The Clinical Initiatives Nurse Role in Emergency Departments

Transcription

1 The Cliical Iitiatives Nurse Role i Emergecy Departmets

2 NSW DEPARTMENT OF HEALTH 73 Miller Street North Sydey NSW 2060 Tel. (02) Fax. (02) This work is copyright. It may be reproduced i whole or part for study or traiig purposes subject to the iclusio of a ackowledgemet of the source. It may ot be reproduced for commercial usage or sale. Reproductio for purposes other tha those idicated above requires writte permissio from the NSW Departmet of Health. NSW Departmet of Health 2010 SHPN (HSPI) ISBN Iformatio Productio ad Distributio Tel. (02) Further copies of this documet ca be dowloaded from the NSW Health website: December 2010

3 Cotets Itroductio... 3 CIN role descriptio... 4 Purpose of the CIN role... 4 Accoutabilities... 4 Outcomes... 5 Experiece ad kowledge... 5 CIN eviromet ad equipmet eeds... 7 CIN resources... 9 Team commuicatio... 9 Referrals Patiet ad carer commuicatio...12 CIN documetatio...13 Appedices...14 Appedix 1: Referal template Referral example Appedix 2: Example of CIN activities NSW Health Emergecy Departmet Cliical Iitiatives Nurse role PAGE 1

4 Purpose of this Documet Target Audiece This booklet has bee produced for Emergecy Departmet (ED) ursig staff, particularly Nurse Maagers, Nursig Uit Maagers, Cliical Nurse Cosultats, Cliical Nurse Educators ad Cliical Iitiative Nurses. Documet Cotet ad Purpose The material i this booklet has bee take from the Cliical Iitiative Nurse role descriptio i additio to iformatio collected i the solutios desig phase of the CIN Redesig project. It icludes a overview of the key elemets of the role, a outlie of the physical resources that have bee show to aid the fuctio of the role ad details of team ad patiet commuicatio which support the role. The iformatio foud i the booklet will assist with the redesig of the role i EDs ad remai a edurig resource for ED maagers, educators ad for ED urses workig i the CIN role. PAGE 2 NSW HEAlth Emergecy Departmet Cliical Iitiatives Nurse role

5 Itroductio Backgroud of the CIN role The CIN role was itroduced ito NSW Emergecy Departmets (ED) i The aims for the CIN role i 2002 icluded*: providig educatio ad advice to patiets ad their carers whilst waitig to be see facilitatig the reassessmet / re-triage processes i the ED waitig room assessig patiets ad costructig a pla of care for each patiet they have see i cosultatio / discussio with a seior emergecy medical officer. Special Commissio of Iquiry I 2009 The Special Commissio of Iquiry ito Acute Care Services i NSW Public Hospitals recommeded the CIN positio should be itroduced, ad `embedded i all metropolita EDs ad major regioal facilities, as it was see as a vital positio carig for people waitig i EDs for medical review. This recommedatio (93) was supported ad icorporated i the Govermet Respose to the Special Commissio of Iquiry uder the Carig Together Health Actio Pla. The Iquiry report oted that the CIN positio was frequetly re-deployed durig `busy periods which was the `very time that it was most eeded to `provide close observatio of patiets i the waitig room ad iitiatio of treatmet where required. Health ad the Miisterial Taskforce I 2010 NSW Health ad the Miisterial Taskforce for Emergecy Care commissioed a review of the role, with the objectives of gaiig a uderstadig of the `As Is picture of the role ad developig a agreed state wide role descriptio. The project highlighted several sigificat structures that are required to be i place to promote effective fuctioig of the role. This guide outlies the role ad supportig framework as defied i the solutios desig phase of the project. * NSW Health Geeric Role Descriptio: Cliical Iitiatives Nurse (CIN) NSW Health Emergecy Departmet Cliical Iitiatives Nurse role PAGE 3

