evaluation of urgent care centres pilot · 4/2/2014 · final report 2 april 2014 3 ... ucc or...

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NSW Agency for Clinical Evaluation

Evaluation of Urgent Care Centres Pilot

Final Report

2 April 2014

NSW Agency for Clinical Evaluation Evaluation of Urgent Care Centres Pilot

Final Report 2 April 2014

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TABLE OF CONTENTS

1 Executive Summary .................................................................................................................... 9

2 Focus, purpose and approach to evaluation ............................................................................... 13

2.1 The focus of evaluation .................................................................................................... 13

2.2 The development of Urgent Care Centres in NSW .......................................................... 14

2.3 Evaluation requirement .................................................................................................... 14

2.4 Development of a program logic ...................................................................................... 15

2.5 Identification of performance indicators............................................................................ 16

2.6 Framing of key evaluation questions ................................................................................ 16

2.7 Establishing a method for Service Delivery Model comparison........................................ 19

2.7.1 Establishing appropriate groups for comparison .............................................................. 19

2.7.2 Identifying a UCC-type patient ......................................................................................... 20

2.7.3 Statistical methods employed for analysis ....................................................................... 20

2.8 Data collection.................................................................................................................. 21

2.9 The profile of evaluation participants ............................................................................... 21

2.9.1 Stakeholder consultations ................................................................................................ 21

2.9.2 Staff survey participants ................................................................................................... 22

2.10 The representativeness of evaluation findings ................................................................. 24

3 Appropriateness of the UCC Service Delivery Model for NSW ................................................ 26

3.1 Trends in emergency department presentations .............................................................. 26

3.2 The rationale underlying UCC implementation ................................................................. 28

3.3 Identifying areas of high service demand ......................................................................... 29

3.4 UCC Service Delivery Model development ...................................................................... 30

3.4.1 Patient profile ................................................................................................................... 30

3.4.2 Patient flow ...................................................................................................................... 31

3.4.3 Hours of operation ............................................................................................................ 31

3.4.4 Physical location and design ............................................................................................ 31

3.4.5 Staffing requirements and roles ....................................................................................... 31

3.5 Alternative approaches to managing UCC-type patients ................................................. 32

3.6 The perceptions of pilot UCCs by key stakeholders ......................................................... 33

4 The efficiency of pilot UCC operations ........................................................................................ 36

4.1 Key processes involved in establishing the UCC pilots .................................................... 36



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4.2 Time taken to implement the UCC Service Delivery Model ............................................. 38

4.3 Significant factors influencing UCC operations ................................................................ 39

4.3.1 Dedicated funding to support service operations ............................................................. 39

4.3.2 Dedicated space for UCC patients ................................................................................... 41

4.3.3 Dedicated staffing to treat UCC patients .......................................................................... 42

4.3.4 Timely access to diagnostic Services............................................................................... 43

4.3.5 Timely access to specialist consultations ......................................................................... 45

4.4 Suggested improvements to enhance UCC operations ................................................... 47

5 Effectiveness of the Service Delivery Model ............................................................................... 49

5.1 Types of patients receiving UCC services........................................................................ 50

5.1.1 Characteristics of patient presentations ........................................................................... 50

5.1.2 The profile of KCC and UCC-type patients ...................................................................... 52

5.2 Demand for emergency and urgent care type services .................................................... 56

5.3 Impact upon patient flow in the emergency department ................................................... 59

5.3.1 ED patient flow for specialist Children’s hospitals ............................................................ 59

5.3.2 ED patient flow for tertiary referral hospitals .................................................................... 62

5.3.3 ED patient flow for major metropolitan hospitals .............................................................. 66

5.3.4 Stakeholder perceptions of UCC impact on patient flow .................................................. 70

5.4 Impact upon staff satisfaction and perceived quality of care ............................................ 70

5.4.1 Staff satisfaction ............................................................................................................... 70

5.4.2 Perceived quality of patient care ...................................................................................... 73

5.5 Impact upon patient/client safety and clinical outcomes .................................................. 74

5.5.1 Patient safety ................................................................................................................... 74

5.5.2 Clinical outcomes ............................................................................................................. 74

5.6 The level of resource utilisation achieved over time at each UCC ................................... 84

5.6.1 Reported budgetary allocations and Pilot site expenditures ............................................ 84

5.6.2 Stakeholder perceptions about resource UTILISATION of UCCs .................................... 88

5.7 Acceptability of the UCC service delivery model .............................................................. 89

6 Summary of findings .................................................................................................................... 90

6.1 Overall summary .............................................................................................................. 90

Appendix 1 Performance Indicators ............................................................................................ 92

Appendix 2 Staff Surveys ............................................................................................................ 97



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Appendix 3 NSW Health UCC implementation stages ................................................................ 130

Appendix 4 Survey findings ........................................................................................................ 132

Appendix 5 KCC diagnostic categories and codes ..................................................................... 149

Appendix 6 UCC diagnostic categories and codes ..................................................................... 161

Appendix 7 Analysis of ED presentations by triage category ...................................................... 174

Appendix 8 Analysis of KCC/UCC re-presentations ................................................................... 177

Appendix 9 List of evaluation and peer group sites .................................................................... 197

Index of Figures

Figure 2-1: Program Logic for UCC Evaluation ................................................................................. 17

Figure 2-2: Survey respondents by pilot site (n=169) ........................................................................ 22

Figure 2-3: Professional occupation (n=169)..................................................................................... 22

Figure 2-4: Type of nursing respondents (n=169) ............................................................................. 23

Figure 2-5: Type of medical respondents (n=169) ............................................................................. 23

Figure 2-6: Years working (n=169) .................................................................................................... 24

Figure 2-7: Areas worked most often across hospital (n=169) .......................................................... 24

Figure 3-1: Emergency department presentations per 1,000 persons, public hospital emergency departments, 2008–09 to 2012–13............................................................... 27

Figure 3-2: Emergency department presentations per 1,000 persons, public hospital emergency departments, states and territories, 2008–2009 to 2012–2013 .................... 27

Figure 3-3: Average growth in ED presentations per 1,000 persons – 2008-2009 to 2012-2013 by state/territory ..................................................................................................... 28

Figure 4-1: Dedicated funding to support day-to-day operations of UCC .......................................... 41

Figure 4-2: Usual time for diagnostic services (n=169) ..................................................................... 44

Figure 4-3: Time to receive medication orders (n=169) ..................................................................... 45

Figure 4-4: Time for ED registrar/consultant review (n=169) ............................................................. 45

Figure 4-5: Time to obtain specialist consultation/review (n=169) ..................................................... 46



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Figure 5-1: Overall trends in number of ED presentations for specialist children’s (A2) hospitals (2006/07-2012/13) ........................................................................................... 56

Figure 5-2: Overall trends in number of ED presentations for other tertiary (A1) and major metropolitan (BM) hospitals (2006/07-2012/13) .............................................................. 57

Figure 5-3: Percent of ‘KCC/UCC-type’ presentations (0900-2200 hours) ........................................ 58

Figure 5-4: Median ED length of stay for patient groups presenting to specialist children’s hospitals .......................................................................................................................... 60

Figure 5-5: Median length of stay for ED components of KCC-type presentations ........................... 61

