Leanne Griffin, Rob Bevan, Timothy Asibey-Berko, Mark Andrews, Rhys Howell, Gautham Appanna and Keir Lewis
Hywel Dda UHB, ABMU Health Board, Cardiff University, Bevan Commission and Swansea University
Recently, the Front of House in Prince Philip Hospital has undergone significant change. The Accident and Emergency (A&E) department has been changed to a Minor Injuries Unit, and the emergency medical patients that present via 999 ambulance are admitted directly under the acute medical take to the acute medical assessment unit which has been open for 6 months. These patients in addition to the GP referrals, need to be triaged effectively and safely.
Prudent Principle 1
Achieve health and wellbeing with the public, patients and professionals and as equal partners through co-production.
The redesign of acute services required many years of planning and included input from the local council, local GPs and patient groups as it was recognised that this significant change would have an impact on the local community. It also meant a new way of working for the clinicians, nursing staff and allied health professionals within the hospital. All of whom agreed on the acute need for a safe method of triage, and therefore a collaborative approach with medical registrars, consultants and nursing staff was sought in the design and implementation
Prudent Principle 2
Care for those with the greatest health need first, making most effective use of all skills and resources.
Emergency departments are subject to national targets such as '4 hour wait', and there is some evidence that patients are prioritised according to times rather than greatest need. The new configuration in Prince Philip Hospital is not subject to the same targets, however early experience suggests that the sickest patients aren't necessarily prioritised. The new triage system would aim to empower nurses to categorise patients into one of three categories (red, orange or green) based on their presenting symptoms and early warning scores. The more unwell patients are therefore given priority, seen in a more timely manner and by the most appropriate doctor.
Prudent Principle 3
Do only what is needed, no more, no less and do no harm.
Medical triage ensures a safe method of prioritising patients based on clinical need. The system is based on information nursing staff and health care associates would normally obtain when admitting a patient to A&E, for example, early warning scores as per RCP guidelines (RCP, 2012). We are aiming to minimise harm by ensuring that every patient presenting to A&E is assessed according to clinical need, and the more acutely unwell patients are identified appropriately to trigger earlier review by more senior clinicians. Patients are continually monitored, and therefore nursing staff would change the triage category should the clinical status alter prior to medical review.
Prudent Principle 4
Reduce inappropriate variation using evidence based practices consistently and transparently.
In the current system, there may be extreme variation between the method of assessment, which depends on the experience of the admitting nurse and the pressures on and within the department. The introduction of the new triage system would aim to considerably reduce this inconsistency by using one triage proforma. In addition, the new service in Prince Philip Hospital is being monitored both internally and externally, and is being considered as a Future Hospital Model, and therefore comparisons are being drawn with other centres both with and without emergency departments. Developing an optimal model for acute medicine in the 21st century could reduce variation in service delivery across the country
Impacts and future actions
The triage system is currently being implemented within A&E. We are gathering data from nursing staff and medical teams regarding the ease of use and the safety and effectiveness of the system. We will also look to seek information on the patient experience within the department. Using this collaborative approach, we will effect change in order to ultimately develop a safe, robust and reliable method of triage.
Part of Cohort Bevan Fellows 2015-16