6 Overview The CIN role is importat to oversee the ED waitig room; improvig safety, commuicatio ad care commecemet The primary purpose of the CIN role is to provide ursig care to patiets i ED waitig rooms. This care is prioritised i the followig way: Maiteace of a ED ursig presece i the waitig room to facilitate a safe cliical eviromet. Commuicatio with patiets ad carers regardig ED processes ad provisio of relevat educatio o their health issues. Assessmet of patiets followig triage with a view to: iitiate diagostics or treatmet (with a set ed poit) escalate care, where required. Appropriate referral of patiets to suitable services, which may be exteral to the ED. Eg Medical Assessmet Uit (MAU). What are the key roles ad accoutabilities for the CIN? Review waitig room patiets coditios regularly to detect chages i cliical urgecy. Commuicate regularly with patiets ad carers i the ED waitig room to keep them iformed of their waitig status, ED processes ad promote patiet focused service delivery. The visible presece of a CIN i the waitig room, ad the proactive maagemet of commuicatio ca lead to a reductio of axiety ad aggressive icidets. Liaise with the: triage urse to re-triage patiets i accordace with chages i patiet acuity urse ad medical team leaders i the ED to escalate care eeds as required ED cliical team to provide cotiuity of care for patiets who have bee redirected back to the waitig room for moitorig or itervetios followig cliical review exteral services to refer patiets where appropriate (eg MAU). PAGE 4 NSW Health Emergecy Departmet Cliical Iitiatives Nurse role

7 Prioritise patiet maagemet ad iitiate CIN protocols i accordace with local guidelies ad policy. Assessmet ad maagemet of patiet s pai is a key priority. Had over patiet care to the appropriate caregiver whe the CIN has reached the boudaries of the CIN protocol (eg maximum aalgesia has bee give ad the patiet has cotiued pai) or whe the patiet is moved to a defiitive care area such as acute care or fast track. Solves problems based o operatioal kowledge ad experiece, lookig for uderlyig causes ad evaluatig applied solutios. Refer uresolved problems. Documet patiet care ad/or itervetios. Utilise a team approach to facilitate patiet flow ad reduce repetitio i patiet care. Practice i a safe maer ad maitai a safe care eviromet for self ad others. How will we kow the CIN role is makig improvemets? The CIN Role is expected to cotribute to the achievemet of the followig key outcomes for the ED: Sustaied improvemets o the NSW Health Patiet Survey for No Admitted ED patiets i the followig categories: Satisfactory waitig time i the ED. Staff doig all they ca to cotrol a patiet s pai. Eough iformatio about coditio / treatmet. Did Not Wait umbers reduced. Improved time to aalgesia for patiets triaged to the waitig room. Reductio of adverse evets i the waitig room. What skills, kowledge ad experiece is eeded to perform the CIN role? Registered Nurse with appropriate emergecy ursig experiece across a broad rage of ED roles. Cofidece, kowledge ad experiece to practice proactively i a self directed role with awareess of role scope ad boudaries. This requires a balace of judgmet ad assertiveess to seek assistace where required. Demostrated ability to iteract ad respod to others i a persoable ad professioal maer which takes ito accout uexpressed cocers. This requires well developed listeig ad questioig skills ad ability to egotiate for desired outcomes. Demostrated ability to read situatios effectively ad use a rage of coflict resolutio strategies to address problems. This icludes the ability to build rapport ad egotiate to assist NSW Health Emergecy Departmet Cliical Iitiatives Nurse role PAGE 5

8 i resolvig coflict ad to seek guidace from others whe eeded. Demostrated team approach to ED care with the ability to liaise cofidetly across professioal boudaries. Kowledge ad applicatio of aalytical thikig skills demostrated by ability to apply experiece ad kowledge to iitiate itervetios ad solve problems. Workig kowledge of local service delivery models ad appropriate referral pathways. Completio of CIN educatioal program ad competecy i the use of relevat CIN practice protocols. PAGE 6 NSW Health Emergecy Departmet Cliical Iitiatives Nurse role

