General principles

Patients requiring emergency care have the right to timely care by skilled staff. The aim of staffing an emergency department (ED) is ultimately to provide care in an acceptable time according to the patient’s clinical urgency (triage category). Staff working in the department also have the right to safe and manageable working conditions and reasonable job satisfaction.

As the activity of an ED fluctuates in both volume and acuity, a threshold level of staffing and resources is required in order to be prepared for likely influxes of patients. In addition, the staffing number and mix needs to take account of the important teaching role of EDs.

The precise number and designation of medical and other staff employed will be determined by the local work practices (what tasks are carried out and by whom). This chapter discusses staffing requirements under the current Australasian model of ED work practices. This includes a major supervisory and teaching role for consultants, and a significant proportion of specialist trainees and junior medical staff in the medical workforce, with a range of tasks, including venepuncture, test requisitioning and written documentation. In addition, roles are expanding into wider realms such as toxicology and observation medicine.

In the UK, there is a move away from the traditional model of staffing based on enthusiastic and committed, but relatively inexperienced, senior house officers, towards more care being delivered by senior medical staff: consultants, registrars, staff grades and associate specialists. There is significant expansion under way in the numbers of registrar training posts and consultants in EDs.

This expansion will ensure that more care is delivered by experienced medical staff in conjunction with nursing colleagues, particularly in the enhanced nurse practitioner role. The concept is of an experienced team of clinicians delivering care.

Calculating clinical workload

ED case-mix and costing studies have sought to measure the medical time commitment for various clinical conditions. Table 27.1.1 describes the approximate average medical time commitment for each of the Australasian Triage Scale categories:¹

Table 27.1.1 Australasian Triage Scale Categories

Table 27.1.2 Benchmarks for waiting time by triage category

Medical staff

The medical workforce of Australasian EDs currently includes the following categories:

The specialist practice of emergency medicine includes non-clinical roles (including departmental management and administration, planning, education, research and medico-political activities) as well as clinical roles. The non-clinical workload of an individual department varies with its size and role, the structure of its staffing and the other management systems within the institution. For senior staff, clinical work generally includes coordination of patient flow, bed management and supervision, and bedside teaching of junior staff, in addition to direct patient care. Some emergency physicians may have other particular roles, such as retrieval and hyperbaric medicine or toxicology services. The increasing number of academic staff may have major research and teaching commitments.

To cover these roles, the ACEM recommends a minimum of 30% non-clinical time for consultants (more for directors of departments) and 15% non-clinical time for registrars.

In 2003, the Australian Medical Workforce Advisory Committee (AMWAC) revised its initial recommendations for the emergency medicine specialist workforce (AMWAC Report 2002–2012, September 2003). The review recognized that greater numbers than previously recommended will be required to provide a 24-h, 7-day consultant cover for major referral hospitals, and a 16-h, 7-day consultant cover for urban district and major rural/regional centres. Throughout Australasia, EDs are experiencing increasing levels of activity. The calculation of medical staff numbers required for a particular department must include not only the extent of consultant cover required, but also the clinical workload and performance, local work practices, and the nature of clinical and non-clinical roles. Because of variations in roles and work practices between sites, it is not possible to devise a staffing profile that is universally appropriate. Other recent changes in staffing patterns include employment across a network, increasing part-time work and sessional contract arrangements. Many emergency physicians are diversifying their practice profile to achieve a balanced and sustainable career, combining salaried and contract work, different types of hospitals and part-time work with a range of other interests.

Ancillary staff

Clerical, paramedical and other ancillary staff are essential to the efficient provision of emergency medical services. They should be specifically trained and experienced for ED work. Clerical staff have a crucial role, encompassing reception, registration, data entry and communications within and outside the department, as well as maintenance of medical records. Dedicated paramedical staff, including therapists and social workers, are important in providing thorough assessment and management of patients, including participating in disposition decisions and discharge support. Other staff, such as porters and ward assistants, play an important role in releasing clinical staff from non-clinical roles.

Optimizing work practices

Traditional hospital work practices involve systems and tasks that are inefficient for the smooth running of modern, busy EDs. In a work environment with a rapid patient throughput and large numbers of staff, efficient work practices are crucial in optimizing clinical performance as well as job satisfaction. A review of staff numbers and seniority cannot provide maximum benefit without consideration of the way the work is done, what tasks are done and by whom.

A review of ED work practices can encompass the following principles:

As the ED workforce develops greater seniority and specialization, and the demands of patient care increase, it is no longer possible to justify outdated work practices. Local research has shown that it is possible to improve clinical service provision by reorganizing roles and tasks in a sustainable way.³ The opportunity exists to create a work environment that both delivers good clinical service and is rewarding and satisfying for staff.

