ASGC-RA is a geographic classification system developed by the ABS which allows quantitative comparisons

between 'city' and 'country' Australia. Remoteness is calculated using the road distance to the nearest Urban Centre in each of five classes based on population size. There are five RA categories: RA1 - Major Cities of Australia; RA2 - Inner Regional Australia; RA3 - Outer Regional Australia; RA4 - Remote Australia; and RA5 - Very Remote Australia

5 Australian Institute of Health and Welfare 2004. Rural, regional and remote health: a guide to remoteness classifications.

AIHW cat. no. PHE 53. Canberra: AIHW.



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Include ED sites with ASGC Remoteness Areas comprising: „RA2 - Inner Regional‟, „RA3 - Outer Regional‟; and

Include ED sites with the following ranges of ED activity: 500 to 4,999 presentations; 5,000 to 9,999 presentations; 15,000 to 19,999 presentations; and 25,000 to 29,999.

The steps involved in selecting ED comparator sites are presented graphically in Figure 7-1. Additionally, a detailed tabular presentation is provided below for each step used to select cases to identify ED presentations relevant to the NDEC MoC.

7.1.1 INCLUSION BY PEER GROUP AND ED LEVEL

The first step involved restricting the sites to peer groups C2, D1a and F3 and ED levels 2 and 3. As shown in Table 7-2, there were 58,146 ED presentations to the 5 NDEC sites for which data was available and 667,264 ED presentations to other sites matched on peer group and ED level. There were 604,233 ED presentations to EDs with a differing peer group or ED level. (In addition, a further 493 ED records were excluded where ED role was missing, resulting in 604,726 records being excluded at this stage of the filtering, as depicted in Figure 6-1.)

Table 7-2: ED activity by peer group and ED level, NDEC vs other sites

Inclusion/exclusion criteria Peer Group ED role

ED presentations

NDEC site Other sites Total

Excluded Hospitals - those with different peer

group and ED role compared to NDEC sites

A3 3 - 38,219 38,219

B 3 - 108,240 108,240

C1 3 - 312,489 312,489

C2 1 - 13,070 13,070

D1a 3 - 12,843 12,843

D1b 1 - 7,803 7,803

D1b 2 - 72,962 72,962

D2 1 - 1,563 1,563

D2 2 - 27,569 27,569

F3 1 - 9,475 9,475

Sub-total - 604,233 604,233

Included Hospitals – those with the same peer group

and ED role as NDEC sites

C2 2 30,413 118,477 148,890

C2 3 16,880 433,384 450,264

D1a 2 6,063 48,309 54,372

F3 2 4,790 67,094 71,884

Sub-total 58,146 667,264 725,410

Total 58,146 1,271,497 1,329,643



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Figure 7-1: Flow chart of case inclusion criteria, NDEC and comparator sites

145950

2554

4351

NDEC

Comp

Walcha

Comp_All

Peer Groups A3, B, C1, C2,

D1a, D1b, D2 & F3ED Levels 1, 2 & 3

N = 1,330,136 Exclude Peer Groups A3, B,

C1, D1b, D2 and ED level 1

N = 604,726Peer Groups C2, D1a, F3

ED Levels 2 & 3

N = 725,410Exclude EDs not matched by

ASGC remoteness & size

N = 456,614

EDs matched on ASGC

remoteness & size criteria

N = 268,796

Cases with ICD10 codes

available

N = 167,344

Exclude cases with missing

ICD10 codes

N = 101,452

Match on NDEC illness/injury

codes

N = 21,394

Exclude ICD10 codes not

matched with NDECillness/injury codes

N = 145,950

Match on NDEC

illness/injury codes and agecriteria

N = 18,840

Exclude NDEC illness/injury codes where age criteria NOT

metN = 2,554

Match on NDEC illness/injury codes, age criteria & triage

score 4, 5N = 14,489

Exclude NDEC injury codes

with Triage Score not = 4 or 5

N = 4,351

NDEC sites

N = 2,956

Comparator sites

N = 11,533



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7.1.2 INCLUSION BY ED SIZE AND GEOGRAPHIC LOCATION

Table 7-3 provides an activity breakdown according to size of ED and ASGC remoteness area. Around one half of the total activity for NDEC sites is attributable to Milton and Ulladulla Hospital which had a total of 27,110 presentations, is in the ED treatment volume category of 25,000 to 29,999 presentations and located in the RA2 – Inner Regional category.

