Winter pressures clinic in the ED - case study

Dr Stephen Mullen, Consultant in Paediatric Emergency Medicine at Royal Belfast Hospital for Sick Children, describes an initiative to introduce a Winter Pressures clinic in the Emergency Department.

What was the challenge?

The Royal Belfast Hospital for Sick Children is a stand-alone paediatric emergency department (PED) which has seen a 10,000 increase in attendances since 2014 with no increase in space and a very limited increase in staff to accommodate this. This has led to issues with patient flow, poor staff morale and an increase in waiting times.

To alleviate some of the pressures we had previously tried opening an outpatient clinical area, to be staffed by primary care in the evenings. However, while this demonstrated some success, it was not a long term solution due to costs, the limits on the category of patients that could be seen (only category 4 and 5 and none that were referred from primary care) and, most importantly, the ability to recruit staff.

What did you do?

In winter 2018, we re-launched the initiative using the same outpatient area but with middle grade paediatric or emergency staff. We put out for locums to cover this shift, who were escalated to consultant level if not filled.

If no one was available, we split the senior team in the department with either the consultant or middle grade running the ‘shop floor’ while the other staffed outpatients. The ‘Winter Pressures clinic’ was staffed by a band 3 receptionist, an enhanced nurse practitioner and a band 5 nurse.

The clinic runs from 17:30 to 22:30 on the three peak days of the week (Monday, Tuesday and Friday). It shares a triage facility with the main ED, and the eligible patients are streamed into the appropriate area by either the triage nurse or the senior medical and nursing team.

The clinic area is within 25 metres of the main department with its own waiting room. It has four clinical spaces, with two utilised for a clinician and emergency nurse practitioner (ENP), a third for nursing treatments and a fourth that can be used if required. Staff are encouraged to take their main break before the clinic opens.

What was the impact of the clinic?

Comparison between 2017-18 and 2018-19 showed a reduction in average time in ED of 11 minutes per patient for all category 4 and 5 patients, despite significantly higher numbers. The clinic ran for 31 days; 404 patients were seen, averaging 13 patients per day.  

A survey was completed by 52 patients and parents. Ninety-eight percent reported that this was an appropriate area to be seen with another 98% stating that the Winter Pressures Clinic was beneficial. They rated their experience as 4.1 out of 5 (mean).

The comments from parents supported the use of this initiative:

A+E was a nightmare, overcrowded and not a nice environment. Minor unit is quiet and less stressful for the baby and parent.

Getting moved to the other emergency department today was for the better.

The A+E was extremely busy, the OPC was a delight and made it more relaxing.

Staff over stretched and overworked, but they still provided a service and warm welcome.

Staff have been very supportive of this service. Their comments acknowledged the ability to provide a more efficient service to those of a lower triage category. They noted there were benefits for the higher acuity patients in the ED, allowing them to be allocated to a treatment room more quickly and prioritising staff to see them in a more efficient and timely manner.

Senior nurses noted a reduction in distraction as there were fewer patients in the main waiting room, meaning more resources could be allocated to those who need it most.

What did it cost to set up?

There was limited costing for this initiative. The space was free but required domestics to clean post use. Pay was needed for a band 5 nurse and a band 3 admin staff. Senior staff and ENPs were already scheduled to work with locum pay / enhanced rate for the senior locum shift.

What advice can you share?

A good manager who is keen to offer support helps massively. This was a team effort involving Sister Galbraith and Sinead Duffin (service manager).  

As staff rotated through this service a huge amount of positivity was generated and this drove the project on. In identifying the need for extra space we were able to secure funding for four additional cubicles for the ED.   

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Disclaimer: RCPCH have been notified that the above is a good example in managing winter pressures in emergency departments and will be reviewed on a regular basis. Sharing examples does not equate to formal RCPCH endorsement.