Introduction

The emergency department (ED) is a core clinical unit within a hospital. The experience and satisfaction of patients attending the ED are significant contributors to the public image of the hospital. Its primary function is to receive, triage, stabilize and provide emergency care to patients who present with a wide range of undifferentiated conditions which may be critical to semi-urgent in nature. The ED may contribute between 15 and 75% of the hospital’s total number of admissions. It plays an important role in the hospital’s response to trauma, and in the reception and management of disaster victims. To optimize its core function, the department should be purpose-built, providing a safe environment for both patients and staff. The physical environment includes an effective communication system, appropriate signposting, adequate ambulance access and clear observation of relevant areas from the triage area. There should be easy access to the resuscitation area, and quiet and private areas should cater to patients and relatives. Adequate staff facilities and tutorial areas should be available. Clean and dirty utilities and storage areas are also required.

Design considerations

The design of the department should promote rapid access to every area with the minimum of cross-traffic. There must be proximity between the resuscitation and the acute treatment areas for non-ambulant patients. Supporting areas, such as clean and dirty utilities, the pharmacy room and equipment stores, should be centrally located to prevent staff traversing long distances. The main aggregation of clinical staff will be at the staff station in the acute treatment area. This is the focus around which the other clinical areas should be grouped.

Lighting should conform to national standards and clinical care areas should have exposure to daylight whenever possible to minimize patient disorientation. Climate control is essential for the comfort of both patients and staff. Each clinical area needs to be serviced with medical gases, suction, scavenging units and power outlets. The minimum suggested configuration for each type of clinical area is outlined in Table 27.2.1.

Table 27.2.1 Configurations for clinical areas

Medical gases should be internally piped to all patient care areas, and adequate cabling should ensure the availability of power outlets to all clinical and non-clinical areas. Although patient and emergency call facilities are often considered, there is often inadequate provision for telephone and information technology ports. Emergency power must be available to all lights and power outlets in the resuscitation and acute treatment areas. All computer terminals in the department should have access to emergency power, and emergency lighting should be available in all other areas. The electricity supply should be surge protected to protect electronic and computer equipment, physiological monitoring areas should be cardiac protected, and other patient care areas should be body protected.

Approximately 35–45% of the total area of the department is circulation space. An example of this would be the provision of corridors wide enough to allow the easy passage of two hospital beds with attached intravenous fluids. Although circulation space should be kept to a minimum, functionality, fire safety, and occupational health and safety requirements also need to be considered. The floor covering in all patient care areas should be durable and non slip, easy to clean, impermeable to water and body fluids, and with properties that reduce sound transmission and absorb shocks. Areas accommodating the administrative functions, interviewing and distressed relatives should be carpeted.

Size and composition of the emergency department

The appropriate size of the ED depends on a number of factors: the census, patient mix and acuity, the admission rate, the desired performance level manifested in waiting times, the length of stay of patients in the ED and the role delineation of the department. Departments of inadequate size are uncomfortable for patients, often function inefficiently, and may significantly impair patient care. Overcrowding of patients increases the risk of infectious disease transmission and increases harmful cognitive stimulation for patients with mental disturbance. For the average Australasian ED with an admission rate of approximately 25–35%, its total internal area (excluding departmental radiology facilities and observation/holding ward) should be approximately 50 m²/1000 yearly attendances. The total number of patient treatment areas (excluding interview, plaster and procedure rooms) should be at least 1/1100 yearly attendances, and the number of resuscitation areas should be at least one for every 15 000 yearly attendances. It is recommended that, for departments with average patient acuity, at least half the total number of treatment areas should have physiological monitoring available.

Clinical areas

Clinical support areas

The clean utility area requires sufficient space for the storage of clean and sterile supplies and procedural equipment, and bench tops to prepare procedure trays. The dirty utility should have sufficient space to house a stainless steel bench top with sink and drainer, pan and bottle rack, bowl and basin rack, utensil washer, pan/bowl washer/sanitizer, and slop hopper and storage space for testing equipment (such as for urinalysis). A separate store room may be used for the storage of equipment and disposable medical supplies. A common design fault is to underestimate the amount of storage space required for a modern department. A pharmacy/medication room may be used for the storage of medications used by the department, and should be accessible to all clinical areas. Entry should be secure with a self-closing door, and the area should have sufficient space to house a refrigerator for the storage of heat-sensitive drugs. Other design features should include spaces for a linen trolley, mobile radiology equipment, patient trolleys and wheelchairs. Beverage-making facilities for patients and relatives, a blanket-warming cupboard, disaster equipment store, a cleaners’ room and shower and toilet facilities also need to be accommodated. An interview room may be designated for the interviewing or counselling of relatives in private. It should be acoustically treated and removed from the main clinical area of the department. A distressed relatives’ room should be provided for the relatives of seriously ill or deceased patients. Consideration for two such rooms should be given in larger departments to allow the separation of relatives of patients who have been protagonists in violent incidents or clashes. They should be acoustically insulated and have access to beverage-making facilities, a toilet and telephones. A single-room treatment area should be in close proximity to these rooms to enable relatives to be with dying patients, and should be of a size appropriate to local cultural practices.