Table 7-3: Activity profile by ED size and ASGC remoteness area

ED treatment volume ASGC Remoteness Area NDEC Site

No Yes Total

0 to 4,999 RA2 - Inner Regional 21,504 4,790 26,294

RA3 - Outer Regional 36,883 3,303 40,186

Sub-total 58,387 8,093 66,480

5,000 to 9,999 RA2 - Inner Regional 29,259

29,259

RA3 - Outer Regional 27,757 6,063 33,820

Sub-total 57,016 6,063 63,079

10,000 to 14,999

RA1 - Major Cities 12,686

12,686

RA2 - Inner Regional 50,626

50,626

RA3 - Outer Regional 10,121

10,121

Sub-total 73,433

73,433

15,000 to 19,999 RA2 - Inner Regional 39,773 16,880 56,653


66,551

Sub-total 106,324 16,880 123,204

20,000 to 24,999

RA1 - Major Cities 23,375

23,375


88,002


42,338

Sub-total 153,715

153,715

25,000 to 29,999 RA2 - Inner Regional 84,733 27,110 111,843

Sub-total 84,733 27,110 111,843

30,000 to 34,999 RA1 - Major Cities 62,659

62,659


31,478

Sub-total 94,137

94,137

35,000 to 39,999 RA2 - Inner Regional 39,519

39,519

Sub-total 39,519

39,519

Total 667,264 58,146 725,410



46

In Table 7-4, total ED activity is shown for those comparator and NDEC sites which are matched in terms of ranges of ED treatment volumes and ASGC remoteness location. Walcha MPS Hospital has been presented separately from the comparator group in Table 7-4 due to the existence of a similar NDEC model of care within their ED.

Table 7-4: Total ED activity by Comparator and NDEC sites

Size and remoteness category Comparator

NDEC site Total Other Walcha

0 to 4,999 - Inner Regional 21,504 0 4,790 26,294

0 to 4,999 - Outer Regional 33,225 3,658 3,303 40,186

5,000 to 9,999 - Outer Regional 27,757 0 6,063 33,820

15,000 to 19,999 - Inner Regional 39,773 0 16,880 56,653

25,000 to 29,999 - Inner Regional 84,733 0 27,110 111,843

Total 206,992 3,658 58,146 268,796

Inclusion of injury/illness codes

The cohort of patients relevant to the evaluation is based on the defined patient conditions eligible for treatment under the NDEC MoC by credentialed RNs. These patient conditions have been mapped to relevant ICD-10 codes as listed in Table 7-5. For hospitals which reported diagnosis codes using Systematized Nomenclature of Medicine (SNOMED) codes, the SNOMED codes were mapped to ICD-10 codes.

Table 7-5: List of ICD10 codes relevant to eligible NDEC injuries/illnesses

ICD CODES GENERAL DESCRIPTION

T21: 1

T22: 0,1

T24: 0,1

T31:0

L55: 0,8,9

Burns (minor)

H92: 0 Earache

H57: 1,8,9 Eye problems

L92:3

M60:2

M79:5

T16

T17.1

M79.5

Foreign body

S00:0,1,2,3,4,5,7,8,9 Head injury (mild / minor)

T63:4 Insect/tick bites and stings

T11:0,1,8,9

T13:0,1,8,9 Limb injuries



47

ICD CODES GENERAL DESCRIPTION

T63:5,6 Marine creatures

G50:1

H57:1

H92.0

K14.6

K08.8

M25:5

M54:5,6

M75.8

M79:6

N23

R07:0

R10.2

R30:0,9

R52:0,1,2,9

Pain (any cause)

L08

L22

L25:1

L27:0

L74:0

R21

Rash

J00

J01:9

J02:8,9

J03:8,9

J04:2

Respiratory type illness

R30:0,9

R:32

R39:1,8

Urinary symptoms

A09:0,9

K52:9

K59:1

R11

Vomiting and diarrhoea

S41:1,8

S51:8,9

S71:1,8

S81:8,9

Wounds



48

In total, 62% of cases had ICD10 codes or had SNOMED codes that were able to be mapped to ICD10 codes. For NDEC sites, ICD10 codes were available for 66% of cases and for comparator sites6, for 61% of cases, as shown in Table 7-6 below.

Table 7-6: Proportion of ED visits with ICD10 codes available

Injury type Comparator sites NDEC sites Total

No. % No. % No. %

ICD10 codes available 129,223 61% 38,121 66% 167,344 62%

ICD10 codes not available 81,427 39% 20,025 34% 101,452 38%

Total 210,650 100% 58,146 100% 268,796 100%

Table 7-7 lists the relevant NDEC injury/illness types for comparator7 and NDEC sites. In total, 12.8% of ED visits with ICD10 codes available (including cases with SNOMED codes mapped to ICD10 codes) were mapped to NDEC injury/illness types. For NDEC sites, the NDEC injury/illness presentations comprised 11.7% of total presentations compared to 13.1% for comparator sites. The highest volume injury/illness category was „Vomiting and Diarrhoea‟ which comprised 3.9% of ED presentations followed by „Pain‟ (2.1%) and „Respiratory Illness‟ 2.0%).

