Modelling resilience in the Emergency Department: Escalation policies and patient flow Janet Anderson, Jonathan Back, Myanna Duncan, Peter Jaye & Alastair Ross Dr. Janet Anderson Centre for Applied Resilience in Healthcare http://resiliencecentre.org.uk
Centre for Applied Resilience in Healthcare • Collaboration between King’s College London, University of Glasgow and Guy’s and St. Thomas’ NHS Foundation Trust • Close clinical and governance links • Quality improvement - drivers and approach • Sites for in depth work – – Emergency Department – Older Person’s Unit
Centre for Applied Resilience in Healthcare 1. Develop, implement and test organisational STUDY DESIGN AND SETUP META NARRATIVE REVIEW OF RESILIENCE CONCEPTS AND TOOLS, DEVELOPMENT OF MEASURE OF RESILIENCE interventions to increase resilience, quality and ANALYSIS OF SECONDARY DATA, OUTCOME MEASURES, SYSTEM MODELLING safety WP8. EDUCATION AND DISSEMINATION DESIGN EVALUATION TOOLS AND PROCESSES 2. Shift focus of safety in the OBSERVATION ETHNOGRAPHIC FIELDWORK Pressures that require organisational and team resilience NHS from analysing and How is safety created through resilient practices? How is safety threatened – drift, sacrificing j’ments, perceptions of risk counting incidents to IMPLEMENTATION AND INTERVENTION DEVELOPMENT organizational resilience Collaborative work with clinical groups to develop tailored multi-level EVALUATION interventions IMPLEMENTATION AND EVALUATION 3. Provide guidance and tools Data collection, observation, analysis of time series data, cost effectiveness to implement resilience OUTCOMES SYNTHESIS OF RESULTS based approaches Synthesis, empirically validated theoretical model of resilience, recommendations for translating research into practice
Organisational resilience • Resilience is “the intrinsic ability of a system or an organisation to adjust its functioning prior to, during, or following changes and disturbances, so that it can sustain required operations under both expected and unexpected conditions” (Hollnagel, 2011, p. xxxvi) • Four cornerstones – anticipating, monitoring, responding and learning
Working Model Demand Success Eg attendance, acuity, standards, targets Work as Imagined Work as Done Adaptations Alignment Adjustments Failure Capacity Eg harm, breaches of Eg staff level, skills, targets, standards, staff equipment, procedures, burnout, complaints, escalation policy poor experience
Fieldwork • Focused study of escalation in action – Document analysis – Non participant observations – n=27 hours – Semi structured interviews – n=6 – Thematic analysis – combined deductive/inductive approach • Resilience narratives that describe how outcomes result from the interplay of misalignments and adaptations
ED Patient Flow
Escalation in the ED • Four hour target for admission to discharge for 95% • Target breaches have financial consequences • Escalation policy – Mix of actions designed to improve flow – Internal and external escalation actions – Pre determined triggers for action – patient numbers at various points in the patient journey • Metrics – Occupancy, ambulance arrivals, acuity, average waiting times, wait for specialist input, bed status for hospital
Monitoring • Patient flow co-ordinator – Dedicated non clinical nurse role – Responsible for monitoring patient flow and initiating actions to avoid breaches • Two hourly sitrep meeting • Compiles patient numbers in each area • Reconciles with IT system – lag • Identifies bottlenecks and how to resolve • Effect of escalation actions not monitored until next sitrep meeting
Learning • Performance metrics are disseminated each day for the previous day • Review of breaches focuses on classification and justification not actions and their effects • RCA performed if performance very bad • Learning from success - successful avoidance of breaches is not discussed • Effect of escalation actions not known
Misalignments • Variable – patient numbers – patient acuity Demand e.g. patient Success – staffing and skill mix Work as Imagined numbers, Work as targets • Capacity to treat and Done Alignment Adaptations discharge patients Adjustments Failure Capacity e.g. harm, e.g. staff level, depends on availability breaches of staff skills, targets, processes of services complaints – Imaging, blood tests, beds, specialist services
Outcomes • Differing definitions of success – Clinical outcomes – Demand Success e.g. patient physicians Work as Imagined numbers, Work as targets – Patient flow – nurses Done Alignment Adaptations • Uneasy co-existence of Adjustments Failure Capacity e.g. harm, e.g. staff sometimes conflicting breaches of level, staff targets, skills, goals complaints processes • All breaches are seen as equal - context of the demands not taken into account
