ADU ASAP: Faster process - faster plans

ADU ASAP: Faster process - faster plansWhat is the Assessment and Diagnostic Unit (ADU)?

The Assessment and Diagnostic Unit (ADU) at North Shore hospital is where patients are seen that are referred by their general practitioner (GP) or from the emergency department (ED) to a specialty, such as general medicine or general surgery.

ADU patients need more complex assessment and diagnostic tests to help the clinical teams decide on the most appropriate care for them.

Overall half of all patients seen in ADU are assessed and treated under general medicine:

  • North Shore Hospital ADU patients' assigned specialties51% of ADU patients are initially seen in emergency department and referred to a specialty after being assessed by the emergency medicine team and 71% of these patients are referred to general medicine.
  • 49% of ADU patients are referred directly from their GP and come straight to the ADU and 38% of these patients are referred to general medicine

Traditionally, patients under general medicine are asked to change into a gown and are put in a bed where they will remain until a decision has been made to either send them home or admit them to a hospital ward. Patients are often kept overnight in ADU while junior medical teams complete initial assessment and diagnostics, such as blood tests and x-rays.

Patients are reviewed the next day by senior medical staff who will make further decisions. This may be that they are either discharged back to their GP, discharged home and return the next day for follow up, or are admitted to an inpatient ward.

This traditional approach is designed around all patients waiting to see the senior doctor in the morning, resulting in long periods of waiting, some unnecessary overnight stays, poor patient experience and pressure on acute care beds.

What is the Acute Specialist Assessment Pathway (ASAP)?

ASAPThe general medicine teams in ADU at North Shore Hospital are trialing a different way of assessing and treating patients in our ASAP Clinic. Our aim is to improve the patient experience and hospital flow by increasing the number of patients that have a decision on the most appropriate care pathway for them on the day that they arrive.

The ASAP Clinic is built on two key philosophies:

  • “Decide to admit: Not admit to decide” challenging the historical default approach of putting patients into beds to await next day review, the underlying principle is that a significant proportion of these patients can be managed safely and appropriately without overnight admission
  • “Faster plan – faster process” – ASAP is about teams working together to complete rapid assessment of ambulatory patients, with early access to assessment, diagnostic services and senior decision-making, to enable safer, faster care and discharge

The first group we are focusing on are patients that are referred to general medicine by their GP and who walk themselves into ADU, otherwise referred to as ‘ambulatory’.

All patients are seen by the ADU clinical charge nurse when they arrive to ensure that they are safe and appropriate for the ASAP Clinic, and if so, are seen and treated by the dedicated ASAP Clinic nursing and medical teams. These patients are not put into a bed space until assessment and diagnostics has been completed, and a proactive decision can be made about the most appropriate care pathway for them.

Why is the ADU ASAP Clinic trying to achieve?

  • Primary Aim: Reduce the time between arrival and a decision on the most appropriate care pathway for general medicine patients in ADU
  • Secondary Aim: Increase the proportion of general medicine patients who have a decision on the most appropriate care pathway on the same day that they arrive

ASAP clinic will deliver the following benefits:

  • Improved patient experience
  • Improved access to diagnostic tests
  • Reduced time waiting to be seen by nursing and junior staff
  • Improved access to senior decision makers
  • Increased day of presentation discharges
  • Reduction in length of stay for all general medicine patients
  • Improved capacity across the emergency department and ADU so patients can be placed in the most suitable location for them
  • Increased work satisfaction for the ADU team
  • More supportive training environment for junior doctors
  • Individualised patient care by enabling different types of care
  • Better patient outcomes

What have we done?

The ADU ASAP Clinic Project team of junior and senior medical and nursing staff has generated more than 30 improvement ideas to change the way we work. Some examples of these are:

  • Appropriately skilled, dedicated staff:
    Two experienced clinic nurses and three dedicated junior medical staff between 8am and 4pm, Monday to Friday. A ‘Home Base’ for senior doctor created in a central location to increase support for junior doctors, and reduce the time to senior decision making
  • Improved access to key services:
    A new ASAP Clinic electronic alert for cardiology referrals ensures that the team are aware there is a patient waiting for their review
  • Patient way-finding:
    A laminated patient way-finding card is provided to patients to encourage ASAP clinic patients walk themselves to radiology, rather than waiting for an orderly

ASAP way-finding cards
Patient way-finding cards

  • ASAP Clinic branding:
    All ASAP patient information is colored bright orange with the ASAP clinic brand, from the doctors and nurses documents to the patient notes folders. Referrals to other teams within the hospital, such as cardiology or radiology, also have ‘ASAP Clinic’ added to re-enforce the ASAP philosophy
  • Visual differentiators:
    An ‘*ASAP Clinic’ flag has been developed to support the easy identification of patients on electronic systems, and a new ASAP patient notes filing system has been developed so that teams can easily see where patients are in their journey and proactively chase up outstanding tasks
  • Improved team work:
    The ASAP team update their board at the new 8am daily huddle, to make sure all team members has been introduced and know how to contact each other and discuss/ resolve issues from the previous day

ASAP team board
ASAP team board

  • Improved patient experience:
    Patient pagers are now available for patients who might want to go for a walk, or grab a coffee while they wait, and are concerned that they might miss their doctor or nurse. Discharge cards have also been created for those patients that are being asked to return the following day, or those that might need a little more reassurance about being discharged without an admission to hospital

North Shore Hospital ADU patients' assigned specialties
Patient pagers

ASAP discharge cards
ASAP discharge cards

Where to from here?

The ASAP teams will continue to develop these and other improvement ideas over the next three months and progress towards the project goal of improving the time general medicine patients wait on ADU for a decision on the most appropriate care pathway for them.