Table 7-7: Listing of NDEC injury/illness descriptors for NDEC and comparator

sites

Injury/illness type Comparator sites NDEC sites Total

No. % No. % No. %

Earache 842 0.7% 285 0.7% 1,127 0.7%

Eye problems 337 0.3% 337 0.9% 674 0.4%

Foreign body 272 0.2% 81 0.2% 353 0.2%

Head injury (minor, mild) 12 0.0% 0 0.0% 12 0.0%

Insect or tick bite 459 0.4% 327 0.9% 786 0.5%

Limb Injury 412 0.3% 115 0.3% 527 0.3%

Marine creatures 75 0.1% 28 0.1% 103 0.1%

Minor burns 149 0.1% 43 0.1% 192 0.1%

Pain 3,223 2.5% 666 1.7% 3,889 2.3%

Rash 1,399 1.1% 247 0.6% 1,646 1.0%

Respiratory Illness 2,819 2.2% 480 1.3% 3,299 2.0%

Urinary Symptoms 94 0.1% 29 0.1% 123 0.1%

Vomiting and Diarrhoea 5,746 4.4% 1,594 4.2% 7,340 4.4%

Wounds 1,088 0.8% 235 0.6% 1,323 0.8%

Sub-total 16,927 13.1% 4,467 11.7% 21,394 12.8%

Other Injury or Illness 112,296 86.9% 33,654 88.3% 145,950 87.2%

Total 129,223 100.0% 38,121 100.0% 167,344 100.0%

6. Includes Walcha MPS Hospital 7. Includes Walcha MPS Hospital



49

7.1.3 AGE INCLUSION CRITERIA

Under the NDEC Nurse Management Guidelines a range of „red flag exclusion criteria‟ are defined for each NDEC injury/illness type including age criteria, as summarised in Table 7-8.

Table 7-8: Age exclusion criteria for NDEC injury/illness categories

Injury/illness type Red flag age exclusion criteria

Earache <= 3 months

Eye problems <= 3 months

Foreign body <= 12 months

Head injury (minor, mild) <=12 months OR > 65 years

Insect bites and stings <= 3 months

Tick bite < 2 years

Limb Injury <=12 months

Marine creatures < 2 years

Minor burns <= 12 months

Pain <= 3 months

Rash <= 6 months

Respiratory Illness <= 6 months

Urinary Symptom <= 12 years

Vomiting and Diarrhoea < 2 OR >= 65 years

Wounds <= 12 months

When the above age criteria are applied to the NDEC ED presentations, in total 2,554 (11.9%) presentations are excluded as summarised in Table 7-9. The injury/illness categories with the largest proportion of cases excluded due to age criteria are „Head injury (minor/mild)‟ and „Vomiting and Diarrhoea‟ for which exclusions accounted 25.0% and 29.5% respectively. (It should be noted that the HIE data-set did not contain a data field with patient age in months and so any case with an age exclusion criteria of less than 12 months was excluded.)

Table 7-9: ED presentations by NDEC injury/illness type and age inclusion criteria

Injury/illness type Age criteria met

Total No Yes

Earache 22 2.0% 1,105 98.0% 1,127 100%

Eye problems 8 1.2% 666 98.8% 674 100%

Foreign body 1 0.3% 352 99.7% 353 100%

Head injury (minor/mild) 3 25.0% 9 75.0% 12 100%

Insect or tick bite 9 1.1% 777 98.9% 786 100%

Limb Injury 0 0.0% 527 100.0% 527 100%

Marine creatures 2 1.9% 101 98.1% 103 100%

Minor burns 11 5.7% 181 94.3% 192 100%

Pain 4 0.1% 3,885 99.9% 3,889 100%



50

Injury/illness type Age criteria met

Total No Yes

Rash 213 12.9% 1,433 87.1% 1,646 100%

Respiratory Illness 102 3.1% 3,197 96.9% 3,299 100%

Urinary Symptom 12 9.8% 111 90.2% 123 100%

Vomiting and Diarrhoea 2,167 29.5% 5,173 70.5% 7,340 100%

Wounds 0 0.0% 1,323 100.0% 1,323 100%

Total 2,554 11.9% 18,840 88.1% 21,394 100%

7.1.4 NDEC PRESENTATIONS BY TRIAGE SCORE

The NDEC MoC is designed to support the management of very low risk, low acuity patients. Accordingly, in addition to the injury-based definition, only patients in triage category 4 or 5 are eligible for NDEC management. It can be seen from Table 7-10 that overall, NDEC presentations in triage category 4 or 5 comprise 77% of total presentations. Triage category 3 presentations comprised 22% of ED visits for NDEC injuries/illnesses.