9 CIN eviromet ad equipmet eeds A Dedicated CIN Area supports the positio. It ca eable the CIN to: maitai privacy durig patiet re-assessmet respect the eeds of the patiet ad others i the waitig rooms whe applyig first aid to wouds, ijured limbs etc udertake diagostic itervetios such as veipucture, itraveous caulatio or ECG recordig i a safe ad private eviromet maitai efficiecy through ease of access to required equipmet i oe locatio. What is the ideal CIN space? There are a umber of opiios about the `best fit for a CIN eviromet, however the agreed priciples are that the CIN area should be: a private area, located close to triage ad the waitig room large eough to accommodate two chairs or a examiatio trolley or a reclier as well as the dedicated CIN equipmet safe (eg visible, 2 exits, close to, or cotaiig, a had washig sik) easy to access ad flow ito the ED desigated as the CIN room, ad thus used primarily for this purpose supported by `busiess rules, (such as a agreed maximum timeframe per patiet) which are reiforced by the maagemet team. Equipmet set A `miimum equipmet set for the CIN role ca cotribute to efficiecies. Cliicias agree that this should iclude: a established cliical area equipmet to assess patiet vital sigs a bed, reclier or chair for patiet assessmet IV access ad pathology collectio equipmet first aid equipmet, badages, ice packs, simple dressig equipmet, sligs, splits simple aalgesics, topical preparatios such as laceraie / emla / Agel, rehydratio solutios NSW Health Emergecy Departmet Cliical Iitiatives Nurse role PAGE 7

10 computer, o wheels or fixed, to update patiet otes pathology request forms, patiet fact sheets etc mobile or portable hadset phoe. What other equipmet may add value? ECG machie. Selle chart. Diagostic set. Small rage of medicatios icludig: aalgesics woud glue brochodilators atiemetics amethocaie. POP trolley. PAGE 8 NSW Health Emergecy Departmet Cliical Iitiatives Nurse role

11 CIN resources Team commuicatio To facilitate performace of the CIN role seamless teamwork is required with key stakeholders. The key stakeholders are: Triage Nurse To prioritise reviews ad care iitiatives. To facilitate re-triage. Nurse Team Leader (Cliical NUM/ NM) To elevate cocers regardig waitig room maagemet (eg escalatig aggressio / complaits). To facilitate referral. To escalate cliical care. Medical Team Leader To facilitate care (especially where patiets ca be rapidly treated with miimal medical collaboratio). To facilitate referral. To escalate cliical care. To promote the CIN role to medical staff that rotate through the ED (as applicable). Others Clerical staff. Iteral ED services (ASET, Metal Health Liaiso, physio). Exteral (to ED) referrals. Allied health professioals. Fast track / Acute Care ED Nurses. Nurse Practitioer / CNC 3. Team commuicatio strategies Strategies that could be used to build teamwork ad improve commuicatio: Triage Nurse Clear role descriptios for triage ad CIN outliig accoutabilities for each role. Commuicatio tool for flaggig priorities to CIN (methods may iclude: FirstNet (utilisig commets colum) triage whiteboard, hadover rouds etc). Nurse Team Leader (Cliical NUM) Regular (eg hourly, phoe cotact / whiteboard roud / waitig room roud) updates o ED waitig room NSW Health Emergecy Departmet Cliical Iitiatives Nurse role PAGE 9

12 status ad issues affectig patiets waitig ad ED waitig room flow. Phoe commuicatio to escalate care or to facilitate patiet flow through referral as required. Clerical Clarificatio of Triage ad CIN role accoutabilities with frot of house Clerical Staff ca assist them to liaise efficietly with the appropriate role. Nurse Practitioer or CNC 3 Agreemet o role boudaries ad referral patters to provide optimal care delivery ad appropriate utilisatio of skills. Medical Team Leader I some cases CINs may be able to progress the patiet s care, almost to completio, requirig miimal medical iput (Eg Triage ad Treat type models). Alterately they may `stack several patiets with diagostics completed (eg x-rays) who require `quick reviews to progress defiitive care or referral. Strategies to support this iclude: Nomiatio of a seior medical positio i the ED to liaise with the CIN (Eg Fast Track Registrar, Career Medical Officer). Agreemet regardig CIN access to the omiated MO (Such as regular scheduled updates, hourly, 90 mis). Agreemet of positio to cotact regardig care escalatio ad to assist with referrals (as required). Fast track / Acute Care ED urses The CIN: iforms the Fast Track / Acute Care ED urse of priorities of care, if they differ from the iitial triage (eg the `ext patiet may be awaitig x-ray while aother patiet could be efficietly treated) hads over care whe the patiet moves from the waitig room. The Fast Track / Acute Care ED Nurse; hads over care of patiets who may be trasitioed back through the waitig room. PAGE 10 NSW Health Emergecy Departmet Cliical Iitiatives Nurse role

