Why the wait in the waiting room?

Margaret Murphy Clinical Nurse Consultant, Emergency Department Westmead Hospital

A case for change........Review of the current environment

What the waiting achieved ……………

Prolonged waits for triage Queue formation (defensive triage) Prolonged wait time for treatment Risk of increased DNWs Large number of undifferentiated patients in the waiting room Increased potential for adverse outcomes No way of differentiating between visitors and patients Prolonged time to definitive decision making Combination leads to increased waits between care Patient, carer and staff dissatisfaction

Patient & carer experience

“When I came in, I think it was a little bit long. I would say about 20 minutes, anything could happen in 20 minutes. They should have put me straight in.”

“After being assessed by the triage nurse & before going into the Emergency ward I was in quite a lot of pain. It would have been good to have had some pain killers and also to have some privacy” (NSW Patient survey)

That was very hard because the triage nurse, she is trying to type your name & address and I’m thinking can we just get him in and I can do all of that later. Then she sent me to the other counter to register my husband” Carer

Did not wait figures

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

2007(Winter)

2008(Summer)

2008(Winter)

2009(Summer)

2009(Winter)

2010(Summer)

Westmead Emergency Did Not Wait for Treatment

DNW

One in every ten patients at Westmead ED is going home without medical attention ~ 20% in last few weeks

Defining a more ideal waiting room ...

What’s the value for the patient?

I’m sick - Will telling a clerk my country of birth treat my

fever?

- Will telling the triage nurse the name of all my medication treat my broken arm?

- Will sitting in the waiting room treat dyspnoea?

What’s the literature tells about front end processing

Weber et al AEM 2011 • > 50% of patients tool longer to triage than their

recommended time to see a provider • Triage is a bottle neck

Aim Complete triage registration within 5 minutes of arrival

Waiting room innovations

Review triage model of care Structural changes to the waiting room

Triage is now………

Process to establish - The reason the patient has presented to ED

- Assign level of urgency

- Stream to the appropriate model of care

Triage now looks differently………

Triage now looks differently………

Acute care waiting room Urgent care waiting room

Has it worked ?

Per week 2011 2014 Difference

Avg. Weekly Presentations 1094 1330 + 236

Avg. time to Triage (ARR-TRI) in minutes

0:25 0:05 - 20

Avg. time to treatment (TRI-SB) in minutes

0:49 0:41 - 0:08

Avg. Ambulance Arrivals 401 467 + 66

Avg. TOC % 82% 82% Nil

DNW % 10.45% 4.02% - 6.43%

In conclusion no one benefits from long waiting