Figure 5-6: Median ED LOS for UCC-type (top), triage category 4/5 (middle), and all presentations (bottom) to tertiary referral hospitals ......................................................... 64

Figure 5-7: Median ED LOS for time to triage (top), assessment (middle) and separation (bottom) for UCC-type presentations .............................................................................. 65

Figure 5-8: Median ED LOS for UCC-type (top), triage category 4/5 (middle), and all presentations (bottom) to major metro hospitals ............................................................. 68

Figure 5-9: Median ED LOS for time to triage (top), assessment (middle) and separation (bottom) for UCC-type presentations .............................................................................. 69

Figure 5-10: Perceptions on set up and operation of UCC – all respondents (n=169) ....................... 71

Figure 5-11: Perceptions of satisfaction – all respondents (n=169).................................................... 72

Figure 5-12: Perceptions of standard of care and waiting times – all respondents (n=169) ................ 73

Figure 5-13: Percent of KCC-type patients discharged to usual accomodation .................................. 75

Figure 5-14: Percent of UCC-type patients discharged to usual accommodation ............................... 76

Figure 5-15: Types of community referral for KCC-type patients discharged from specialist children’s hospitals .......................................................................................................... 78

Figure 5-16: Tertiary hospital UCC-type patient referrals to no-source (top) GP (middle) or hospital outpatients (bottom) after discharge .................................................................. 80

Figure 5-17: Major metro UCC-type patient referrals to no-source (top) GP (middle) or hospital outpatients (bottom) after discharge .................................................................. 81

Figure 5-18: Average revenue for KCC-type (top) vs all category 4-5 (bottom) patients treated at the children’s hospitals ................................................................................................ 85

Figure 5-19: Average revenue for UCC-type (top) vs all category 4-5 (bottom) patients treated at tertiary referral hospitals .............................................................................................. 86



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Figure 5-20: Average revenue for UCC-type (top) vs all category 4-5 (bottom) patients treated at major metropolitan hospitals ....................................................................................... 87

Figure 5-21: Perceptions of community impact – all respondents (n=88) ............................................ 89

Index of Tables

Table 2-1: Key evaluation questions ................................................................................................ 18

Table 2-2: Stakeholder consultations at site visits ........................................................................... 21

Table 4-1: Commencement of UCC/KCC model and infrastructure ................................................. 38

Table 4-2: Capital and recurrent allocation by NSW Health ............................................................. 40

Table 5-1: Key characteristics of KCC presentations ....................................................................... 50

Table 5-2: Key characteristics of UCC presentations ....................................................................... 51

Table 5-3: ICD10-AM grouped profile of KCC presentations ........................................................... 54

Table 5-4: ICD10-AM grouped profile of UCC presentations ........................................................... 55

Table 5-5: Discharge disposition of KCC/UCC-type patients by hospital group ............................... 74

Table 5-6: Community referrals for KCC/UCC-type patients by hospital group ................................ 77

Table 5-7: Representation characteristics between commencement and 2 years following KCC/UCC implementation .............................................................................................. 83



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List of Abbreviations AAUCM American Academy of Urgent Care Medicine

ACI Agency for Clinical Innovation

CHF Congestive Heart Failure

CHW Children’s Hospital Westmead

CMO Chief Medical Officer

ED Emergency Department

ED SAS Early ED Senior Assessment and Streaming

ED SSU Emergency Department Short Stay Units

EOI Expressions of Interest

GP General Practitioner

DVT Deep Vein Thrombosis

KCC Kids Care Centre

LOS Length of Stay

MAU Medical Assessment Unit

NEAT National Emergency Access Targets

PL Program Logic

SAS Senior Assessment and Streaming

SAU Surgical Assessment Units

SOB Short of breath

SSU Short Stay Unit

UCC Urgent Care Centre

URTI Upper Respiratory Tract Infections

Disclaimer

Please note that in accordance with our Company’s policy, we are obliged to advise that neither the Company, nor any employee nor sub-contractor, undertakes responsibility in any way whatsoever to any person or organisation (other than NSW Agency for Clinical Evaluation), in respect of information set out in this report, including any errors or omissions therein, arising through negligence or otherwise however caused.



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A note on interpretation of text and figures

1. Text denoted in un-bolded blue font is a summary of findings relating to the individual section of the report or aggregated in the overall executive summary.

2. Text denoted in bolded blue is a highlight point.

3. Text denoted in grey is a quote from individuals interviewed or surveyed as part of the evaluation

[Supplementary coding denotes whether these individuals were working in the UCC or Non-UCC staff members at participating pilot hospital sites]

4. Figures denoting average/mean levels of performance are presented with 95% confidence intervals (calculated according to the standard practice) – these intervals are typically symmetrical.

5. Figures denoting median levels of performance are presented with 95% confidence intervals (calculated according to the Sign Test as standard practice) – these intervals are typically asymmetrical.



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1 Executive Summary

Background and evaluation methodology

Urgent Care Centres have recently been implemented in a number of overseas jurisdictions to streamline the management of non-complex, low acuity patients presenting to the Emergency Department (ED), and free up resources to manage more critically ill patients. In line with international developments, NSW Health has sought to pilot and evaluate the introduction of Urgent Care Centres (UCCs) in a selected number of public hospitals.

An independent evaluation was commissioned by the NSW Agency for Clinical Innovation (ACI) to assess the perceived appropriateness, efficiency and effectiveness of the UCC Service Delivery Model for public hospitals in NSW. Five pilot sites were evaluated, including one tertiary referral hospital, two children’s hospitals, and two major metropolitan health facilities.

Data relating to the UCC pilot were collected from a range of sources; including policy and program documentation, Service Delivery Model documents, stakeholder interviews with key clinical and government personnel (n = 55), a survey of staff at each pilot site (n=169), and an analysis of individual (de-identified) patient presentations to all pilot sites and their peer group hospitals (n > 7,800,000).

The clinical profile of a UCC-type patient was constructed from key patient presentation characteristics (hours of presentation, age, triage category, ICD10-AM diagnostic classifications). Patient profiling was used to compare the ED performance of each pilot site with peer group hospitals.

Longitudinal site-specific and peer group comparisons were undertaken before and after implementation of the UCC Service Delivery Model to ascertain:

whether changes in ED performance had occurred at pilot hospitals; and

whether these changes were significantly different from those observed in other hospitals that had not implemented the UCC Service Delivery Model.

Appropriateness of the UCC Service Delivery Model

Emergency Department (ED) presentations are increasing across the developed world. In Australia, the largest net number of presentations to EDs occurs in New South Wales. The volume of patient presentations and the need to find more effective methods of demand management prompted further investigation by NSW Health into emerging models of ED service delivery, particularly for patients with non-complex, low acuity conditions.

The typical profile and volume of non-complex, low-acuity patients was examined by NSW Health, together with areas of greatest demand across the public health service system. An evidence-based Service Delivery Model was developed to support implementation of UCCs in selected pilot sites across NSW. The pilot Service Delivery Model was designed to complement (and be



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evaluated against) other existing Service Delivery Model arrangements put in place by local health services to manage rising demand.

Stakeholders involved in local implementation of the pilot UCCs were positive about the design, implementation and preliminary impacts upon patients, staff and ED performance. Other stakeholders expressed a variety of opinions about the appropriateness of introducing UCCs into the NSW health system, ranging from guarded scepticism to positive support for the new Service Delivery Model.

