Changes at Christchurch ED show the way.

Changes introduced at Christchurch Hospital's emergency department (ED) in the last month have already cut patient waiting times and improved patient flow.

British-based health care consultant and emergency nursing expert Brian Dolan has been working with clinicians in the department and throughout the hospital to improve patient flow. He was a keynote speaker at the combined emergency, flight and neonatal nurses' conference in September (see report on p29). He returned to New Zealand in October to work at the ED. One of the most significant changes has been that a registered clinician can see, treat and discharge patients, without patients having to see a doctor. This is supported by the Canterbury District Health Board (DHB).

Dolan, who works with "challenged organisations" in the National Health System (NHS) in England and acts as a "catalyst for change", says in his work he "challenges orthodoxies that nurses can't do things".

The emphasis was on the competencies and skills needed in the best interests of the patient, rather than on the job title or clinical background. "If a patient needs analgesia we want them to get it as soon as possible. But the issue is that a doctor has to sign for paracetamol or brufen. Nurses can give their children paracetamol at home, but when they are in uniform they are not allowed to give paracetamol That's a nonsense. We want competent practitioners to do what's right for patients. Emergency nurses should be empowered to do that."

He believes the Ministry of Health's new chief nursing adviser, Mark Jones--"a world authority on nurse prescribing"--will support the concept of focusing on competencies and skills rather than job title.

Dolan's work is under the auspices of the Improving the Patient Journey project, which has been underway for some time. In one week, the changes had cut patient waiting times on average by 10 minutes per patient, which, cumulatively, amounted to ten less days' waiting time that week. An average of 1400 patients a week are seen at the ED. Seventy-five percent of patients were discharged from the ED within four hours, up from 69 percent the previous month. "Staff reported that the department felt much calmer, so the experience for both patients and clinicians has improved," Dolan said. He stressed that as ED overcrowding was not just an ED but a systems problem, then the rest of the hospital deserved credit for enabling the ED to achieve its improved performance.

The best interests of patients

The principles behind the changes were what was in the best interests of patients and to keep patients moving through the department. "We want competent practitioners to do what is right for patients. We want a system that is designed around patients, we want a senior clinical decision maker to see patients as soon as possible, and we want to improve patient flow either through the back door, ie into the hospital or back out through the front door."

Dolan said he had not encountered any resistance from doctors or nurses. "What is striking here is that the ED staff are change receptive. They are very willing to try something different. They realise the present system is unsustainable and are willing to try to change it for the better. It is fantastic working here because people realty want to change, which is different to my experience in some challenged organisations, where staff often feel overwhelmed and lose sight of the fact they can make change happen. There is more optimism here that things can improve."

A key element in his work was building relationships and credibility with managers and clinicians. "The fact I was the first nurse in England to be a clinical director of an ED service reassures them that I have some understanding of the field." His initial four weeks in the department finished early this month and he returns later this month for another two weeks. A future change he hopes for is a dedicated space for the observation of medical and surgical patients.

"What's happening at the Christchurch ED is showing the way, especially in relation to admission avoidance strategies for patients. It's a long way ahead of what we are doing in the NHS and that's a tribute to everybody at the DHB."

NZNO professional nursing adviser and a former ED co-ordinator Suzanne Rolls said the changes at Christchurch Hospital's ED had "complex implications" for nursing staff but these were being worked through, using the change process established under the national DHB multi-employer collective agreement.