Pressures on hospital emergency departments (EDs) in recent years, exacerbated by the impact of COVID-19, have led to overcrowding and long waits, performance challenges and low staff morale. To help hospitals address these challenges, the national CLEAR programme was commissioned to support 16 trusts with service innovation and workforce redesign within their urgent and emergency care (UEC) services.
Kettering General Hospital NHS Foundation Trust (KGH) took part in the CLEAR UEC programme in 2021. One of the key recommendations for the trust was the creation of an ambulatory pit stop which was implemented in July 2022. The pit stop model is inspired by Formula 1 racing where highly skilled professionals from different disciplines work together as a fast, efficient and well co-ordinated team. In this first of a three-part blog series, Lizzie Wren, a Practice Education Nurse at KGH, who was seconded part-time to CLEAR for the transformation project, describes her experiences of playing a crucial role in the project and following the four stage CLEAR methodology to come up with recommendations.
“I hadn’t heard about CLEAR before but I was approached to take part in the project by our Head of Nursing for Urgent Care because of my background. I was a Band 6 nurse on the medical Same Day Emergency Care Centre (SDEC) – a role which included navigating patients from ED – and I’ve had previous experience of working in an urgent care centre. We had an ED doctor working on the project but I brought an outsider’s view which enabled me to think outside the box. It’s really positive that people who took part in the programme were people who understand what’s happening at the sharp end rather than more senior colleagues.
I’d never done anything like this before and I was completely out of my comfort zone. The whole idea of presenting to the trust’s directors was completely scary to be honest but I managed it. The support we received from both CLEAR and staff in the trust was fantastic.
The CLEAR team helped me with my confidence and presentation skills and taught me how to analyse and present information so that people would take notice of our ideas. They organised an actor to come in and pretend to be one of our directors so we could practise on them. I’d never done any data analytics like this before but the colour coding and tables make it really easy to understand.
All the teaching I had as part of the project enabled me to analyse the data, work with my team to come up with ideas for improvements and write the final report with recommendations. I had no clue what would come out of it until we started talking to people in the clinical engagement and looking at the data. It’s very easy to say this is a problem and that’s a problem but it’s only when you sit down and look at things in detail that you start thinking of ways to resolve those problems.
I spent time talking to staff and patients in the ED and also other departments – including the SDEC services within gynae, surgical and medical – to see what pressures they were under and the implications for ED. I think the fact that people knew my face helped with the clinical engagement and because I’d worked in that area before they didn’t have to spend a lot of time explaining all the processes to me before we got onto talking about where the main issues were and what needed to improve. I made sure I only talked to them when I could see they had time and I wasn’t trying to pull them away from something they were trying to do.
A lot of the things we recommended came from the staff engagement but the data analysis helped to provide the backbone for that information. It showed us the key pressure points when most people were coming into the department – for example 11am on a Monday is a key time when thing start to get really busy.
Triage is quite a difficult and scary place to be because it’s crucial that you make the right decision about whether someone needs to be seen or not and how quickly they need to be seen. You could be looking for a room for someone with cardiac chest pain, bleeding or acute abdominal pain, meanwhile there are 15-20 other people waiting to be triaged and some of those patients might have something very serious.
The pit stop model helps reduce risk – it was never meant to replace the triage nurse. Either the triage nurse or reception staff highlight patients of key concern to go to the pit stop – for example patients who are bleeding profusely, who have severe chest pain or who look severely unwell. The problem with ambulatory majors is that they’re not always picked up early enough at triage so they end up sitting in the waiting room and it’s not always possible to get an ECG done in a timely manner. With the pit stop they can be seen and assessed by the right people earlier than before.
In the engagement phase, a lot of people raised concerns about chest pains but when we looked at the data we found there was a significant percentage of other category 2 (very urgent) patients waiting a long time for first diagnostics. They might have sepsis, a diabetic emergency or appendicitis. We recommended the pit stop model for a much broader range of patients than those with chest pains.
We recommended some other ‘quick wins’ as part of the project and while they haven’t been implemented yet, they were part of our report so they’re things which might be looked at in future. One of the things we recommended was a portable buzzer that vulnerable patients could use to attract the attention of staff if they need help. It was really useful being an observer in ED because you notice things you might be too busy to see when you’re working in that stressful environment. I noticed an elderly patient in a wheelchair who kept putting her hand up because she needed someone’s help to get to the toilet. But no-one picked that up because they were just too busy and that’s quite sad to see, especially as it wasn’t an isolated issue.