The efficiency of UCC pilot implementation

All pilot sites commenced the three year UCC implementation between December 2010 and February 2011. It is estimated that around $17.7 million has been allocated to the pilot program, comprising $1 million annual funding to each site for operational expenses. This is in addition to site-specific funding allocations to modify ED infrastructure or build co-located UCC facilities.

Time-lines for modifications to ED infrastructure varied across participating hospitals. Two of the pilot sites were unable to modify existing facilities until the final year of pilot implementation. One site will commence building of a co-located UCC following the three year pilot period. Delays in capital redevelopment were attributed to a range of factors including the availability of sufficient funds to complete renovations or redevelopments, the need to relocate other services prior to UCC clinic construction, or the need to accommodate broader planning for ED redevelopment.

Other factors reported to influence the success of UCCs operations included:

the availability of dedicated funding to implement the Service Delivery Model;

the capacity to designate waiting areas and treatment rooms;

the availability of staff with sufficient skills and experience; and

the timely availability of diagnostic tests and the time waiting for clinical consultations from inpatient specialists.

Suggestions to improve future service delivery included:

improved access to GP services;

the availability of additional staff to handle rises in UCC demand;

clarification or expansion of the UCC scope of practice; and

increasing current UCC operating hours.

The effectiveness of the UCC Service Delivery Model

Data received from the pilot sites relating to the ‘actual’ characteristics of Kids Care Centre (KCC) / UCC-type patients was used to create a profile of those attending for treatment through the pilot service delivery model. Profiling captured 77% of all KCC-type presentations and 81% of all UCC-type



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presentations. These profiles were subsequently applied to more than 7,800,000 presentations to pilot sites and their peer group hospitals between 2006/07 to 2012/13 in order to understand the nature of KCC/UCC-type presentations over the reporting period.

By 2012/13, KCC/UCC-type presentations accounted for approximately 23% of all triage 4-5 presentations to the specialist children’s hospitals, around 69% of the same group of presentations to tertiary referral hospitals, and around 70% of all triage 4-5 presentations to major metropolitan hospitals. Significant reductions in overall length of stay in the ED were observed for KCC/UCC-type patients treated by hospitals participating in the pilot. In the main, these differences were attributed to improved time to clinician assessment for patients streamed to the KCC/UCC model of service delivery.

Improvements in ED flow for KCC/UCC-type patients were not unique to the pilot hospitals sites (compared with the respective hospital peers), especially when the overall length of stay for all triage category 4 and 5 patients were considered. Staff were accepting and generally satisfied with the pilot model of service delivery and perceived the model to have a positive impact upon patient outcomes and satisfaction.

Analysis of available clinical outcome data revealed that, whilst changes in the proportion of UCC-type patients discharged home (vs admitted to hospital) were observed at some of the pilot hospital sites, these gains were not consistent across similarly grouped pilot hospitals, nor significantly better than other peer hospitals which did not participate in the pilot model of service delivery.

The proportion of patients referred to their GP following treatment at the pilot hospital sites varied significantly from 0% to around 95%. Changes in clinical outcomes relating to GP referral, after implementation of UCCs, also varied in a similar manner to those observed for other peer group hospitals who did not participate in the pilot service delivery model.

Examination of patient re-presentations for treatment within 48 hours of discharge from the KCC/UCC revealed that: there was no significant difference in the proportion of patients re-presenting to the pilot sites within two years of UCC implementation; of those who did re-present, there were no differences in overall ED length of stay or clinical outcomes, with the exception of community referrals to GPs which increased for two sites (Westmead Hospital and Wyong Hospital); and that in general, pilot site performance was not significantly better or worse than other peer group hospitals

Finally, the overall revenue per patient (or average price) for UCC-type patients was generally comparable to the revenue per patient generated for all triage category 4 and 5 patients treated at the same pilot sites. Similarly, revenue per patient differences mirrored the pattern of overall differences in revenue per patient generated for all triage category 4-5 patients between pilot sites and their peer group hospitals.



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Summary of findings

On the basis of the available information, there is no evidence that a KCC/UCC model of care is any better or worse than other models for streamlining and treating non-urgent, non-complex patients within NSW public hospital EDs.

Moreover, there is sufficient evidence to indicate that a number of other single (or multiple) models of ED streaming and treatment may produce superior outcomes for ED performance and patient outcomes with the same types of patients treated in UCCs. These should be actively investigated in order to understand the service delivery models underlying what has been identified as system-wide better practice.



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2 Focus, purpose and approach to evaluation

Urgent Care Centres (UCC) have recently been implemented in a number of overseas jurisdictions to streamline the management of non-complex, low acuity patients presenting to the ED, and free up resources to manage more critically ill patients. In line with international developments, NSW Health has sought to pilot and evaluate the introduction of UCCs in a selected number of public hospitals.

An independent evaluation was commissioned by the NSW Agency for Clinical Innovation (ACI) to assess the perceived appropriateness, efficiency and effectiveness of the UCC Service Delivery Model for public hospitals in NSW. Five pilot sites were evaluated including one tertiary referral hospital, two children’s hospitals, and two major metropolitan health facilities.

Data relating to the UCC pilot were collected from a range of sources, including policy and program documentation, Service Delivery Model documents, stakeholder interviews with key clinical and government personnel (n = 55), a survey of staff at each pilot site (n=169), and an analysis of individual (de-identified) patient presentations to all pilot sites and their peer group hospitals (n > 7,800,000).

The clinical profile of a UCC-type patient was constructed from key patient presentation characteristics (hours of presentation, age, triage category, ICD10-AM diagnostic classifications). Patient profiling was used to compare the ED performance of each pilot site with their peer group hospitals.

Longitudinal site-specific and peer group comparisons were undertaken before and after implementation of the UCC Service Delivery Model, to ascertain:

whether changes in ED performance had occurred at pilot hospitals; and,

whether these changes were significantly different from those observed in other hospitals which had not implemented the UCC Service Delivery Model.

2.1 The focus of evaluation

UCCs have been introduced in a number of overseas jurisdictions to ease pressure on hospital EDs, resulting from an increase in the number of patients attending for assessment and management of non-complex, low acuity conditions.

The American Academy of Urgent Care Medicine (AAUCM) defines urgent care as:

“…the provision of immediate medical service offering outpatient treatment of acute and chronic illness and injury.”

The use of UCCs is generally recommended for consideration when a condition requires attention within 24 hours but is not life-threatening. Unlike EDs, UCCs tend not to operate 24 hours per day but during peak periods, particularly after-hours and on weekends. UCCs in North America offer services available in an Emergency Room but do not accept



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ambulances, reinforcing the position that this service does not provide care for life-threatening conditions. Medical staff in UCCs treat urgent or acute medical problems such as cuts, sprains, fractures, headaches, bronchitis and pneumonia.

Internationally, UCCs are generally stand-alone services that operate independently of hospitals or other health facilities.

In the United States and Canada, and to a lesser degree in the UK, UCCs tend to be privately operated for-profit businesses that provide a convenient alternative to over-crowded EDs for those able to afford the service. However, there are some UCCs associated with hospitals where patients do not have to pay for services.

