This is a longer than usual update because there is so much going on within the EMP. We did not anticipate that the Programme would grow to this size when we started but we think all the content is very important for the future of our specialty; including important issues relating to work force and NCHD staffing
The Programme launch date has been set for Tuesday 19th June 2012. The Minister has agreed to launch the Programme and Mr. Cathal Magee, CEO HSE, has also been invited to participate. A brief ceremony will be held at 15:30pm in the Albert Lecture Theatre, RCSI. Consultants are welcome but we understand it may not be feasible for everyone to travel to Dublin for a 45-minute ceremony. The HSE Communications Directorate has offered to host edited highlights of the launch on the HSE website. The EMP Report will be published in hard copy along with of our page Programme Summary.
There will also be a press briefing after the launch. Please be prepared toanswerquestions about the Programme from colleagues in other specialties, local representatives and media. The key Programme message is that this is a strategy to improve patient care in our EDs that has been developed by ED staff in consultation with patient representatives. The Programme launch marks the official start of EMP Implementation (vide infra). Thanks to everyone who has contributed to the Programme to date and new volunteers will be needed during the coming year.
We are attaching an overview of the EMP implementation plan. While the EMP working group will address implementation at national level, interfacing with the DoH, HSE and other relevant groups, the part of implementation that really matters will occur in every ED and Local Injury Unit and will involve all staff members. All EDs have named their implementation teams by now, many EDs are undertaking COG meetings and most EDs have completed their First Steps check-lists – this in itself is amazing progress. We will shortly be asking EMP Implementation teams to provide 2011 baseline data from their units (where available), so that we can use this to measure the progress of EMP implementation.
We appreciate that it’s not going to be easy to implement the Programme in the current resource-constrained environment, but not to try is unacceptable. We owe it to our patients and staff to do what we can.
Quality Improvement in Emergency Care
Improving patient care in EDs is at the core of EMP implementation. While significant improvements will come from system-wide initiatives to resolve ED overcrowding, there is much we can also do within the ED to improve the quality and timeliness of patient care. International experience indicates that small successive improvement projects undertaken by frontline multidisciplinary teams are the most effective way to deliver sustainable improvement in the quality of patient care. Teams are more successful if they are provided with training and ongoing coaching in improvement science. We are recommending a Clinical Microsystems improvement approach as this is proven to be effective in the ED setting and is in keeping with our philosophy. It comprises analysis, adaption, innovation and respect for patients, clinicians and local work cultures. A Clinical Microsystem ED workbook “Assessing, Diagnosing and Treating your ED” will be made available to all units once it has been signed off by the Programme team. We are trying to secure resources to provide improvement training and coaching for ED teams.
This is currently in development and will host the EMP guidelines ad all materials relating to the Programme. When complete there will be a members’ section that EMP implementation teams can use to share work in progress and other resources.
An updated version if the First Steps is attached. A minor discrepancy is the patient journey diagram has been amended to indicate the starting point. The draft Terms of Reference for the Unscheduled Care Governance Group mentioned in First Steps is being reviewed by MS Lis Nixon (vide infra) at present and will be circulated to the system once signed off.
The SDU/DoH/HSE – What’s Happening?
Considerable uncertainty pervades the health system at present .It would appear that the EMP, along the AMP, Acute surgery and the Medicine for the Elderly Programme will be linked in some way to the SDU, while retaining the joint parentage of the training body (ICEMT). Ms Lis Nixon, who has been appointed Director for Performance Improvement for Unscheduled Care, will have an oversight role in the roll-out of the Unscheduled Care Programmes across the health system. Some of you will know Ms. Nixon from her previous involvement in the AMP. It is not clear at present precisely how her role will influence EMP implementation. We are keen that the implementation should be driven by the Programme itself, though we will welcome any facilitation and support that the SDU can provide. The issue of hospital groups or networks is currently being discussed in the DoH but we have no clear indication as yet when the groups will be decided or announced.
HIQA Tallaght Report
We welcome the Report’s recommendation of implementation of the EMP, though some details require clarification e.g. GPs working in EDs. A group has been set up within the HSE to ensure HIQA’s recommendations are introduced and an oversight group has been established within the DoH. It remains to be seen how quickly the recommendations will be implemented. The EMP working group is preparing a position paper on transition of care issues in response the report. This will clarify referral issues and the transition of Consultant responsibility for patient care in EDs. A draft will soon be circulated for consultation.