13 Referral* Appropriate referral ca improve the patiet experiece by reducig delays ad duplicatio of assessmet or diagostics. It s about gettig the patiet to the right service at the right time. Referral may be to services that co-operatively maage patiets i the ED (iteral) or exteral to the ED. These are: Iteral ED services (ASET, Metal Health Liaiso, physio, REAT, EMU) ad Allied Health. Exteral (to ED) Referrals (eg Short Stay Uits such as MAU, Ipatiet teams, Specialty CNCs) usig established, edorsed protocols. CINs require a workig kowledge of the referral guidelies for these services to facilitate care. Additioally these services must be acquaited with the CIN role. * A CIN Referral Template is located i Appedix 1. NSW Health Emergecy Departmet Cliical Iitiatives Nurse role PAGE 11

14 Improvig patiet ad carer iformatio about the CIN role Promotig the CIN role Promotig the CIN role to patiets ad carers allows them to uderstad how the positio works ad how they ca work with it. Promotig the CIN ca be doe i several ways icludig: Referrig patiets ad carers to the CIN brochure / poster. The triage urse briefly explaiig the CIN role at poit of triage. The clerical staff referrig suitable patiets to the CIN if they retur to the clerical desk after triage with cliical questios. The CIN itroducig themselves to patiets ad givig a explaatio of what their role is, how to cotact them, ad what the patiet ca expect from the role. The CIN beig idetifiable i the waitig room. This may take the form of a badge or a sig deotig the CIN area. Patiet ad Carer commuicatio strategies Regular cotact with patiets ad carers i the waitig room ca assist greatly i gettig the ED visit off o the right foot, relievig axiety ad egagig people to work with you. The A-E of better commuicatio is a strategy to successful regular iteractio with patiets ad carers.* Ackowledge their presece Make eye cotact. Use the patiet s ame. Ackowledge patiets ad carers preset. Be yourself Explai who you are ad what you do. Establish teamwork. Commuicate the pla Explai what you are doig ad why, ad let them kow if you are commecig their care. Explai what to expect ad what will happe ext ad use active listeig to cofirm that this is uderstood. Duratio ad timeframe Tell them the expected wait time. Explai whe you will be back ad how they ca cotact you. Explore their eeds What questios do they have? Is there aythig they eed while they are waitig? * Developed by Campbelltow ED i partership with Studer as part of the Improvig Staff ad Patiet Experiece Program. PAGE 12 NSW Health Emergecy Departmet Cliical Iitiatives Nurse role

15 CIN documetatio I meetig professioal stadards for documetatio CINs are required to documet: Routie cliical documetatio icludig: iteractios with patiets icludig time ad date ad outcomes i the patiet s otes chages i patiet s coditio ad what actio resulted CIN history ad assessmet, ivestigatios / treatmets commeced, ursig care pla, ad cosultatios / referrals ad re-assessmets. Did Not Waits As much detail as is available if a patiet chooses ot to wait for medical review. Eg ay further assessmets, advice give ad who (ame ad positio holder) this was referred to i the ED / hospital (as applicable). Care commeced o iformatio system Care commecemet i CIN Itervetio uder `protocol commeced (emr FirstNet or equivalet i other systems). NSW Health Emergecy Departmet Cliical Iitiatives Nurse role PAGE 13