For many patients this service offers a convenient alternative as UCCs provide imaging, pathology and other services not found in primary care physician rooms. In the United States UCCs are also of benefit to employers, insurers and other payers, as the cost of services provided at these facilities tend to be significantly less than those provided during an ED visit.

The NHS concept of walk-in centres and nurse-led units are a more ‘nationalised’ version of UCCs that operate in North America. These centres are NHS-funded, primarily nurse-led, and offer a drop-in service with extensive opening hours, in convenient locations. One of the stated aims of NHS walk-in centres is “to reduce demand on other NHS providers, particularly general practitioners and accident and emergency departments in hospitals.” This is to be achieved by providing advice and treatment for minor illnesses and injuries that do not require the attention of a doctor.

The AAUCM notes that currently there are approximately 9,300 walk-in, stand-alone UCCs in the United States, with about 700-800 new clinics opening each year.

2.2 The development of Urgent Care Centres in NSW

In line with international developments, NSW has piloted a number of UCCs to address the rising demand for non-acute ED presentations recognised by the ‘Garling Report’ (2008). UCCs are designed to perform minor procedures such as suturing, fracture management and plastering. The intended business outcome of the Pilot was to divert 30-40% of ED attendances from hospitals to UCCs, enabling the majority of patients with minor injury or illness to be treated in a timely manner (with a majority seen within one hour of initial presentation).

Five hospitals were selected to implement a pilot UCC Service Delivery Model across NSW, including Westmead Hospital, the Children’s Hospital at Westmead, Sydney Children’s Hospital, Campbelltown Hospital, and Wyong Hospital. NSW Health has sought to evaluate the quality, efficiency and effectiveness of this Service Delivery Model in addressing the needs of patients with lower acuity health conditions, and the impact that this Service Delivery Model has had upon ED services provided by the same hospitals.

2.3 Evaluation requirement

The NSW Agency for Clinical Innovation (ACI) established a brief for evaluation of the five pilot sites implementing the UCC Service Delivery Model. The evaluation was required to



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assess and compare the pilot sites and consider the implementation of the Service Delivery Model and long-term outcomes, including:

clinical outcomes and patient safety;

process indicators such as wait time to be seen, duration of stay, did not waits, planned and unplanned returns, GP referral rates, transfers to ED;

the impact on overall emergency care pathways in hospitals including access block;

governance and accountability arrangements;

the suitability of each hospital environment for UCC implementation;

the scope of practice undertaken by each UCC;

the impact of UCCs on patient satisfaction;

staff satisfaction with the UCC Service Delivery Model;

recruitment and other workforce issues impacting upon Service Delivery Model operations;

overall impacts on ED activity (e.g. numbers of patients, primary condition treated and complexity, triage category and response, patient length of stay, other ED activity variables, all criteria compared with peer EDs); and

the cost-effectiveness and resource utilisation of UCC model (e.g. NWAU activity, and proportion of patients admitted (and, if admitted, resource usage measures such as bed days/ALOS/DRG etc.).

An evaluation work-plan was submitted and approved by the ACI prior to commencement of the evaluation. Key stages of the evaluation methodology are outlined in the following section.

2.4 Development of a program logic

Key components of the UCC pilot were articulated in a ‘Program Logic’, summarising the rationale, hypothesised mechanism of influence, key activities and intended outcomes of the UCC Service Delivery Model. Program logic is essentially a self-defined concept. As the name suggests, it outlines the ‘logic’ underlying how a program is implemented, and the benefits that are intended to arise from major program activities. More specifically:

Program logic provides a visual representation of how a program, project, or Service Delivery Model is intended to work. Program logic highlights key assumptions involved in program design, major activities that are to

take place, and the outcomes that are anticipated to arise from these activities in the short, medium and longer terms for program

beneficiaries.1

1 For a worked example of the principles and outcomes of program logic development, the reader is referred to the W.K.

Kellogg Foundation (2006) Logic Model Development Guide. Available (free of charge) at: http://www.wkkf.org/ knowledge-center/resources/2006/02/WK-Kellogg-Foundation-Logic-Model-Development-Guide.aspx

http://www.wkkf.org/knowledge-center/resources

http://www.wkkf.org/knowledge-center/resources



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In this instance, the program logic devised for evaluation of the UCC pilots sought to identify and specify elements that constitute ‘appropriateness’, ‘efficiency’ and ‘effectiveness’ of the model of service delivery. The components include the rationale for initiating the UCC pilots, the requisite planning activities by government, the establishment and operational issues for health services and the likely impacts sought from the service delivery model (Figure 2-1).

2.5 Identification of performance indicators

A series of performance indicators were then developed to measure the range of activities identified for government and health service implementation as well as measures to assess short-medium and medium-longer term outcomes outlined in the program logic. In addition to the indicators, specific data sources for gathering the information to assess results for each indicator were also detailed, discussed and agreed with the client. Specific indicators to guide the evaluation and potential sources of data collection are presented in Appendix 1.

2.6 Framing of key evaluation questions

A series of key questions were then identified to guide the evaluation process. Key questions were grouped into three main areas focusing upon the:

appropriateness of the service delivery model in meeting the rising demand for services;

efficiency with which the service delivery model arrangements have been implemented and maintained; and

effectiveness of the service delivery model in meeting the needs of patients, staff, local health services and the broader NSW health system.

Specific questions for evaluating the appropriateness, efficiency and effectiveness of the UCC Service Delivery Model were discussed and approved by the ACI, and are set out in Table 2-1 below. These questions were used to inform subsequent document interrogation, data collection, stakeholder interviews, data analysis, and evaluation reporting.


Working Paper: Final Report 2 April 2014

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Figure 2-1: Program Logic for UCC Evaluation

Assess concerns

against government

policy

Identify variations in

demand between health

services

Identify areas of

community concern

(emergency demand)

Investigate areas of

concern in accordance

with government policy

Identify effective

approaches to address

demand

Discuss issues and

potential approaches

with key stakeholders

Determine an

appropriate government

response

Identify resources to

support the government

response

Government

Activities

Patients with minor

injuries and illnesses can

be identified and treated

separately in order to:

reduce waiting times,

length of stay at hospital

and the overall cost of

treatments provided by

health services without

compromising the safety

and quality of patient

care

An increasing number of

people are presenting to

public hospital

Emergency Departments

for treatment, resulting in

longer waiting times for

non-urgent patients to be

assessed, and placing

significant burden upon

public sector resources

Monitor the operation,

impact and

sustainability of

government response

Confirm local need,

patient eligibility and

referral criteria

Identify operational

arrangements for new

initiative

Establish commitment to

implementing new

government initiatives

Establish governance

arrangements for new

initiative

Establish physical

infrastructure required

for new initiative

Establish appropriate

equipment and links to

hospital support services

Identify and implement

IT and communication

systems to support new

initiative

Implement evaluation

and monitoring systems

for new initiative

Health Service

Activities

Planning Establishment Operation ImpactRationale

Allocate patients to

appropriate treatment

streams (ED vs UCC)

Perform diagnostic

testing and re-evaluate

patient needs

Register and triage

patients presenting to

the Emergency

Department

Assess patient needs

Implement appropriate

treatments to address

patient needs

Discharge patient, or

transfer patient to an

appropriate stream of

care

Decreased time to

assessment for patients

Staff and patient

satisfaction with service

delivery

Improved streamlining of

patients for emergency

care

Decreased time spent in

treatment by patients

Increased effectiveness

of emergency service

delivery

Decreased cost of

emergency service

delivery

Short-Medium Term

Outcomes (6-12 months)