Non-clinical areas

Likely developments over the next 5–10 years

Over the last 20 years EDs have been providing care of an ever-increasing complexity. Changes in technology have enabled the management of greater numbers of patients in the community who would previously have required hospitalization. As financial pressures on hospitals have also increased, the importance of the ED has grown considerably, and modern departments have significantly expanded facilities. Future design considerations are likely to centre on advances in the areas of information technology, telecommunications and new non-invasive diagnostic modalities. In addition to these technologically driven changes, it is likely that a greater emphasis will be placed on developing ED design configurations that maximize efficient work practices. Computerized patient tracking systems using electronic tags and built-in sensors will provide additional information that may further improve operational efficiency. The electronic medical record will make detailed medical information immediately available and will greatly facilitate quality improvement and research activities. Digital radiography, personal communication devices, voice recognition systems and expanded telemedicine facilities will make the ED of the future as reliant on electricity and cabling as it is on oxygen and suction.

The increasing age of the population needs also to be considered when designing an ED. Older patients are more likely to have poor mobility, vision and balance as well as being at increased risk of delirium due to underlying disease or hospitalization. They are likely to require greater space for the use of mobility aids and require greater shielding from sources of cognitive overstimulation than other patients. Standard hospital trolleys may pose a falls risk and contribute to the development of pressure areas so consideration should be given to the use of more comfortable ‘reclining lounge chair’ style seating or hospital beds for this group of patients. Adequate lighting and the maintenance of a normal diurnal ‘night-day’ light pattern should be considered for elderly patients who spend prolonged periods of time in the emergency department.

Introduction

A primary role of the emergency department (ED) is to deliver the best possible care to presenting patients. In order to deliver optimal care, a system of quality management must be part of the culture for all staff and must be applied to all functions of the department. Quality management requires effective leadership, organizational vision, strategic development, commitment to improving processes and systems, accountability, communication, support for staff development and commitment to analysis, change and review. Quality management is a continuous cycle, with measurement and monitoring required to establish that change is required, planning and implementation of the change and re-evaluation and monitoring to ensure the change has the desired effect. Consumer involvement is a fundamental part of quality management. In the emergency setting, consumers include patients, staff and the other clinical and hospital staff who interface with the ED.

History

The traditional approach of quality assurance involves a number of retrospective attempts to police various activities of the ED. The types of tools used in this approach are pathology result checking, missed fractures, medical record reviews, death audits and patient complaints. Although these checks are essential, it must be recognized that the traditional quality-assurance (QA) philosophy involves crisis management and implies ‘fault’, and the apportioning of blame. The trend currently involves movement from the QA model to the philosophy of total quality improvement and total quality management (TQM).¹ This management system has been adopted from industrial models, and applied to hospitals.² Much of the change has been triggered by the climate of accountability and clinical governance.

Definitions

Continuous quality improvement

The Deming cycle (described by WE Deming) is a fundamental tool for the approach to quality in any system. The PDCA (plan, do, check, act) cycle should incorporate the important sequential steps of planning, staff engagement, implementation, measurement, re-measurement and re-evaluation, followed by an improved plan and so on.

A QI system covers a number of dimensions. These are:

There are a number of vital characteristics of a CQI programme that are necessary for its successful operation.¹ A CQI programme:

A more detailed outline of TQM is beyond the scope of this book; however, the recent literature abounds with discussion on the various tools used, pitfalls in introduction, and so on.^5–14

National bodies

The push to TQM has been facilitated by various bodies, including The Australian Council on Healthcare Standards (ACHS), that in 1997 introduced its Evaluation and Quality Improvement Program (EQuIP) as a framework for hospitals to establish quality processes.¹⁵ This is a requirement for accreditation with the ACHS. In 2006, the Australian Commission for Safety and Quality of Health Care was established to oversee improvements in the Australian context (previously the Australian Council for Safety and Quality). In the USA, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Institute for Healthcare Improvement have led the way in the move from QA to QI.^16–17

The Australasian College for Emergency Medicine, the American College of Emergency Physicians and the British Association for Accident and Emergency Medicine are facilitating the process of QI by their training role, introduction of clinical indicators, policy development and standards for EDs.^18–19 In Australasia, the introduction of the Australasian Triage Scale, which has been widely adopted in EDs, has been used in the process of benchmarking, and the development of standards.²⁰

Quality in the ED

The ED is a complex environment, which involves close interaction with the rest of the hospital and the community. The inputs are uncontrollable and unregulated, and the ‘customers’ are under a high level of stress because of the nature of their problems, the unfamiliarity of the environment and the lack of control they perceive at a time when they are feeling personally vulnerable.