Table 7-10: NDEC injury/illness presentations by triage category

Injury/illness type

Triage Category

Total 1 2 3 4 5

Sub-total: 4 & 5

No. %

Earache 0 1 89 649 366 1,015 92% 1,105

Eye problems 0 9 104 377 176 553 83% 666

Foreign body 0 0 19 189 144 333 95% 352

Head injury (mild, minor) 0 1 3 4 1 5 56% 9

Insect or tick bite 1 8 75 359 334 693 89% 777

Limb Injury 0 14 80 303 130 433 82% 527

Marine creatures 0 6 37 53 5 58 57% 101

Minor burns 1 3 36 88 53 141 78% 181

Pain 1 110 1,346 1,977 451 2,428 62% 3,885

Rash 0 5 89 821 518 1,339 93% 1,433

Respiratory Illness 0 17 563 2,012 605 2,617 82% 3,197

Urinary Symptom 0 0 18 56 37 93 84% 111

Vomiting and Diarrhoea 1 59 1,493 3,047 573 3,620 70% 5,173

Wounds 0 8 154 834 327 1,161 88% 1,323

Total 4 241 4,106 10,769 3,720 14,489 77% 18,840



51

Table 7-11 summarises the distribution of ED presentations according to NDEC and comparator sites before and after the application of the NDEC MoC eligibility criteria. In total, there were 167,344 ED presentations across comparator and NDEC sites with ICD10 codes available. After applying the abovementioned exclusion criteria – that is, filtering by NDEC injury/illness type; patient age; and triage scores – there were 14,489 cases. Of these, NDEC sites comprised 2,956 cases and comparator sites 11,533.

Table 7-11: Profile of eligible cases by comparator and NDEC sites

Scope of cases Size and remoteness category Comparator

NDEC site Total Other Walcha

All injury codes


0 to 4,999 - Outer Regional 18,013 3,170 2,371 23,554

5 to 9,999 - Outer Regional 25,372 0 9,673 35,045



Total 126,053 3,170 38,121 167,344

Cases meeting NDEC MoC criteria

0 to 4,999 - Inner Regional 734 0 386 1,120

0 to 4,999 - Outer Regional 1,662 487 259 2,408

5 to 9,999 - Outer Regional 1,811 0 186 1,997

15 to 19,999 - Inner Regional 2,114 0 481 2,595


Total 11,046 487 2,956 14,489

7.2 Time from triage to first seen clinician

Time from triage to the time a patient was first seen by a clinician was calculated for all ED presentations in the data-set for which valid data was available. This involved subtracting time recorded for the data field „first seen clinician time‟ from the data field „triage time‟. Results involving negative scores were excluded as were results of more than 24 hours.

Across all sites, the mean time from triage to „first seen clinician‟ was 56.5 minutes with a 95% confidence interval of 55.0 to 57.9 minutes.

Table 7-12: Mean time from triage to first seen clinician, NDEC sites by comparators

ED SIZE AND LOCATION CATEGORY

SITE NO. OF

ED VISITS MEAN TIME (MINUTES)

95% LCI 95% UCI

0 to 4,999 - Inner Regional

Comparator 579 43.12 38.67 47.57

NDEC 163 81.75 64.21 99.29

0 to 4,999 - Outer Regional

Comparator 993 43.98 38.81 49.14

Comparator - Walcha 342 48.35 40.88 55.82

NDEC 121 43.43 34.80 52.05

5,000 to 9,999 - Comparator 1,342 41.27 38.50 44.04



52


SITE NO. OF

ED VISITS MEAN TIME (MINUTES)

95% LCI 95% UCI

Outer Regional NDEC 135 82.15 52.20 112.09

15,000 to 19,999 - Inner Regional

Comparator 1,484 64.62 60.87 68.38

NDEC 455 77.12 62.52 91.72


Comparator 4,144 62.12 59.92 64.32

NDEC 1,483 51.24 48.60 53.87

Total 11,241 56.46 55.03 57.88

Differences in mean time from triage to first seen clinician are shown for EDs in the category „0 to 4,999 ED visits – Inner Regional‟ in Figure 7-2. It is apparent that the NDEC site, Nimbin MPS, has a significantly longer average at 81.8 minutes (64.2 to 99.3) relative to comparator sites which averaged 43.1 minutes (38.7 to 47.6).