Medium-Long Term

Outcomes (12-24 months)

Increased efficiency of

hospital services

Improved utilisation of

community treatment

options

Appropriateness Efficiency Effectiveness

Appraise current

arrangements against

proposed service

delivery model

Identify a model of

service delivery

Establish patient

selection criteria

Dedicate waiting and

treatment areas

Fund specific workforce



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Table 2-1: Key evaluation questions

The appropriateness in meeting rising demand:

1. What was the impetus for developing UCCs in NSW?

2. What analysis was undertaken to identify the elements of the service delivery model?

3. What is the evidence supporting each element of the UCC service delivery model?

4. What are the key elements of the UCC service delivery model?

5. What analysis was undertaken to identify the sites for UCC implementation?

6. What alternative service delivery models exist to meet the needs of UCC patients?

The efficiency with which arrangements have been implemented and maintained:

7. What processes were involved in establishing, operating and maintaining the service delivery model?

8. What factors have supported or inhibited the service delivery model operations?

9. How were services structured and funded to deliver the service delivery model?

10. What elements or processes could be improved to enhance the efficiency of service delivery model operations?

11. What level of resource utilisation has been achieved?

The effectiveness in meeting the needs of patients, staff, local health services and the broader NSW health system:

12. What has been the overall demand for UCC services?

13. What types of patients have received UCC services?

14. What has been the impact upon patient flow in the emergency department?

15. What has been the impact upon perceived quality and satisfaction with care experienced by staff, patients?

16. What has been the impact upon patient/client safety and clinical outcomes?

17. What level of resource utilisation has been achieved over time at each UCC?

18. How does the level of resource utilisation compare with alternative service delivery models?

19. How acceptable is the UCC service delivery model to government, service providers and consumers of health services?



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2.7 Establishing a method for Service Delivery Model comparison

This stage of the evaluation focused upon identifying the best-available evidence that could be used to attribute any observed changes occurring in UCC pilot sites to the new Service Delivery Model, rather than influences impacting upon the number of ED presentations or patient outcomes. Normally, statements of ‘causation’ would be supported through a randomized-controlled allocation of patients (or more preferably hospitals) to a ‘pilot’ or a ‘usual’ Service Delivery Model intervention. However, randomized-controlled trials of government programs are rarely achievable. Accordingly, alternative sources of comparison were developed.

2.7.1 ESTABLISHING APPROPRIATE GROUPS FOR COMPARISON

The impacts of the UCC Service Delivery Model were examined separately for three groups of pilot sites, comprising presentations to:

the children’s (A2) hospitals (between the ages of 0 and 15 years);

other tertiary referral (A1) hospitals (between the ages of 16 and 60 years); and

other major metropolitan (BM) hospitals (between the ages of 16 and 60 years).

Standardised systems data reported to the NSW Health Emergency Minimum Dataset was examined for all pilot sites (n > 7,800,000). Three primary questions guided the evaluation of systems data:

1. Have significant changes in ED performance been observed at the pilot sites following UCC Service Delivery Model implementation?

2. Have significant changes in ED performance been observed at other (peer group) hospitals who have not implemented the UCC Service Delivery Model?

3. Is there a significant difference between the changes in ED performance observed at the pilot sites compared with other (peer group) hospitals?

These questions were designed to ascertain whether the UCC had made any impact at pilot sites, and whether the significance and magnitude of any impacts were different from other models of care operating across similar health services.

Accordingly, three types of data comparison were undertaken for each pilot group, including:

a longitudinal analysis of any significant changes in ED performance at each pilot site before and after UCC implementation (on a 7 month quarterly, and 7 year annual basis);

a longitudinal analysis of any significant changes in ED performance at other peer group hospitals before and after the dates of UCC implementation at pilot sites; and

a comparative analysis of the significance of changes identified at each pilot site with other peer group hospitals.



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2.7.2 IDENTIFYING A UCC-TYPE PATIENT

In order to undertake any meaningful comparisons, a ‘profile’ of UCC-type patients was required. This profile was used to compare patient presentations with similar characteristics before and after UCC implementation at the pilot sites, and to compare pilot sites with other similar hospitals.

Patient profiling was based upon all available UCC data reported to NSW Health, and focused upon classifying the majority of UCC-type presentations which included:

all presentations to the pilot site UCCs between the hours of 0900 and 2200;

presentations between the ages of 0-15 years (for children’s hospitals) or 16-60 years (for other hospitals);

presentations triaged as semi-urgent (category 4) or non-urgent (category 5); and

presentations with an ICD10AM classification that had a greater ‘probability’2 of streaming to the UCC rather than the ED3.

UCC patient diagnostic information (coded through ICD9, ICD10 and SNOWMED CT) was translated into ICD10-AM diagnostic codes using URGv13 Grouping Software provided by the Australian Independent Hospital Pricing Authority (IHPA).

Patient profiling captured 77% of all UCC presentations to the children’s hospitals, and 81% of all UCC presentations to other pilot hospital sites.

Specific outcomes associated with patient profiling are presented in Section 6 of this report.

2.7.3 STATISTICAL METHODS EMPLOYED FOR ANALYSIS

A variety of complex multivariate statistical approaches could be used to analyse the evaluation data. In order to increase the transparency and simplify interpretation of data, information was analysed and presented according to:

the performance of pilot sites over a specified period of time (quarters, years); and

the performance of other peer group hospitals over the same time period.

Data are presented as ‘average’ or ‘median’ levels of performance, together with 95 percentile confidence limits4. In general terms, non-overlapping confidence intervals indicate significant differences in performance. Where tighter confidence intervals were observed, specific significance testing was undertaken (if considered relevant or important). Given the exploratory nature of the evaluation, statistical controls for experiment-wise error were not considered appropriate (e.g., adjustments to hold overall probability from grouped statistical analyses at alpha=.05).

2 An acceptable level of probability was deemed to be more than 2 in every 3 presentations (67%+) in order to

accommodate the small sample sizes for some diagnostic classifications. Classifications with fewer than 3 cases were therefore excluded from the profile.

3 The utilisation of diagnostic codes means that the sample profiling excluded around 10% of individuals who ‘did not wait’ for treatment or ‘left at own risk’ following triage (as diagnostic codes are only classified following ED separation).

4 95% confidence limits for median values are obtained using the Sign Test and based upon the probability of individual values falling above or below the median observed value for a given distribution.



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2.8 Data collection

Data collection commenced with an analysis of available policy, program and operational reports received or generated by pilot site data. Key stakeholder interviews were then conducted in two phases.

early interviews were conducted via teleconference with 15 stakeholders to identify early implementation issues and preliminary impacts associated with the pilot Service Delivery Model;

more extensive interviews were conducted on-site with 20 stakeholders to explore key elements of Service Delivery Model implementation and perceptions of the outcomes achieved for patients, staff and health services.

A staff survey was also developed and implemented to gather the perceptions of ED staff (including those who had worked and those who had not worked in the UCC) about the impact of UCC operations upon workload, skill development, professional scope of practice arrangements, job satisfaction, patient outcome, community impacts and areas for future improvement or development.

