Subject(s)
Cognitive Behavioral Therapy/methods , Exercise Therapy/methods , Huntington Disease/complications , Nutrition Therapy/methods , Patient Care Team , Sleep Wake Disorders/rehabilitation , Adult , Combined Modality Therapy , Female , Functional Status , Humans , Huntington Disease/physiopathology , Male , Middle Aged , Pilot Projects , Polysomnography , Sleep , Sleep Wake Disorders/etiology , Treatment OutcomeABSTRACT
OBJECTIVES: To evaluate a patient flow streaming system within a teaching hospital's ED, using functional principles to separate patients into two streams on the basis of complexity rather than acuity, severity or disposition. METHODS: The project used conceptual principles, such as patient complexity and 'lean thinking' theory, to create a new Fast Track patient stream, which was separately resourced. Data collected before and after implementation of the Fast Track system were analysed to evaluate the system. RESULTS: Following implementation of the system, significant improvements were observed in several key ED performance indicators. Mean waiting time was reduced from 55 to 32 min, mean treatment time was reduced from 209 to 191 min, compliance with New South Wales Department of Health waiting-time benchmarks increased from 59% to 77% and the percentage of patients who did not wait to complete their treatment halved from 6.2% to 3.1%. CONCLUSIONS: Key features in the success of the system included use of dedicated senior staff for Fast Track patients, and quarantining of clinical resources. The ED aiming to improve their waiting times and throughput should consider using complexity as a key criterion for triaging patients into separate streams. A low-complexity patient stream in the ED provides an ideal focus for advanced nursing practice.
Subject(s)
Emergency Service, Hospital/statistics & numerical data , Health Services Accessibility , Health Services Needs and Demand , Adult , Female , Humans , Male , Middle Aged , Models, Organizational , Models, Theoretical , New South Wales , Quality of Health Care , Waiting ListsABSTRACT
OBJECTIVE: To evaluate the impact of a chest-pain guideline on clinical decision-making and medium-term outcomes of patients presenting to a hospital emergency department (ED) with non-traumatic chest pain. DESIGN: Before-and-after guideline implementation study. SETTING: Bankstown-Lidcombe Hospital, Sydney, NSW (454-bed metropolitan teaching hospital), in the six-month periods before and after guideline implementation in February 2001. PARTICIPANTS: Patients presenting to the ED with non-traumatic chest pain who had chest-pain assessment forms completed by ED doctors, comprising 422/768 (54.9%) of those presenting before and 461/691 (66.7%) after guideline implementation. MAIN OUTCOME MEASURES: Appropriateness of admission/discharge decisions compared with decision of senior cardiologist based on guideline; death, recurrent chest pain, ED re-presentation and hospital readmission in the ensuing three months. RESULTS: After guideline implementation, appropriate admission/discharge decisions increased significantly from 180/265 (68%) to 261/324 (81%) (difference, 13%; 95% CI, 6%-20%). The largest increase was for patients at moderate risk of death or acute myocardial infarction within six months, from 39/96 (38%) to 57/103 (55%) (difference, 18%; 95% CI, 4%-31%). Increases were seen for both junior doctors (interns and resident medical officers) (18%; 95% CI, 7%-30%) and senior doctors (11%; 95% CI, 2%-19%). Logistic regression showed that implementation of the guideline, seniority of assessing doctor and patient history of coronary disease were independent predictors of appropriate decisions. There was a significant decline in re-presentations to ED with recurrent chest pain in patients previously presenting with cardiac or possibly cardiac pain, from 46/201 (23%) before implementation to 32/247 (13%) after (difference, 210%; 95% CI, 217% to 23%). CONCLUSIONS: The chest-pain guideline resulted in a significant improvement in clinical decision-making in the ED and reduced re-presentations with cardiac/possibly cardiac chest pain.