Figure 7-2: Mean time from triage to first seen clinician: 0 to 4,999 ED visits – Inner

regional

- 20 40 60 80 100 120

Coolamon MPS - c

Junee MPS - c

Culcairn MPS - c

Boorowa MPS - c

Braidwood MPS - c

Gloucester Soldier's Memorial Hospital - c

Henty MPS - c

Comparator - c

Nimbin MPS - i

NDEC - i

0 to 4,999, Inner Regional

Average time in minutes from triage to first seen clinician

i = implementation site c = comparator site



53

For ED sites in the category „0 to 4,999 ED visits – Outer regional‟, the NDEC site Bellinger River District Hospital averaged 43.4 minutes (34.8 to 52.1). This was similar to the comparator site, Walcha, with 48.4 minutes (40.9 to 55.8) and other comparator sites which averaged 44.0 minutes (38.8 to 49.1).

Figure 7-3: Mean time from triage to first seen clinician: 0 to 4,999 ED visits – Outer

regional

- 20 40 60 80 100 120 140 160

Batlow/Adelong MPS - c

Berrigan MPS - c

Tumbarumba MPS - c

Bombala MPS - c

Temora Health Service - c

Jerilderie MPS - c

Merriwa MPS - c

Bingara MPS - c

Lockhart MPS - c

Guyra MPS - c

Boggabri MPS - c

Urbenville and District MPS - c

Dorrigo Plateau MPS - c

Lake Cargelligo MPS - c

Warialda MPS - c

Comparator (exc'g Walcha) - c

Comparator - Walcha - c

Bellinger River District Hospital - i

NDEC - i

0 to 4,999, Outer Regional

Average time in minutes from triage to first seen cliniciani = implementation site c = comparator site



54

Results for ED sites in the category „5,000 to 9,999 ED visits – Outer regional‟ are shown in Figure 7-4. The mean time from triage to „first seen clinician‟ for the NDEC site, Pambula District Hospital, was 82.2 minutes (52.2 to 112.1) significantly above the mean for comparator ED sites of 41.3 minutes (38.5 to 44.0).

Figure 7-4: Mean time from triage to first seen clinician: 5,000 to 9,999 ED visits – Outer regional

In the category „15,000 to 19,999 ED visits – Inner regional‟, the NDEC site, Cooma Health Service, had a mean time from triage to „first seen clinician‟ of 77.1 minutes (62.5 to 91.7), not significantly different from the mean time for comparator ED sites of 64.6 minutes (60.9 to 68.4), as shown in Figure 7-5.

Figure 7-5: Mean time from triage to first seen clinician 15,000 to 19,999 ED visits –

Inner regional

- 20 40 60 80 100 120

Manilla MPS - c

Barraba MPS - c

Leeton Health Service - c

Glen Innes District Hospital - c

Comparator - c

Pambula District Hospital - i

NDEC - i

5-9,999 ED visits - Outer regional


- 10 20 30 40 50 60 70 80 90 100

Moruya District Hospital - c

Cowra District Hospital - c

Comparator - c

Cooma Health Service - i

NDEC - i

15-19,999 ED visits - Inner regional

Average time in minutes from triage to first seen clinician




55

The NDEC site Milton and Ulladulla Hospital, in the category „25,000 to 29,999 ED visits – Inner regional‟ had a mean time from triage to „first seen clinician‟ of 51.2 minutes (48.6 to 53.9) significantly lower than the mean for EDs in the comparator group of 62.1 minutes (59.9 to 64.3) as shown in Figure 7-6.

Figure 7-6 : Mean time from triage to first seen clinician: 25,000 to 25,999 ED visits -

Inner regional

7.3 Time from triage to discharge

Time from triage to discharge was calculated by subtracting „actual time of discharge‟ from „time to triage‟ for cases containing valid time data. In addition to missing time values or cases with invalid time reported, cases were excluded where the subtraction yielded a negative time result or where the time duration exceeded 24 hours.

The results for mean time from triage to discharge are summarised in Table 7-13. Across all sites, the mean time was 97.96 minutes (96.15 to 99.77). NDEC sites typically had on average a shorter duration from triage to discharge than comparator sites excepting the category „5,000 to 9,999 – Outer Regional‟.