A copy of the staff surveys (KCC and UCC specific) are attached as Appendix 2. The survey was administered over a 4 week period to each pilot site and active requests to participate were sought by the ED medical and nurse directors.

2.9 The profile of evaluation participants

2.9.1 STAKEHOLDER CONSULTATIONS

Table 2-2 shows key staff involved in evaluation consultations.

Table 2-2: Stakeholder consultations at site visits

Hospital Name Position

Wyong Dr Simon Battersby ED Director

Sue Evans DON

Andrew Roberts ED Manager

Mark Constable ED NUM

Kay Penney ED Data Manager

Campbelltown Lynne Bickerstaff CEO

Graeme Loy Director of Operations

Dr Sellappa Prahalath ED Director

Leanne Scott ED NUM

Ron Wilson CNC

Westmead Dr Matthew Vukasovic ED Director

Donna Robertson A/Nurse Manager

Margaret Murphy CNC

Scott Daczko ED NUM

SCHN Dr Michael Brydon Director of Operations

CHW Dr Mary McCaskill ED Director

Leonnie Dawson ED NUM

SCH Dr Matthew O'Meara ED Director

Kylie Stark ED NUM



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2.9.2 STAFF SURVEY PARTICIPANTS

There were a total 169 survey respondents across all pilot sites with a majority (34%) from Wyong Hospital, followed by the Children’s Hospital at Westmead (CHW: 30%) (Figure 2-2).

Figure 2-2: Survey respondents by pilot site (n=169)

The majority of responses were received from nurses (50%) and doctors (40%). Comparatively fewer responses were received from clerical (5%), hospital administration (3%) or allied health (1%) staff (Figure 2-3).

Figure 2-3: Professional occupation (n=169)

Registered nurses comprised the majority (75%) of nursing staff responses (Figure 2-4).



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Figure 2-4: Type of nursing respondents (n=84)

A wide range of medical staff also responded to the survey, including registrars (43%), consultants (27%), and medical officers (19%). Medical staff participation is presented in Figure 2-5.

Figure 2-5: Type of medical respondents (n=67)

The professional experience profile of staff responding to the survey was well represented, with over fifty percent of the workforce having more than five years’ experience. Approximately a quarter (27.2%) of respondents had between 0-3 years’ experience with another quarter (26%) having more than 10 years’ experience.

A further breakdown revealed that in general, medical staff were less experienced than nursing staff. Fifty-seven percent of medical respondents had less than five years’ experience, whereas 64% of nursing staff had more than five years’ experience (Figure 2-6).



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Figure 2-6: Years working (n=169)

The majority of respondents indicated that the ED was the area where most working time was spent, with around 13% of all spending specific time in the Urgent Care Centre (Figure 2-7).

Figure 2-7: Areas worked most often across hospital (n=169)

2.10 The representativeness of evaluation findings

In general, the findings of the evaluation were considered to be highly representative of information obtained from the pilot hospital sites, by incorporating:

100% capture of all ED systems data reported to NSW Health for analysis;

100% capture of all senior medical and nursing staff involved in Service Delivery Model implementation; and

a wide (and representative) range of other staff input at each pilot sites via survey responses.

It is acknowledged that without a specific staffing profile from each of the participating hospitals, the true representativeness of staff cannot be determined. However, in the



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absence of such information the profile of respondents appears generally consistent with the overall workforce distribution across EDs.

The absence of documented financial information relating to program allocations and expenditures was considered to be a significant shortcoming to the evaluation. Despite formal attempts to obtain this information the evaluators were unable to locate relevant official financial documentation.

Thus, as a whole, the information upon which the evaluation has drawn was considered to be sufficiently robust to support any conclusions about the impact of the UCC Service Delivery Model upon ED performance and patient outcomes. Lack of available information relating to total cost, including allocations to each pilot site for program and capital expenditure, limit the degree to which conclusions relating to overall ‘efficiency’ (i.e. cost per unit of output) and cost-effectiveness (i.e. relative cost associated with changes in outcome) can be made about the pilot program due to lack of available evidence.



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3 Appropriateness of the UCC Service Delivery Model for NSW

ED presentations are increasing across the developed world. In Australia, the largest net number of presentations to EDs occurs in New South Wales. The volume of patient presentations and need to find more effective methods of demand management has prompted further investigation by NSW Health into emerging models of ED service delivery, particularly for patients with non-complex, low acuity conditions.

The typical profile and volume of non-complex, low-acuity patients was examined by NSW Health, together with areas of greatest demand across the public health service system. An evidence-based Service Delivery Model was developed to support implementation of UCCs in selected pilot sites across NSW. The pilot Service Delivery Model was designed to complement (and be evaluated against) other existing Service Delivery Model arrangements put in place by local health services to manage rising demand.

Stakeholders involved in local implementation of the pilot UCCs were positive about the design, implementation and preliminary impacts upon patients, staff and ED performance. Other stakeholders expressed a variety of opinions about the appropriateness of introducing UCCs into the NSW health system, ranging from guarded scepticism to positive support for the new Service Delivery Model.

3.1 Trends in emergency department presentations

The demand for emergency health care has been rising consistently across the developed world, with presentations to emergency departments (ED) increasing by between 3% to 6% per annum.5,6 A recent RAND Corporation report into The evolving role of EDs in the United States7 comments on the evolution of EDs since the Second World War. In particular, the report notes the statutory obligation EDs have to provide care to all, regardless of their ability to pay. Amongst other findings, the study recognises that EDs have become an important source of hospital admissions and a place to conduct complex diagnostic workups for patients with “worrisome symptoms”. Importantly, the principal reason for non-emergency ED visits continues to be a lack of timely alternative treatment options in the community, despite continued efforts to strengthen primary care.

In Australia, the recently released AIHW report Australian Hospital Statistics 2012-2013 Emergency Department Care8 notes that nationally, ED presentations have increased by 4.0% on average year on year between 2008-09 and 2012-13 (Figure 3-1).9

5. Lowthian, JA, Curtis, AJ, et al, MJA Australia 2012, 196(2) 128-132 6. PLOS ONE, Volume 8 (6) June 2013 7. RAND Corporation, Research Report The Evolving Role of Emergency Departments in the United States, 2013 8. AIHW, Australian hospital statistics 2012-2013: emergency department care (2013) 9. Following adjustment for changes in the coverage of the collection, the increase was noted to be in the order of 2.9% on

average each year.



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Figure 3-1: Emergency department presentations per 1,000 persons, public hospital emergency departments, 2008–09 to 2012–13

When this trend is considered at a jurisdictional level, it is evident that NSW has the most ED presentations of all states and territories (Figure 3-2). There has been an average growth of 3.2% since 2008-09, with the greatest growth being from 2010-11 to 2011-12, when ED presentations increased by 7.8%.

Figure 3-2: Emergency department presentations per 1,000 persons, public hospital emergency departments, states and territories, 2008–2009 to 2012–2013

However, when rate of growth (per 1000 population) is examined, it is evident that Western Australia, South Australia and Queensland have experienced a more significant increase in community use of ED services during this time than NSW (Figure 3-3).