The ED is dealing simultaneously with life-threatening illness and minor complaints. It is an area under a high level of scrutiny from all quarters, the patients, the families and friends, the other departments in the hospital, and the wider community – both medical and non-medical. This in itself is stressful, and is compounded by the fact that many of the staff working in the ED are rotating through the department for relatively short periods of time, are often relatively junior and are undergoing training themselves. This training role is of critical importance in most EDs, and must not be forgotten in any process dealing with quality issues. All these aspects of an ED make the maintenance of quality difficult and all the more imperative. In order to establish a system where quality care can be delivered with any degree of reliability, it is important that all staff are committed to the process, and that management provide appropriate leadership and resources. The delivery of quality involves a continuing process of data collection (performance measures), analysis, feedback and introduction of strategies to improve the system, followed by re-analysis of the performance measures (the quality cycle).

Common measures of clinical performance or outcome

The following are commonly used measures:

The first three of these are the current ACHS/ACEM Clinical Indicators for Emergency Medicine.¹⁷

It is clear from the list that the measures are potentially innumerable, that local factors must dictate those areas of special interest and that this will vary from hospital to hospital. In deciding which areas should be measured it is important to focus on areas that have been targeted as requiring improvement.

It is also evident that all EDs have common areas where there is high potential for problems to develop, and that these areas should be routinely monitored. The mechanism for doing this will vary from institution to institution.

Another aspect of the measuring of performance is that the process is one in evolution. Not only should the quality of the service improve as the measures are improved and re-assessed, but the areas for attention can change and develop with the whole system. Peeling off layers as problems are addressed, exposes new things to improve. Again, this process must be internally driven to be effective. There is little point in collecting an enormous amount of data, unless the process is useful to the improved functioning of the whole system. Those best able to make those improvements should be an integral part of the system.

Likely developments over the next 5–10 years

Introduction

Emergency departments (EDs) in public sector health services in Australasia are typically mid-sized clinical units within the organizational structures of hospitals. Staff numbers may range from 20 to over 200 and expenditure budgets from $1m to over $20m per annum. ED efficiency directly affects the global efficiency of the healthcare process in the hospital, and purchasers are therefore increasingly interested in the value and performance of emergency medicine services. ED managers are being required to report on the dimensions of cost, output, quality and efficiency through a business planning process and other reporting mechanisms in order to justify their level of resourcing.

Types of plans

ED plans are relatively low in the hierarchy of planning instruments that begin with national and state health policy, health departments’ strategic and corporate plans, regional and hospital strategic and business plans and, finally, the business and project plans of individual clinical units and departments. Strategic plans describe how organizations propose to respond to changing technology, altered demographics, shifting paradigms of care and industrial and regulatory reform, as well as issues associated with the cost, quality and accessibility of health care. These plans typically look 5–10 years into the future, and the ED should reasonably expect to have input at a variety of levels into the strategic planning process.

Project plans, on the other hand, are highly focused on a particular objective outcome to be achieved within a given timeframe, and with a specified level of resources. Project plans may need to be created by an ED for the implementation of a new and significant piece of technology, major refurbishment or redevelopment, or some types of work practice reform. However, the most important planning instrument for an ED is its annual business plan.

The business plan

The business plan is an important multipurpose document that needs to be developed by the ED management group, in consultation with hospital management, on an annual basis. At one level, the business plan represents a management contract between the executive of the hospital and the ED. At another level, the business plan provides information to the staff of the department about the agreed targets for expenditure, activity, efficiency and quality of services to be provided in the next financial year.

Planning process

The plan should be developed by the medical director, business manager and nurse manager of the ED. It is often useful to include a representative from the hospital’s financial services department early in the process, so that there is a clear understanding of the financial framework for the plan. It is vitally important that the process be informed with as much useful data as possible, including accurate and up-to-date financial and activity statistics, and quality and efficiency indicators. The premises, or context, of the business plan need to be established. Unless there are specific reasons for change, it can usually be assumed that hospital managers will require that the business plan be based on management of the same level of activity at a similar quality to the previous year. Other assumptions, relating to estimated wages growth, non-labour cost escalations, leave requirements and so on, should be stated.

The timing of business plan development depends on the government budget cycle for public sector EDs and the timing of the financial year for private sector EDs. In most jurisdictions this process needs to commence in early January, with the draft business plan available for the hospital executive by the end of February. The process may need to begin much earlier if significant additional or special funding is being sought. Such requests are best handled as separate submissions, which will then need to pass through the various evaluation and approval steps to be finally included in the government’s forward estimates and budget. It is uncommon for special projects requiring substantial funds to be approved and funded within one budget cycle.

A typical business planning cycle is illustrated in Figure 27.4.1.

Fig. 27.4.1 Business plan cycle.

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