Implementation evaluation of the Emergency nurse Protocol Initiating Care—Sydney Triage to Admission Risk Tool (EPIC-START) model of care

EPIC-START model of care, with three components. Implementation of EPIC-START will use a detailed strategy supported with behaviour change and implementation science theory. Emergency nurse Protocols Initiating Care (EPIC): A clinical framework to support the earlier delivery of standardised evidence-based nurse-initiated treatment by emergency nurses for 74 EPICs (41 Adult + 33 Paediatric) for the most common emergency department (ED) presentations, for example, there are protocols for abdominal pain, chest pain, mild head injury, asthma, bites and stings, limb fractures, shortness of breath, headache, wound care, and burns. The EPIC protocols were developed by the NSW Agency for Clinical Innovation (NSW ACI) with clinicians and policy stakeholders across NSW with metropolitan, regional and rural input. Emergency nurses at sites will be trained in the epic protocol use with online and in person training. There will be recognition of prior learning for experienced staff for some of the skills. It is anticipated the training will occur in the months leading up to the implementation date. There will be support with the implementation clinical nurse consultants for each Local Health District (LHD). There will continue to be support post-implementation. The EPIC protocols will be stored on the NSW ACI website and the staff will be able to enter information relating to the EPIC into the patient medical record. The EPIC protocols will support the standard care of the patients in ED. It will mean nurses can commence some treatments earlier prior to doctor review. Use of the EPIC protocols should not increase the time it takes to care for a patient. It may take extra time to read the protocols until the staff are more familiar with the protocol use. NSW ACI will lead the NSW state rollout of EPIC protocols across the rest of the state, with this study evaluating alongside the state rollout. Once implemented it is unlikely that EPIC will be cancelled, though the study may inform changes to the rollout at the state level and small changes to the EPIC protocols themselves. Sydney Triage to Admission Risk Tool (START): A validated decision support/risk tool at the point of triage. This tool combines the presenting health concern with various other data elements available at the point of triage to estimate a risk of hospital admission or discharge to support senior clinical decisions about streaming and disposition from ED. Clinical deterioration tool: A clinical deterioration alert system that supports the earlier detection of, and senior medical response to, patients at risk of clinical deterioration in the ED.The clinical deterioration alert system is based on Modified Early Warning Score (MEWS) and Paediatric Early Warning Scores (PEWS) tools. These validated tools estimate the risk of clinical deterioration resulting in death or Intensive Care Unit admission based on vital sign observations routinely recorded by clinicians in electronic medical record (EMR) observation charts with a reported AUROC of 0.83 (95% CI, 0.83-0.84)1. MEWS tool: https://www.mdcalc.com/calc/1875/modified-early-warning-score-mews-clinical-deterioration PEWS tool: https://www.mdcalc.com/calc/3901/pediatric-early-warning-score-pews The START and clinical deterioration tool will run on the electronic medical record (eMR) with data pulled from the eMR. The system will automatically run based on the observations at triage and highlight patient risk. This will be mainly used by senior medical clinicians, bed managers, in-charge and / or patient flow coordinators. These staff will receive training in the use of the tools prior to implementation. Evaluation of adherence to the EPIC-START model of care will happen in several ways: medical record audit, surveys with implementers, web-portal analytics, emR reports on usage, post-surveys, implementation logs. The timeline of the stepped wedge will be dependant on the state rollout and the readiness of the protocols. However we anticipate that there will be a 2 month step between site implementation. Four Stages of the study (all these phases will be done as a part of this study): 1. Pre-implementation – collect baseline comparison data and identify barriers to implementation 2. Implementation strategy – develop site-specific implementation strategies based on stage 1 3. Implementation 4. Evaluate the implementation – patient, health service, implementation outcomes (cost, fidelity, usability)