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Figure 3-3: Average growth in ED presentations per 1,000 persons – 2008-2009 to 2012-2013 by state/territory

Consistent demand for, and growth in, ED presentations is well documented in the literature. Increases in the number of ED presentations places significant pressure upon the acute health care system. These issues have become more critical following the recent introduction of the National Hospital and Health Care Reforms. Service funding will now be more closely aligned to the number of patients treated and discharged within specified time lines (e.g., 4 hours for the ED). Penalties for unplanned re-presentations to the ED or admissions to hospital will remain. Thus, approaches to reduce the load of non-acute presentations upon the ED have become a primary focus of hospitals in NSW and across Australia.

3.2 The rationale underlying UCC implementation

A decision to pilot UCCs in NSW was largely influenced by the ongoing increase in number of ED presentations across the state, particularly for individuals with less acute or complex medical needs who may otherwise receive services in the community (primary care) setting. These trends were officially recognised by Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals Report (Garling Report) which included a specific recommendation that:

“… where a hospital has an Emergency Departments, it should establish a Primary Care Centre which would provide services for all patients who attend the hospital seeking urgent or unplanned care and who are not determined clinically

to be in need of immediate or emergency care.” (Recommendation 101)

More broadly, it was recognised that a range of factors are contributing to the ongoing increase in ED presentations, including (but not necessarily limited to) the:

lack of availability of general practitioners (GPs), particularly after hours;

increasing age of the population and consequent increase in the prevalence of age related disease and comorbidities;

increasing prevalence of chronic disease across the spectrum of ages and the resultant higher levels of comorbidities and potential for complications associated with medical treatment in the community;



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shifts in community attitudes that see ED as a convenient ‘one stop shop’ for treatment of minor injuries and illness, particularly where medical imaging, pathology and/or specialist medical consultation may be required;

perceived affordability of ED attendances compared with general practice visitations which may attract out-of-pocket costs to the consumer; and

changes accompanying the healthcare reforms and the new National Health Care Agreement, which more closely aligns patient treatment times (e.g. 4 hours in the ED) with funding of services.

In order to identify the most appropriate model for ‘Primary Care Centres’, NSW Health conducted an extensive review of existing models of care operating in Australian and overseas jurisdictions. Urgent Care Centres were identified as an emerging model that appeared suitable for management of non-complex, low acuity patients presenting to the ED in NSW. This approach was considered to be a promising addition to the range of existing ED patient management strategies currently employed across NSW public hospital EDs.

3.3 Identifying areas of high service demand10

NSW emergency patient data was analysed to identify the types and volumes of patients who may benefit from implementation of a UCC Service Delivery Model.11 ED presentations were examined over a seven year period (from 2001 to 2007) to identify key characteristics of low acuity, non-complex patients, which included individuals:

presenting to the ED between the hours of 0900 and 2200;

between the ages of 1 and 60 years of age;

classified as emergency, semi-urgent or non-urgent;

presenting with a variety of non-complex conditions, excluding:

Initial labour; Patients presenting with abdominal

pain/miscarriage; Those requiring substantial workup to

arrive at a fairly simple diagnosis (e.g. viral infection);

Generalised diagnosis types (e.g.: examination and observation, other general symptoms, other mortality, maltreatment, examination not carried out);

Dislocation/contusions/injury involving c-spine or trunk;

Relatively uncommon conditions (e.g. diagnoses with <1000 presentations as the state total);

Diagnoses involved major trauma; Intensive care or cardiac monitoring; Most lung disorders or SOB except for

URTI; Any mental health type presentation; Poisonings; Burns that would necessitate

treatment/referral at burns centre (e.g. hands/genitalia/face);

Diagnoses which appeared as otherwise complex;

Bleeding disorders.

10. NSW Health, Assessment of Establishment of Care Centres in NSW, 2009 (prepared by Health Service Performance Improvement Branch)

11. NSW Health – Assessment of Establishment of Urgent Care Centre in NSW, December 2009



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Three alternate models were examined to see whether specific hospitals had a sufficient volume of patients to support the establishment of a UCC.

ED Conversion - converting an existing ED which sees low volumes of patients into a UCC. Sites considered suitable for this model had less than 9,500 patients per year suitable for an UCC;

co-located UCC based on 10,000+ UCC type presentations per year; or

co-located UCC based on 15,000+ UCC type presentations per year.

Following identification of facilities that had the requisite volume of UCC type patients, expressions of interest (EOI) were called from Area Health Services to pilot the model. Five sites were subsequently selected for piloting a co-located UCC Service Delivery Model, including:

Westmead Hospital;

Westmead Children’s Hospital;

Sydney Children’s Hospital;

Campbelltown Hospital; and

Wyong Hospital.

3.4 UCC Service Delivery Model development

A Service Delivery Model was developed by NSW Health to guide UCC development and implementation by pilot sites. Key features of the Service Delivery Model included a range issues for consideration by health services, including:

the profile of patients who may benefit from UCC services;

the patient journey anticipated to result from the Service Delivery Model;

the hours of operation, physical location, design and layout of UCC centres; and

staffing requirements.

For specific details regarding Service Delivery Model recommendations the reader is referred to the Urgent Care Centre Pilot Service Delivery Model document (March, 2011, NSW Health). An overview of key Service Delivery Model characteristics is provided in the following sections.

3.4.1 PATIENT PROFILE

Eligible patients were determined to comprise those “currently being seen in NSW EDs with minor injury and illness or in Fast Track Zones” (p.19, Urgent Care Centre Pilot Service Delivery Model document). Common presentations were anticipated to include patients requiring assessment and management of:

Abrasions and minor lacerations;

Acute otitis media, tonsillitis, pharyngitis, sinusitis;

Bites;

Cystitis, pyelonephritis and renal colic;

Foreign bodies in the ear or nose;

Minor eye injuries;

Musculoskeletal problems;

Strains and sprains;

Acute back or neck pain;



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Asthma;

Cellulitis and infections;

Dermatological issues

Minor or moderate headaches;

Minor fractures and dislocations;

Respiratory tract infections; or

Mild gastrointestinal illness

3.4.2 PATIENT FLOW

A relatively common patient journey was anticipated across each UCC. Patients would present to a central point of triage and registration where a decision to stream ongoing management to the UCC would occur. Selected patients would be referred to a designated UCC waiting area, either within the ED or in a co-located space, to await initial assessment by a treating clinician. Initial assessment would confirm their suitability for ongoing management within the UCC environment (with protocols in place for transfer back to the ED at any stage if clinically appropriate). Patients assessed in the UCC would require a relatively limited range of diagnostic tests and investigations, available on-hand to promote rapid diagnosis. Clinical equipment and skills would also be available within the UCC to complete patient treatment, organise discharge (transfer to the ED, or admission to hospital), and arrange any follow-up services required.

3.4.3 HOURS OF OPERATION

Guidelines noted that most UCCs operating internationally were open 14-16 hours per day, 7 days per week, with a focus on after-hours availability. Specific operating hours were left to the discretion of individual hospitals, in accordance with the volume of suitable patients presenting for treatment to the ED.

3.4.4 PHYSICAL LOCATION AND DESIGN

The individual design and layout of UCCs was also left to participating health services. A number of general considerations were specified in the guidelines including:

the design of entry, patient registration, and waiting areas;

the availability of age-appropriate, private, and sufficiently equipped consulting rooms and treatment areas;

access to adult and paediatric resuscitation equipment; and

a range of appropriate amenities to support clinical service delivery.