Table 7-13: Mean time from triage to discharge, NDEC sites versus comparators by

ED size and location categories


SITE NO. OF ED

VISITS

MEAN TIME

(MINUTES) 95% LCI 95% UCI

0 to 4,999 – Inner Regional

Comparator 732 91.48 83.63 99.32

NDEC 371 64.04 55.59 72.50

0 to 4,999 – Outer Regional

Comparator 1,630 79.85 74.94 84.75

Comparator - Walcha 483 69.60 62.40 76.79

NDEC 252 67.40 59.86 74.95

5,000 to 9,999 – Comparator 1,740 73.11 69.21 77.02

- 10 20 30 40 50 60 70 80

Casino and District Memorial Hospital - c

Bateman's Bay District Hospital - c

Ballina District Hospital - c

Comparator - c

Milton and Ulladulla Hospital - i

NDEC - i





56


SITE NO. OF ED

VISITS

MEAN TIME

(MINUTES) 95% LCI 95% UCI

Outer Regional NDEC 180 116.09 89.23 142.96


Comparator 2,082 131.00 125.02 136.98

NDEC 480 123.90 108.68 139.11


Comparator 4,696 108.27 105.16 111.38

NDEC 1,640 84.88 81.24 88.53

Total 14,286 97.96 96.15 99.77

Average time from triage to discharge for EDs in the category „0 to 4,999 ED visits - Inner regional‟ is shown in Figure 7-7. The mean time for the NDEC site, Nimbin MPS was 64.0 minutes (55.6 to 72.5) significantly below the mean time for comparators of 91.5 minutes (83.6 to 99.3).

Figure 7-7: Mean time from triage to discharge: 0 to 4,999 ED visits - Inner regional

- 20 40 60 80 100 120 140 160

Henty MPS - c

Coolamon MPS - c

Boorowa MPS - c

Junee Multi-Pupose Service - c

Gloucester Soldier's Memorial Hospital - c

Culcairn MPS - c

Braidwood MPS - c

Comparator - c

Nimbin MPS - i

NDEC - i


Average time in minutes from triage to discharge




57

For NDEC sites in the category „0 to 4,999 ED visits – Outer regional‟, mean time from triage to discharge was not significantly different for the NDEC site of Bellinger River District Hospital with a mean of 67.4 minutes (59.9 to 75.0) compared to Walcha MPS‟s mean of 69.6 minutes (62.4 to 76.8). As shown in Figure 7-8, other comparator sites had a longer average duration of 79.8 minutes (74.9 to 84.8) although the difference was not statistically significant.

Figure 7-8: Mean time from triage to discharge: 0 to 4,999 ED visits – Outer regional

- 50 100 150 200 250 300

Batlow/Adelong MPS - c

Berrigan MPS - c

Bingara MPS - c

Boggabri MPS - c

Bombala MPS - c

Dorrigo Plateau MPS - c

Guyra MPS - c

Jerilderie MPS - c

Lake Cargelligo MPS - c

Lockhart MPS - c

Merriwa MPS - c

Temora Health Service - c

Tumbarumba MPS - c

Urbenville and District MPS - c

Warialda MPS - c

Comparator (exc'g Walcha) - c

Walcha MPS - c

Comparator - Walcha - c

Bellinger River District Hospital - i

NDEC - i






58

The NDEC site, Pambula District Hospital, with a mean time of 116.1 minutes (89.2 to 143.0) had the longest average duration from triage to discharge compared to all comparator sites which averaged 73.1 minutes (69.2 to 77.0). As shown in Figure 7-9, in the category, „5,000 to 9,999 ED visits - Outer regional‟, Barraba MPS was well below the average for the comparator group at 55.2 minutes (50.6 to 59.9).

Figure 7-9: Mean time from triage to discharge: 5,000 to 9,999 ED visits - Outer

regional

EDs in the category „15,000 to 19,999 ED visits – Inner regional‟ had relatively similar durations in average time from triage to discharge, all in excess of 100 minutes. As shown in Figure 7-10, the NDEC site Cooma Health Service averaged 123.9 minutes (108.7 to 139.1) relative to the comparator average of 131.0 minutes (125.0 to 137.0). Of the two comparator hospitals, Moruya District Hospital had a longer average duration of 148.5 minutes (139.5 to 157.6) and Cowra District Hospital a shorter average duration of 108.9 minutes (102.0 to 115.8).


regional

- 20 40 60 80 100 120 140 160

Barraba MPS - c

Glen Innes District Hospital - c

Leeton Health Service - c

Manilla MPS - c

Comparator - c

Pambula District Hospital - i

NDEC - i




- 20 40 60 80 100 120 140 160 180

Cowra District Hospital - c

Moruya District Hospital - c

Comparator - c

Cooma Health Service - i

NDEC - i


Average time in minutes from triage to dischargei = implementation site c = comparator site



59

For EDs in the larger size category, the NDEC site of Milton and Ulladulla Hospital averaged 84.9 minutes (81.2 to 88.5), significantly lower than the average for comparator EDs of 108.3 minutes (105.2 to 111.4). Of the three comparator hospitals, Casino and District Memorial Hospital‟s average of 76.7 minutes (72.7 to 80.6) is significantly shorter than other comparator EDs and also Milton and Ulladulla Hospital as shown in Figure 7-11.


