The Clinical Nursing and Midwifery Dashboard (CNMD): A State-Wide Implementation.

The clinical nursing and midwifery dashboard (CNMD) was built to provide a near real-time information and data visualisations for nurse unit managers (NUMs) and maternity unit managers (MUMs) within only a 5-15 minutes delay from when they enter data to the integrated electronic medical records (ieMR) system. The dashboard displays metrics and information about current adult inpatients in overnight wards. The aim is to support NUMs and MUMs to manage their daily workload and have continuous visibility of patients nursing risk and safety assessment documentation. A quantitative evaluation approach was conducted to measure the impact of the dashboard on key performance indicators. Statistical analysis was completed to compare risk assessment average completion times prior to and post CNMD implementation. The results of the evaluation were positive, and the statistical analysis shows significant reduction in the average time to complete different risk assessments with p-value<0.01.

National Emergency Access Targets metrics of the emergency department-inpatient interface: measures of patient flow and mortality for emergency admissions to hospital.

BACKGROUND: Movement of emergency patients across the emergency department (ED)-inpatient ward interface influences compliance with National Emergency Access Targets (NEAT). Uncertainty exists as to how best measure patient flow, NEAT compliance and patient mortality across this interface. OBJECTIVE: To compare the association of NEAT with new and traditional markers of patient flow across the ED-inpatient interface and to investigate new markers of mortality and NEAT compliance across this interface. METHODS: Retrospective study of consecutive emergency admissions to a tertiary hospital (January 2012 to June 2014) using routinely collected hospital data. The practical access number for emergency (PANE) and inpatient cubicles in emergency (ICE) are new measures reflecting boarding of inpatients in ED; traditional markers were hospital bed occupancy and ED attendance numbers. The Hospital Standardised Mortality Ratio (HSMR) for patients admitted via ED (eHSMR) was correlated with inpatientNEAT compliance rates. Linear regression analyses assessed for statistically significant associations (expressed as Pearson R coefficient) between all measures and inpatient NEAT compliance rates. RESULTS: PANE and ICE were inversely related to inpatient NEAT compliance rates (r = 0.698 and 0.734 respectively, P < 0.003 for both); no significant relation was seen with traditional patient flow markers. Inpatient NEAT compliance rates were inversely related to both eHSMR (r = 0.914, P = 0.0006) and all-patient HSMR (r = 0.943, P = 0.0001). CONCLUSIONS: Traditional markers of patient flow do not correlate with inpatient NEAT compliance in contrast to two new markers of inpatient boarding in ED (PANE and ICE). Standardised mortality rates for both emergency and all patients show a strong inverse relation with inpatient NEAT compliance.

Aiming to be NEAT: safely improving and sustaining access to emergency care in a tertiary referral hospital.

OBJECTIVE: To implement and evaluate strategies for improving access to emergency department (ED) care in a tertiary hospital. METHODS: A retrospective pre-post intervention study using routinely collected data involving all patients presenting acutely to the ED of a major tertiary hospital over a 2-year period. Main outcome measures were changes in: the percentage of patients exiting the ED (all patients, patients discharged directly from the ED, patients admitted to inpatient wards); mean patient transit times in the ED; inpatient mortality rates; rates of ED 'did not wait' and re-presentations within 48 h of ED discharge; and selected safety indicators. Qualitative data on staff perceptions of interventions were also gathered. RESULTS: Working groups focused on ED internal processes, ED-inpatient unit interface, hospital-wide discharge processes and performance monitoring and feedback. Twenty-five different reforms were enacted over a 9-month period from April to December 2012. Comparing the baseline period (January-March 2012) with the post-reform period (January-March 2013), the percentage of patients exiting the ED within 4 h rose for all patients presenting to the ED (from 32% to 62%), for patients discharged directly from the ED (from 41% to 75%) and for admitted patients (from 12% to 32%; P<0.001 for all comparisons). The mean (±s.d.) time all patients spent in the ED was reduced from 7.2±5.8 to 4.4±3.5 h (P<0.001) and, for admitted patients, was associated with reduced in-hospital mortality (from 2.3% to 1.7%; P=0.045). The 'did not wait' rates in ED fell from 6.9% to 1.9% (P<0.001), whereas ED re-presentations within 48 h among patients discharged from the ED rose slightly (from 3.1% to 3.8%; P=0.023). Improvements in outcome measures were maintained over the subsequent 12 months. CONCLUSIONS: Multiple reforms targeting processes both within the ED and its interface with inpatient units greatly improved access to ED care over 12 months and were associated with decreased in-hospital mortality. WHAT IS KNOWN ABOUT THIS TOPIC?: Prolonged stays in the ED result in overcrowding, delayed ambulance access to ED care and increased adverse outcomes for admitted patients. The introduction in Australia of National Emergency Access Targets (NEAT), which stipulate at least 70% of patients in the ED must exit the department within 4h, have spurred hospitals into implementing a wide range of reforms with varying levels of success in achieving such targets. WHAT DOES THIS PAPER ADD?: This study demonstrates how multiple reforms implemented in a poor performing tertiary hospital caused the proportion of patients exiting the ED within 4h to double within 9 months to reach levels comparable with best performing peer hospitals. This was associated with a 26% reduction in in-hospital mortality for admitted patients and no clinically significant adverse effects. It demonstrates the importance of robust governance structures, executive sponsorship, cross-disciplinary collaboration, regular feedback of NEAT performance data and major redesign of existing clinical processes, work practices and bed management operations. WHAT ARE THE IMPLICATIONS FOR CLINICIANS AND MANAGERS?: Improving access to emergency care should be regarded as a problem located and resolved both within and without the ED. It requires a whole-of-hospital solution involving interdisciplinary collaboration and significant change in culture and practice relating to inpatient units and their interface with the ED.