16 Appedix Oe Referral template Referral template Service ame Brief descriptio of service model Referrals from emergecy departmets Service hours Patiet presetatios suitable for referral / admissio criteria Patiet presetatios usuitable for referral / exclusio criteria referral PROceSS Activities that must be udertake prior to referral Activities that may be udertake prior to referral Cotact umber Suitable for CIN referral? Yes / No Requires prior cosultatio with Nurse Team Leader? Yes / No Requires prior cosultatio with Medical Team Leader? Yes / No PAGE 14 NSW Health Emergecy Departmet Cliical Iitiatives Nurse role

17 Referral example Referrals from emergecy departmets Service ame Brief descriptio of service model Service hours Patiet presetatios suitable for referral / admissio criteria Patiet presetatios usuitable for referral / exclusio criteria referral PROceSS Activities that must be udertake prior to referral Activities that may be udertake prior to referral Medical Assessmet Uit This model of care provides a alterative pathway for complex medical patiets. These patiets typically require extesive medical ad multi-discipliary assessmet, which may take may hours. Patiets i the MAU ca expect to stay for a period of up to 48 hours, after which time it is expected that most patiets will be discharged home (with commuity services where appropriate) while some who require specialised care will be trasferred to a ipatiet bed. Service Hours 24 hrs, 7 days/ week The MAU is targeted for; medical patiets who require early ad rapid ivestigatio ad evaluatio, who the may require trasfer to a regular Ward or medical patiets who may have a potetially short hospital stay of 48 hours ad the itesive iput available i the MAU will help facilitate discharge withi this timeframe Need for Cardiac Moitorig Age < 16 Procedural surgical patiets Need for ICU or HDU admissio Patiets who may eed BiPap or CPAP Patiets with spial ijuries, acute head ijuries Patiets with delirium Patiets who require immediate care i a specific specialty uit (eg acute stroke, eutropaeic patiets ) Nursig mothers requirig ifat boardig Patiets with acute psychiatric illess Patiets who require isolatio ad are ot MRSA positive. The fial decisio about a patiet s suitability for admissio to the MAU will lie with the Cliical Coordiator i the MAU. Sample oly Patiets idetified at the ED triage, or by CIN, if they meet the iclusio criteria: Refer to the MAU seior registrar ED assessmet to commece MAU SRMO will perform a brief assessmet i ED ad idetify ivestigatios required MAU SRMO will otify the admittig specialty cosultat o call ad the MAU team either prior to trasfer or followig assessmet i MAU. The Bed Maager will facilitate trasfer to the MAU I Hours Pathology or radiology ivestigatios ca be iitiated i ED Cotact umber Suitable for CIN referral? Yes / No Requires prior cosultatio with Nurse Team Leader? Yes / No Requires prior cosultatio with Medical Team Leader? Yes / No NSW Health Emergecy Departmet Cliical Iitiatives Nurse role PAGE 15

18 Appedix Two Examples of CIN activities Review ad re-assessmet Regular cotact with patiets ad carers. This may iclude: a quick catch up to foster ogoig commuicatio ad to check the patiet s coditio withi their triage bechmark time (eg guided by the A-E of commuicatio) a repeat set of vital sigs as required (particularly if they have bee outside of ormal rage) a iitial or repeat set of targeted observatios as required (eg eurological, eurovascular, urialysis, urie HCG, pad checks for patiets with PV bleedig, blood glucose levels) a update o the waitig time addressig cocers ad resolvig coflict reassurace ad educatio regardig their cliical coditio. Commecemet of defiitive diagostics or care iitiatives Provisio of first aid (split applicatio, RICE, woud care, coolig burs). Provisio of aalgesia. Orderig of x-rays. IV Caulatio / veipucture ad orderig of pathology. Iitiatio of oral rehydratio therapy. ECG recordig. Woud care. Commecemet of CIN pathways for specific patiet presetatios. Follow up with patiets diagostic tests Referral Escalate care i ED i collaboratio with Nurse / Medical Team Leader ad/or Triage Nurse. Appropriate referral to acillary services i the ED. Appropriate referral to services exteral to the ED. Documetatio PAGE 16 NSW Health Emergecy Departmet Cliical Iitiatives Nurse role

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20 SHPN (HSPI)