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PleDG: Please don’t go, it’s worth the wait

Project Added:
20 August 2015
Last updated:
26 August 2015

PleDG: Please don’t go, it’s worth the wait

Reducing 'did not wait' / 'leave at own risk' and re-presentations at the Broken Hill Health Service emergency department (ED).

Summary

Health outcomes are poorer for patients if they disengage from a service before receiving or completing care. This project is working to ensure that at the Broken Hill Health Service ED:

  • patients receive the right care at the right time and in the right place
  • patients needing access to emergency care can access it when they need it
  • patients will remain engaged with the emergency services to achieve optimal management of their medical conditions
  • staff can focus on their core business of providing quality rapid response care
  • there is an overall reduction to re-presentation, do not wait and leaving at own risk rates overall, and in particular for Aboriginal people.

Download a poster from the Centre for Healthcare Redesign graduation, August 2015.

Aim

To improve access and completion of care rates for Aboriginal and non-Aboriginal people attending the ED at Broken Hill Health Service, by addressing planned re-representations and streamlining of emergency and non-emergency care to services best suited to meet the needs of the person.

Benefits

By decreasing the re-presentation rate at the Broken Hill Health Service ED there will be increased capacity within the existing resources of the ED to address the issues of people leaving the ED before receiving or completing their care.

By decreasing the overall rate and rate for Aboriginal people of leaving the ED before receiving or completing care, there will be an improvement in patient experience.

Project status

Project started: August 2014

Project status: Implementation - the initiative is currently being implemented, piloted or tested.

Background

The Broken Hill Health Service ED performs as the best in NSW for non-admitted National Emergency Access Target targets at present, however the Whole of Hospital Programme data summaries showed that the Broken Hill Health Service ED had the highest unplanned re-presentation rate in the Whole of Hospital Programme group (12.4% for Jan – June 2014, up from 7.8% in 2013) compared with an average of 5.57% across the group, and was slightly higher than average for 'did not wait' / 'leave at own risk' (5.61% compared with the average across the group of 5.4%, June 2014 Whole of Hospital Programme data report).

The 2012 Aboriginal Health Chief Health Officer report showed that Aboriginal people were more likely to leave ED before completing treatment than non-Aboriginal people, and were more likely to re-present to the same ED within 48 hours. The same report showed that in 2012, Far West Local Health District had double the rate of Aboriginal people who did not wait or left at own risk compared to non-Aboriginal people (8.7% Aboriginal compared to 4.2% non-Aboriginal). The Far West Local Health District has set a performance goal of reducing the rate of Aboriginal people leaving the ED before completing treatment to below the NSW state average by July 2015 and be the best in NSW by July 2016. This project focused initially on Broken Hill Health Service as the largest ED in the district.

Implementation

Consumer feedback

  • Aboriginal and non-Aboriginal consumers report that waiting room comfort, access to care (registration form being a barrier to care and delays to access triage), being able to see into the back of the ED from the waiting room, lack of care while waiting, and timely access to care after hours are all contributing factors to leaving before commencing or completing care.
  • Aboriginal consumers also reported that the service lacks cultural competency and the environment is not culturally welcoming.

Solutions implemented

  • Waiting room comfort: bubbler fixed and a larger television installed. Attempting to source a snack vending machine for the waiting room is proving difficult due to lack of local suppliers. A door to block heat/cold entering the waiting room is waiting on funding.
  • Access to care and lack of care while waiting: The registration form has been eliminated and replaced with a verbal check in to update personal details. A patient flow trial is underway where triage occurs before registration and horizontal space in the ED is replaced with vertical space (chairs) with a dedicated rapid response nurse and doctor to supervise and attend to these patients (trials so far have indicated reduced wait and increased access to the nurse if waiting).
  • Consultation continues with the Aboriginal community to identify strategies to increase cultural competency of the service and how to build cultural competency in a fly in fly out medical workforce.

Implementation sites

Broken Hill Health Service is the focus of this project at present. Smaller outlying sites within the district that operate emergency /primary care clinics where did not wait/leave against advice is a problem will be included in the spread of successful interventions. Ongoing Aboriginal community and consumer consultation will also include Menindee and Wilcannia residents.

Support

The Studor group provided an ED expert to undertake a table top activity examining areas of concern in the patient flow through the ED. The PleDG project scope initially excluded patient flow through the ED, however the root causes pointed at issues with access to care. The table top activity highlighted the inefficient use of space in the ED creating blockages to flow and hence blockages to accessing care. The result was to incorporate patient flow trials into the PleDG project and monitor impact on did not wait objectives and patient feedback.

Kempsey District Hospital provided a range of resources and reports based on their work titled “Closing the Gap –Innovation in Emergency Departments”, which was in turn based on the research of Leanne Wright titled “They just don’t like to wait: a comparative study of Aboriginal and non-Aboriginal people who do not wait for treatment or discharge themselves against medical advice from rural emergency departments”.

Partnerships

Broken Hill Aboriginal Community Working party, for providing feedback and governance, as well as support for the project.

University of Sydney Department of Rural Health (Broken Hill) Kath Naden (Community Development Officer) and Denise Hampton (Aboriginal Project Officer PHC) for facilitating links with Aboriginal community and supporting the project.

Results

Data related to key objectives is closely monitored throughout the project.

As of July 2015

  • Consumer feedback has indicated approval for removal of the registration form.
  • Consumer feedback is also positive for access to care during patient flow trials.
  • Re-presentation rate continues to fluctuate as a result of changing staff entering incorrect visit type at time of triage, with ongoing audit and feedback to correct the problem and ongoing staff orientation /training to prevent re-occurrence. Changes to the operation of Fast Track clinic (undertaken separate to this project) are expected to have an impact on repeat presentations.
    Trend of unplanned re-presentations within 48 hours
  • Overall did not wait/leave against advice rate has become more controlled as a result of removing the registration form and trials of patient flow models where triage is first and unmanaged waits are reduced.
    Trend showing overall delcine in DNW after change of registration form
  • Closing the gap between the rates of Aboriginal and non-Aboriginal did not waits continue to fluctuate, and identification and implementation of solutions continues to be a focus with Aboriginal community.
    Trend showing higher rate of DNW-LOAR for Aboriginal people

Awards

This project won the ACI Innovation Award at the 2016 Far West Local Health District Innovation Awards.

Lessons learnt

  • Project scope: This project had three clear objectives at the outset. In hindsight, the project could have been split into two, with re-presentations and overall did not wait/leave against advice objectives forming one project, and closing the gap between Aboriginal and non-Aboriginal did not wait/leave against advice as a stand-alone project flowing on.
  • Community and consumer engagement: Aboriginal community are keen to see change occur, but this requires trust between community and the health service. Engagement, if done well, needs to be continuous beyond the life of a short to medium term project. For effective and sustainable change to occur, the trust and lines of communication between the organisation and the community need to be opened and remain open in the longer term. This project is the first in a while looking to re-build relationships with the Aboriginal community, and is in essence laying the groundwork for what is to come beyond the life of this project.
  • Project governance: in a small district with very small staff numbers, high staff turnover and prolonged vacancies in key positions pending recruitment, there is limited time capacity of key personnel in the governance structure to oversee the many projects underway at any given time. This requires creativity in overcoming governance hurdles and black holes, and a high degree of autonomy and persistence on the part of the project leads.

Contact

Melissa Welsh
Clinical Redesign and Innovation Manager
Far West local Health District
Phone: 08 8080 1549
Melissa.Welsh@health.nsw.gov.au

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