Emergency department short term treatment areas

Guideline number: QH-GDL-352:2022

Effective date:  18 August 2022

Review date: 18 August 2025

Supersedes: Version 2

1. Purpose
2. Scope
3. Related documents
4. Guideline for the operation of EDSTTA
5. Definitions
6. Approval
7. Version control

1. Purpose

The Emergency Department Short Term Treatment Areas (EDSTTA) Guideline outlines the suite of business rules and processes for ensuring best practice and equity of access for patients requiring admission from the Emergency Department (ED) to Short Term Treatment Areas at Queensland public hospitals by providing physical environmental standards, nomenclature consistency and reporting processes aimed at providing consistency in care and reporting to enhance system visibility of this cohort.

2. Scope

This guideline details the recommended principles for those caring for patients in an EDSTTAs. Sound reasoning must exist for departing from the guideline
An EDSTTA is defined as:

• a dedicated area designed to accommodate patients after their initial ED assessment and emergent management
• where ongoing assessment and treatment is provided, but need for inpatient admission is unlikely
• under the operational responsibility of the Emergency Department
• under the clinical governance of a credentialed Emergency Medicine Senior Medical Officer (SMO)
• where the ED departure status is recorded as “Short Term Treatment Area” (previously Short Stay Unit).

2.1 Out of scope

The following services are out of scope for the business rules and processes outlined in the EDSTTA Guideline.
Inpatient Short Term Treatment Areas (STTAs), which are defined as:

• a dedicated area designed to accommodate patients either after their initial ED assessment and emergent management or directly from the community
• where ongoing assessment, treatment or admission planning is required, and the need for inpatient admission is likely
• under the operational responsibility of the general hospital or as a dedicated hospital unit
• Under the clinical Governance of Credentialled Inpatient Senior Medical Officer (s)
• Where the patient ED Departure status is recorded as “Admitted (excl. ED Bed).”

3. Related documents

• The Emergency  Department Admission Interface (ED-AIR) Project: Report finding 2021
• Australasian  College of Emergency Medicine: Nowhere Else to Go  Report 2020
• Australasian  College of Emergency Medicine: Emergency  Department Short Stay Units 2019
• Clinical  Services Capability Framework for Public and Licensed Private Health Facilities  v3.2
• Australasian  College of Emergency Medicine (ACEM) Emergency Department Design Guidelines  2014
• Business  Planning Framework, 6th Edition 2021
• Health and  Hospitals Network Act 2011
• Public Service Act 2008 (Queensland)
• Public Health Act 2005 (Queensland)
• National Safety  and Quality Health Service Standards

4. Guideline for the operation of EDSTTA

4.1 Intent of guideline

• The evidence-based evolution of Emergency Medicine, Acute Medicine, and management of exacerbations of chronic disease have increasingly required an environment for more definitive diagnostic work-up, multidisciplinary input and initiation of management which may or may not be continued in a typical inpatient environment.
• This document is intended to:
• supersede the existing ED Short Stay Unit Guideline with guidelines that reflect contemporary Emergency Medicine and acute care practices
• provide guidelines to hospitals and clinicians regarding contemporary practices for admitting patients from the ED to STTAs other than typical inpatient ward admissions
• to enable consistency in nomenclature and data collection to enable optimal system improvements to enhance patient care and improve patient outcomes and experiences.

4.2 Principles

The Queensland Emergency Department Strategic Advisory Panel (QEDSAP) endorsed the principles provided by the ED-AIR Report.

• Admission to any destination after attendance at an ED is a clinical decision made after a documented ED assessment, management and disposition plan has been undertaken.
• Any patient disposition, including admission, must involve a definitive change in clinical care and therapeutic environment that progresses the patient journey in a safe and timely fashion.
• The environment for admission should be discrete from the main ED and appropriate to deliver care to a particular patient group for a particular phase of their care.
• Admissions solely for administrative, statistical, performance, or funding reasons should not occur as they are resource-intensive for no discernible difference in clinical care, and they have been shown to reduce the utility of reported data for system improvement.
• Admission is under clear clinical governance for every patient, and overall operational responsibility for each admission environment is clearly articulated.
• Reporting is able to clearly differentiate between admissions under ED clinical governance (such as EDSSU) and admissions under inpatient team governance (such as Admissions Units).
• Delays in egress from admitted environments should be reported and visible at a statewide level. This will enable both real-time local management and system level performance and improvement activities that compliment ED performance reporting to ensure timely emergency access to hospital care.