Regional

7.4 Disposition status

The analysis of disposition status has been based upon four main „mode of separation‟ categories:

Patients admitted to hospital from ED;

Patients who did not wait or who left at own risk;

Patients who departed the ED and were transferred to another hospital without being admitted to the hospital at which ED treatment was provided; and

Patients who departed the ED with treatment completed.

- 20 40 60 80 100 120 140 160 180

Ballina District Hospital - c

Bateman's Bay District Hospital - c

Casino and District Memorial Hospital - c

Comparator - c

Milton and Ulladulla Hospital - i

NDEC - i


Average time in minutes from triage to dischargei = implementation site c = comparator site



60

7.4.1 PATIENTS ADMITTED FROM ED

As shown in Table 7-14, relatively few patients were admitted to hospital from ED, with 2.91% of patients in NDEC sites (2.33% to 3.58%); 6.37% in Walcha (4.37% to 8.92%); and 8.11% in other comparator hospitals (7.61% to 8.63%).

Table 7-14: Patients admitted from ED

7.4.2 PATIENTS WHO DID NOT WAIT OR LEFT AT OWN RISK FROM ED

Very few patients „did not wait or left at own risk‟ with NDEC sites reporting 0.64% (0.38% to 1.00%) of patients in this category; 1.03% (0.34% to 2.38%) for Walcha; and 0.59% (0.46% to 0.75%) for other comparators.

Table 7-15: Patients who did not wait or left at own risk from ED

No. % 95% LCI95%

UCINo. % 95% LCI

95%

UCINo. % 95% LCI

95%

UCI

0 to 4,999 - Inner Regional 102 13.90% 11.48% 16.62% 0 0.00% 0.00% 0.00% 5 1.30% 0.43% 3.00%

0 to 4,999 - Outer Regional 159 9.57% 8.20% 11.09% 31 6.37% 4.37% 8.92% 15 5.79% 3.28% 9.37%

5,000 to 9,999 - Outer Regional 106 5.85% 4.81% 7.03% 0 0.00% 0.00% 0.00% 9 4.84% 2.24% 8.99%

15,000 to 19,999 - Inner Regional 191 9.04% 7.85% 10.34% 0 0.00% 0.00% 0.00% 14 2.91% 1.60% 4.83%

25,000 to 29,999 Inner Regional 338 7.15% 6.43% 7.92% 0 0.00% 0.00% 0.00% 43 2.62% 1.90% 3.51%

Total 896 8.11% 7.61% 8.63% 31 6.37% 4.37% 8.92% 86 2.91% 2.33% 3.58%

Comparator - exc'g Walcha Walcha NDEC

Size and remoteness category

No. % 95% LCI95%

UCINo. % 95% LCI

95%

UCINo. % 95% LCI

95%

UCI






Total 65 0.59% 0.46% 0.75% 5 1.03% 0.34% 2.38% 19 0.64% 0.38% 1.00%





61

7.4.3 PATIENTS WHO DEPARTED THE ED AND WERE TRANSFERRED WITHOUT

BEING ADMITTED

Although there was a very low incidence of patients who were transferred without being admitted for NDEC sites, at 0.03% (0.0% to 0.18%) and 0.24% (0.16% to 0.35%) for other comparator sites, there was a somewhat higher rate for Walcha at 2.26% (1.13% to 4.01%).

Table 7-16: Patients who departed the ED and were transferred without being

admitted

7.4.4 PATIENTS WHO DEPARTED ED WITH TREATMENT COMPLETED

NDEC sites had the highest proportion of patients in the category „patient departed ED with treatment completed‟ at 96.41% (95.68% to 97.05%). The next highest proportion was for other comparators at 91.06% (90.51% to 91.59%) followed by Walcha at 90.35% (87.37% to 92.82%).

Table 7-17: Patients who departed ED with treatment completed

No. % 95% LCI95%

UCINo. % 95% LCI

95%

UCINo. % 95% LCI

95%

UCI






Total 26 0.24% 0.16% 0.35% 11 2.26% 1.13% 4.01% 1 0.03% 0.00% 0.18%



No. % 95% LCI95%

UCINo. % 95% LCI

95%

UCINo. % 95% LCI

95%

UCI


0 to 4,999 - Outer Regional 1,467 88.27% 86.62% 89.78% 440 90.35% 87.37% 92.82% 244 94.21% 90.63% 96.72%

5,000 to 9,999 - Outer Regional 1,663 91.83% 90.47% 93.05% 0 0.00% 0.00% 0.00% 163 87.63% 82.02% 91.99%

15,000 to 19,999 - Inner Regional 1,923 90.96% 89.67% 92.16% 0 0.00% 0.00% 0.00% 461 95.84% 93.65% 97.44%