Considerable pressure is being brought to bear on the EMP to change the agreed model of care and to recommend that not all patients referred to EDs or AMUs/AMAUs should receive basic Manchester Triage at a single entry point. We recognise that current hospital infrastructure does not allow implementation of the agreed model on all sites at this time. We remain convinced however that this is the safest model of care for patients and will allow all patients to have rapid access to resuscitation-level care, irrespective of their referral source. The recommended model of care remains as previously outlined.
We are deeply frustrated by the almost six-month delay that has been imposed on this project. These delays have resulted from attempts by others to move the project away from the concept of an EDIS to provide a facility for wider forms of unscheduled care. Ms. Nixon has recently been asked to oversee the project from an SDU perspective and we await feedback on the status of the procurement document that is due within the coming week. Despite the unanticipated delay and associated challenges, we are preparing for EDIS by doing some background work on developing standard datasets for patient registration, presenting complaint and diagnostic coding. Gemma Kelleher and Rob Eager are leading this work. These datasets, when agreed, will need to be adapted by EDs that currently have EDISs that are not going to be replaced. Draft datasets will be circulated to you for consultation – pleas respond when they do. This is very important.
Early Warning Score
The EMP working group was also asked to implement EWS in EDs for all patients who are referred for admission. We explained to all concerned that EWS is a ward-based tool and that it is not appropriate for automatic implementation in an ED setting. The Emergency Nursing Interest Group and the EMO working group are developing a standardised system of patient monitoring for Triage to ED departure that will be reconcilable with ward-based EWS. A draft will be circulated for consultation with IAEM members in the coming weeks.
The AMP circulated the attached document on Casemix without prior consultation with the EMP. We have submitted a response that explains why this guidance is unworkable, unjust and would create unintended incentives in the unscheduled care system. In response, the Casemix Lead has indicated a willingness to discuss the issue of in-patient recognition for CDU work. We await further discussion with Dr Barry White in this regard.
NCHD Staffing and Future Consultant Posts
Please be aware of the dangers of local attempts to borrow or trade NCHD in EM posts. All future Consultant in EM posts will require NCHD suppression and no matter how inappropriate we consider this rule is, it has been implemented by the Department of Finance and will apply to all future posts. In addition, future Consultant posts will require a 2:1, not the 1:1 suppression that was allowable with the initial raft of EMP posts. Any NCHD post traded is a potential Consultant in EM post lost. The IAEM/ICEMT proposal for the creation of Staff Grade posts in EM has been submitted to the HSE and work is in progress on this.
Ambulatory Care and Observation Medicine
Ronan O’Sullivan is leading a group preparing a paper on current ACOM practice and is planning future research in this area. We will progress this in the coming months.
The Academic Committee is leading guideline development for the EMP. We appreciate that everyone on the committee is busy with ICEM at present, but we will need all guidelines in development and any requiring amendment to be completed by the end of July please.
Major Trauma Audit
Many of you will be aware of the development of the National Office for Clinical Audit (NOCA) at RCSI. Trish Houlihan led a group that developed a proposal for Major Trauma Audit that was not implemented by the HSE. The Programme will revisit the proposal with Trish in the coming months and our aim is to have Major Trauma Audit funded by the HSE, implemented in all hospitals that receive major trauma and housed within NOCE. Work will be progressed after ICEM.
Other work-streams and subgroups – volunteers needed from July 2012
Many of the people invited in the EMP are also key organisers of ICEM 2012 and it is amazing that all are managing to appear relatively sane despite the gruelling demands being placed on them. Once ICEM is behind us and everyone has recovered, we will circulate a list of current work-streams and new ones that EMP will be developing in the next 12 months. Volunteers are always welcome and thanks to those who have volunteered to help already. Hopefully everyone will be busy doing local EMP implementation work and quality improvement in the coming months but we hope some people will be keen to get involved in projects at national level too. We hope that everyone feels included in the work of EMP already and we look forward to implementation – it is now that the real work starts.
Please phone Una (01 4103597) or any member of the EMP working group if you want to discuss any of the issues outlined above.
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