4.3 Recommendations

4.3.1 Hospitals suitable for EDSTTAs

EDSTTAs should only be established to complement level 3, 4, 5 and 6 Emergency Services as defined by the Clinical Services Capability Framework for Public and Private Health Facilities v3.2.

Other level Emergency Care Centres may also have established or be establishing similar areas which will operate under this Guideline, as determined by the Hospital and Health Service (HHS) in consideration of case mix and admitting services in individual hospitals.

4.3.2 Physical environment

EDSTTAs should be physically, visually, and acoustically separate from the Acute ED assessment area.

EDSTTAs should contain a static number of beds or treatment spaces:

• This should include dedicated oxygen, suction and other infrastructure as for an inpatient hospital bed where the EDSTTA accommodates non-ambulatory patients.

EDSTTAs should provide an appropriate environment for the ongoing assessment and management of ED patients where that assessment and management may impact on their final departure status.

Where appropriate, hospitals may develop multiple EDSTTAs to cater for different patient types (e.g. children, frail and aged patients, toxicology patients, mental health patients). The physical environment of these specialty EDSTTAs should reflect the required therapeutic environment for the type of patient at this phase of their care.

Where an EDSTTA is used for the purposes of ongoing mental health assessment and/or crisis intervention it should provide the appropriate levels of privacy, external stimulus reduction (especially light and sound) and an environment tailored to the ambulatory nature of this patient cohort (e.g. the ability to sit out of bed, ready access to bathroom facilities).

EDSTTA beds should be clearly visible in the ED information system (EDIS or FirstNet).

4.3.3 Clinical Governance and staffing

Patients admitted to an EDSTTA are to be admitted under a credentialled Emergency SMO who is ultimately responsible for that patient’s care.

Delegated operational clinical responsibilities (medical, nursing and allied health) for the EDSTTA are to be clearly documented and articulated in unit operating procedures.

Dedicated nursing staff should be supplied in accordance with recommended staffing levels and skill mix.

Overarching operational responsibilities for EDSTTAs (e.g. budget, administration services and performance) lie with the ED Executive.

4.3.4 Admission to an EDSTTA

Admission to an EDSTTA is a clinical decision that occurs after a documented ED assessment and initiation of management.

Admission to an EDSTTA should be for the purposes of ongoing assessment, investigation or management where that assessment, investigation or management is likely to determine that patient’s departure status, and where an environment other than an acute ED cubicle is appropriate.

The ED SMO should only approve admissions to an EDSTTA if there is a reasonable (>75%) chance that the patient’s ultimate departure status and destination will not be admission to an inpatient bed of that hospital.

The ED SMO should only approve admission to the EDSTTA if a length of stay (ED and EDSTTA) is anticipated to be less than a maximum of 48 hours, or shorter if specified by local operating procedures.

Admissions to EDSTTAs of patients awaiting an inpatient bed, or where the decision to admit to an inpatient bed has been made are not permitted.

Admission to an EDSTTA occurs when the patient is physically transferred to the EDSTTA.

The admission, management plan, and ongoing care arrangements should be discussed with the patient and carers and be clearly documented in the patient record.

Patients who deteriorate and require acute emergency intervention while admitted to the EDSTTA, should be transferred to the most clinically appropriate area for ongoing treatment and remain under the care of the ED Consultant/ED SMO.

The ED* Clinical Leadership Team should  approve any locally developed admission or exclusion guidelines and ensure they complement the recommendations of the EDSTTA Guideline.