Escalation Adjustments • Invoking escalation creates extra demands Work as Imagined Success Demand Work as – Planning and prioritising Done Align – Staff handover Failure Capacity – Skills assessment and matching • Escalation is avoided if possible to deal with problems
Resilience narrative The emergency department team considered triggering an internal escalation because patient occupancy numbers were approaching a predetermined trigger level (75 patients at 6PM). It was agreed that the situation should be monitored carefully, as patient waiting times to be treated were starting to increase. The Rapid Assessment Team doctor decided to work alongside the triage nurses, to expedite the treatment and discharge of low-acuity patients, so that the capacity to assess newly arrived patients could be increased. He had observed this need independently of the discussions of escalation in response to the top-level numbers in the whole unit. The overall trigger level does not in itself take into account imbalance (e.g. where levels in one area may be problematic despite the threshold not being met); thus this doctor took the decision to flex despite no formal escalation. Breaches were averted.
Resilience narrative The department triggered an external escalation because of very high occupancy levels and the realisation that the incoming night shift was short of nursing staff. This allowed for additional nursing staff from agency/bank (temporary staffing) to be used at short notice. As the new staff arrived, this generated additional workload as handovers had to be performed while nurses were reallocated across the patient bays in the major injury unit. This process took around thirty minutes to complete. Meanwhile, there were patients waiting for intravenous infusions. It transpired that three of the additional nursing staff were not able (lack of qualifications) or willing (lack of experience) to perform the infusions. The Nurse in Charge had to reallocate these nurses to other areas, and seconded an experienced nurse from triage, assigning her to the task of performing infusions in the Majors area. Breaches not avoided.
Escalation Adjustments • Under pressure normal functions are neglected • Leads to increased need for adaptation – Documentation not updated – Case reviews rushed – Patients unwell at discharge – Co-ordination failures
Resilience narrative During a red internal escalation a porter arrived to transport a patient but the patient could not be transferred as notes were missing. Handover had been rushed and nurses were complaining about lack of information. One patient who was discharged was refusing to leave because he said he was too unwell. A number of patients were forgotten because reminder stickers placed on the computer screen had been lost. Junior doctor presenting case to his consultant was challenged to justify his actions. The consultant was annoyed about the lack of relevant details being provided. Breaches not avoided.
Escalation Adjustments • Unclear which metrics are most important • Timing of escalation is important • Previously successful actions no longer work • System becomes uncontrollable and opaque
Resilience perspective • Adaptive capacity concentrated in one or two dedicated roles • Need to unpack the black box of patient flow – Unclear which metrics are most important – Limited monitoring of actions taken to manage flow – Inadequate review of effective responses • Implementation of escalation is subject to adjustments and adaptations that are poorly understood but which are crucial to success and failure
Implications • Opportunities for improvement – Making the escalation process more transparent – understanding repertoire of adjustments and adaptations and under what circumstances they are successful – Improved monitoring of escalation actions – better targeting of actions taken during Sitrep meeting – Improved learning from what goes right – reports of previous day to include reflection on what worked and what didn’t
Dr Janet Anderson Janet.anderson@kcl.ac.uk Centre for Applied Resilience in Healthcare (CARe) http://resiliencecentre.org.uk/ Twitter: @CARe_KCL
• “Understanding resilience makes the difference between organizations that inadvertently create complexity and miss signals that risks are increasing, and those that can manage high-hazard processes well”. (Nemeth et al, 2008)
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