25,000 to 29,999 Inner Regional 4,387 92.85% 92.08% 93.57% 0 0.00% 0.00% 0.00% 1,601 97.38% 96.49% 98.10%

Total 10,059 91.06% 90.51% 91.59% 440 90.35% 87.37% 92.82% 2,850 96.41% 95.68% 97.05%


Disposition

category Size and remoteness category

Departed,

treatment

completed



62

Appendix 1 Stakeholder discussion guide

Stakeholder Discussion Guide

Evaluation of Nurse Delegated Emergency Care (NDEC) model of care

Purpose and context

Nurse Delegated Emergency Care (NDEC) is a model of care that is being implemented in rural and remote Emergency Departments (EDs) across NSW, led by the Agency for Clinical Innovation through the Emergency Care Institute. An initial round of stakeholder consultations is planned to seek early perspectives from sites in the planning stage or which have commenced the NDEC model of care to identify operational issues relevant to local implementation.

Planning and implementation

1. To what extent has your health service implemented the NDEC model of care? Have you commenced implementation? What has been the lead-time required to plan for implementation?

2. What motivated your site to apply for NDEC? Have these goals been realised? Do you feel that this model will achieve these?

3. At this stage, what have been the main barriers and facilitators to implementing the NDEC model of care?

4. What project management arrangements are you using to implement the NDEC model of care? Did you receive specific project management training to assist you with the implementation of the NDEC model of care and if so, was it helpful?

5. Did you access project management training from the NSW Ministry of Health e-Learning web-site, from your LHD or coaching provided by the Emergency Care Institute? Do you feel you have the skill set to project manage the implementation process locally? Would you benefit from further project management training?

6. Have you established an implementation team? Does this include representation from an executive sponsor (e.g. your hospital or a senior executive from your LHD), a project lead and what clinical representation (e.g. medical, nursing and allied health)? Did you include or will you include a consumer representative?

7. What process are you using to engage with key stakeholders? What approach have you used to consult with GPs, staff in your hospital and your Local Health District?

8. How supportive have stakeholders been to the NDEC model of care? Did you feel you had sufficient information to explain the purpose of NDEC to local stakeholders to gain their support and cooperation?

9. Do you have a view on the acceptability of the NDEC model of care to government, service providers and consumers of health services? What alternative models of care exist to meet the needs of this patient cohort?

10. What assistance and support have you received from the Emergency Care Institute in planning for implementation? Did you receive the following implementation resource templates:



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Site project plan template?

Stakeholder invitation template?

Implementation team meeting templates?

NDEC approval templates?

Common frequently asked questions?

11. Which of these resources have you found most useful and relevant? Were there any changes you would recommend to these templates? Were there any other templates you consider would be helpful to you?

12. Do you envisage any changes in relation to workforce and infrastructure in implementation of the model of care? Are your current IT systems and communication strategies appropriate to support the model of care?

13. What opportunities have you identified to simplify or improve ongoing model of care implementation?

Core components of the model of care

14. What process have you used to ensure local ratification of the core components (specifically, Nursing Management Guidelines, Medication Standing Orders, and RN accreditation) of the NDEC model of care? Were there any non-core components that have or that will require local adaptation?

15. Has there been any feedback from individual clinicians or your LHD about any gaps or concerns with the NDEC core components including Nursing Management Guidelines, Standing Orders, RN accreditation? What process have you followed to address these concerns or gaps?

16. What‟s your perception on the legitimacy / robustness of the NDEC tools (in particular the Nursing Management Guidelines and Medication Standing Orders)? Have these been developed collaboratively with relevant groups and individuals, are they evidence based, are they recognised as best practice etc.?

Education and accreditation

17. What education and training was provided by the Emergency Care Institute to support the introduction of the model of care? Was the education and training suitable? Are there any changes to the training and assessment program relevant to the NDEC model that you would recommend?

18. What has been the level of interest from RNs at your health service in considering the option of training to be a credentialed RN under NDEC?

19. What process was used to select an RN at your health service to be invited for training and credentialing in the NDEC model of care?

20. Has your health service completed the RN accreditation process for the NDEC model of care?

Audit

21. Was a pre-implementation audit undertaken prior to introduction of the model of care and were any changes made locally following this audit? Did this audit highlight other areas requiring attention?



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22. Are there audit tools that you are implementing for NDEC to collect, collate and report NDEC data?

Governance

23. What governance process has been planned or is in place to provide local oversight of the NDEC implementation?

24. Is there a formal governance committee for NDEC at your hospital? Does it have documented terms of reference? Who is on the governance committee? What is the frequency of meetings? Are there minutes recorded from these meetings?

Evaluation Framework for Nurse Delegated Emergency Care · NSW Agency for Clinical Innovation Nurse...

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