4.3.5 Discharge/transfer of care from an EDSTTA

The ED Consultant/ED SMO or delegate should authorise all discharges/transfer of care from the EDSTTA.

• The use of nurse-led and criteria-led discharges are encouraged where clinically appropriate.

If discharge/transfer of care of a patient from the EDSTTA is within one hour of admission to the EDSTTA, the authorising clinician should update the patient’s clinical record with:

• certification that an admission was appropriate
• details of the medical condition and treatment provided.

For any patient who has been in an EDSTTA for 24 hours or more, the ED Consultant/ED SMO or delegate after hours should

• review the patient
• document the management plan to expedite either discharge/transfer of care from EDSTTA, admission to an inpatient unit or transfer to another facility.

4.4 Business processes

Only health facilities with Level 3, 4, 5 or 6 Emergency Services as defined by the Clinical Services Capability Framework for Public and Private Health Facilities v3.2 and which have established an EDSTTA in line with this guideline should use the Emergency Department Information System (EDIS) or FirstNet electronic medical record STTA (previously known as SSU) functionality.

Each facility with an EDSTTA should nominate a person, for each shift, to be responsible for ensuring that the information systems, EDIS, FirstNet and Hospital Based Corporate Information System (HBCIS) are updated regarding admissions and discharges/transfer of care.

The person nominated to update information systems regarding admissions and discharges/transfer of care should:

• use EDSTTA as the standardised naming convention for updating the relevant information systems (EDIS/FirstNet/HBCIS)
• record approved admissions when the patient physically arrives to the EDSTTA on EDIS/FirstNet with an ED departure status of EDSTTA and the date and time of admission
• record approved admissions to the EDSTTA as an inpatient admission on HBCIS
• update the physical location of patients when they move in or out of the EDSTTA on the EDIS/FirstNet floor map or location status on the clinical screen.
• ensure adherence to recommended workflows in the relevant clinical information systems (HBCIS, EDIS, FirstNet).

The movement of a patient from the EDSTTA back to the ED acute assessment or resuscitation area due to clinical deterioration should not be recorded as a discharge on HBCIS and/or triaged and re-entered in EDIS/FirstNet as a new presentation. Both events are coded as the same episode of care.

If the patient subsequently requires an admission to another clinical area under the governance or care of a specialist the person responsible for admissions and discharges should record the transfer of admission in EDIS/FirstNet and HBCIS with a departure status of discharge/admission to inpatient bed.

4.5 Responsibilities

4.6 Monitoring and reporting

HHSs should monitor the utilisation and function of an EDSTTA against performance indicator data monthly.

Performance indicators to be monitored include:

Proportion of patients admitted to an EDSTTA with a transfer of care destination of admitted to inpatient ward (HBCIS)

• Target 15-30%.
• Individual EDSTTA subunits within a hospital may have a higher admission rate, but when aggregated for all EDSTTAs for that hospital, conversion to inpatient admission rates should be expected to be within this range.

EDLOS of patients admitted to EDSTTA

• Mean and median EDLOS for ED patients with a departure status of EDSTTA.
• Proportion of patients admitted to the EDSTTA where EDLOS was less than 4 hours (target 80%).

Length of Stay in EDSTTA

• Mean and median time from EDSTTA admission to departure from the EDSTTA.

Transfers to other hospitals

• Proportion of patients admitted to the EDSTTA with a discharge destination of transfer to another hospital (HBCIS) e.g. Transfer from SSU Discharge Code: (16) Hospital Transfer

Access performance

• Average length of time from request for EDSTTA admission to transfer to EDSTTA.
• Number and proportion of patients in whom EDSTTA admission is requested but are discharged prior to transfer to EDSTTA.

Egress performance

• Average length of time from request for transfer to inpatient bed to actual departure to inpatient bed
  • Target <1 hour

5. Definitions

6. Approval

Document custodian: Co-Chairs, Queensland Emergency Department Strategic Advisory Panel

Approval officer: Deputy Director General, Clinical Excellence Queensland

Approval date: 18 August 2022

7. Version control