3.4.5 STAFFING REQUIREMENTS AND ROLES

It was recognised that an appropriate staff skill mix is essential to UCCs to meet patient demand and deliver a safe and quality service. Ideally, guidelines recommend a mix of senior medical and nursing staff as the UCC environment requires the capacity to assess, treat and discharge patients within a limited time period and requiring minimal supervision and advice. In this context, the preferable skills for UCC staffing (including Senior Registrars



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with ED experience, senior nurses, ED Nurse Practitioners and CMOs with recent ED experience) were recommended to include:

assessment, diagnosis and treatment of minor injury and illness;

adult and paediatric resuscitation and stabilisation;

pharmaceutical prescribing;

radiology and pathology ordering and interpretation;

suturing and wound care;

venepuncture and cannulation; and

application of plasters and back-slabs.

In addition, guidelines also include recommendations in relation to the appointment of a UCC manager and employment of an appropriate range of qualified clerical and other support staff. Specific staffing allocations were to be determined by individual pilot sites in accordance with their current staffing complement, patient profile and designated UCC operating hours.

3.5 Alternative approaches to managing UCC-type patients

Early development of the UCC Service Delivery Model recognised that a dedicated co-located area for treatment of non-complex, low acuity patients may not be suitable for every ED in NSW. Similarities to existing models of care allocating ED resources to different streams of patient presentation were also acknowledged, including:

Fast Track Areas, which are dedicated to treat ambulant, non-complex (single system problem) patients who can be discharged in < 2 hours. Patients are triaged into Fast Track using pre-determined inclusion/exclusion criteria.

Early Treatment Zones and Senior Clinical Streaming, which rely upon initial patient assessment by the most senior (medical or nursing) staff in order to refer patients to the most appropriate area of the ED for more comprehensive diagnostic work-up and intervention based upon probable diagnosis, the risk of clinical complications, and most efficient use of available ED resources.

The 2:1:1 Service Delivery Model, which divides the 4-hour emergency access target for admitted patients into 3 manageable time-frames (2 hours for assessment, 1 hour for specialist consultation, and 1 hour for transfer to an appropriate ongoing treatment environment):

A range of other initiatives have been trialled in NSW and other jurisdictions to address the needs of ED patients, including those presenting with non-complex, low acuity conditions, such as:

Out of hospital care including diversion of non-serious calls to emergency services to nurse advisory lines (e.g., Connecting Care and Healthdirect Australia); increasing the ability of ambulance crews to treat people at the scene rather than transporting them to hospital; and the use of alternative destinations to EDs;



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Primary care including GPs working in EDs; co-located primary care clinics; other interventions to promote better use of primary care settings; walk-in centres and minor injury units; and initiatives such as NHS Direct in the UK, which provides both a national call service and a range of digital health services to support patients;

ED process redesign, including different approaches to patient registration, triage and initial assessment; triage out to alternative services; the introduction of co-payments; a range of approaches to streamline services according to different clinical needs of patients (including short-stay and medical assessment units); ‘frequent flyer’ programs to monitor and address underlying reasons for re-presenting patients; social care in the ED; and different approaches to waitlist management, including early patient information and strategies to allow self-monitoring of waiting times;

Patient education such as encouragement to telephone for advice prior to going to an ED; as well as better self-management of chronic conditions including asthma and diabetes;

Diagnostic service redesign involving the introduction of point of care laboratory testing for certain conditions; and selected referrals for imaging being initiated (or conducted) by a range of non-medical staff (e.g. ultrasound);

Admission avoidance programs for specific chronic diseases such as congestive heart failure (CHF), diabetes, and Chronic Obstructive Pulmonary Disease (COPD) to promote early identification and management of clinical deterioration; and Hospital in the Home to reduce hospital admissions (through the ED) and encourage ongoing management in the community;

Inpatient bed management strategies including discharge lounges, nurse-led discharge and improvements to discharge planning to reduce access block or lack of an inpatient bed to which a patient can be admitted from the ED; and

Workforce redesign such as increasing the seniority of staff at “the front end” of ED patient assessment processes; and the introduction of nurse practitioners, specialist nurses, emergency care practitioners and allied health staff in EDs.

3.6 The perceptions of pilot UCCs by key stakeholders

Staff at all pilot sites involved in the UCC implementation were positive about the impact of the Service Delivery Model upon staff satisfaction, patient flow and clinical outcomes achieved for non-complex, low-acuity patients at their health service. Other stakeholders reported a range of views were about the potential appropriateness of UCCs for public hospital EDs in NSW.

Some stakeholders considered the piloting of a UCC Service Delivery Model represented an extension of existing models of service streaming offered across EDs, and have the potential to waste valuable resources that might otherwise have been distributed across the service system to employ more staff.

“It’s just Fast Track on steroids”

“Why couldn’t the money have been given to EDs to support existing models of service delivery?”



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“We need more funding (for the ED)”

“We need more staff in the ED”

“Close the UCC and make more use of (existing ED streaming arrangements)”

Others believed that local ED models of care would be more appropriately developed according to the identified need of individual hospitals.

“We know what we need. We don't need anyone telling us how to run our ED.”

“…The money would have been far better spent on providing the (existing Service Delivery Model arrangements) with adequate staffing and facilities.”

Some considered the types of patients presenting to the UCC to be a waste of hospital resources.

“Patients need to go to their GP, not the Emergency Department.”

“Go to their doctor – and charge for the service”

“Encourage further education for patients to see their LMO.”

A few stakeholders were unaware or unclear about the value of any UCC operating at their health service. These individuals were working as clinicians in the pilot site EDs with little or no knowledge about the UCC Service Delivery Model.

“I have no awareness of the UCC.”

“There is nothing called an ‘Urgent Care Centre’ at [this hospital]. I think you are referring to the “Fast Track” area…If ‘Urgent Care Centre’ means ‘Fast Track’, then the assumption that the Urgent Care Centre is somehow a different place

to the ‘Emergency Department’ is nonsensical.”

“It has helped manage the less urgent ED presentations with less wait, but the overall outcome is unclear other than a shorter wait.”

“The premise of UCC works well – but will more than likely improve when it is separate to (existing ED models of care).”

Others were more optimistic about the Service Delivery Model and the benefits achieved for staff, patients and their local health service.

“The UCC has allowed non-urgent patients, whom would otherwise wait long periods of time to be seen, have a medical review and treatment initiated

quickly. It shortens their length of stay in our department and has a positive impact of the view of (carers) and patients upon our department.”

“I think it works well. The patients who don't have complex issues and for example lacerations are seen and sent home quicker.”



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Thus in the absence of knowledge about overseas experience or definitive evidence about the effectiveness of local UCC Service Delivery Model arrangements, a variety of perceptions are held by different stakeholders involved in implementation of the pilot.



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4 The efficiency of pilot UCC operations

All pilot sites commenced the three year UCC implementation between December 2010 and February 2011. It is estimated that around $16.5 million of government funding has been allocated to the pilot program, comprising $1 million annual funding to each site for operational expenses as part of the UCC pilot, in addition to site-specific funding allocations to modify ED infrastructure or build co-located facilities UCCs priority funded through the Local Health Districts.

Timelines for modifications to ED infrastructure varied across participating hospitals. Two of the pilot sites were unable to modify existing facilities until the final year of pilot implementation. One site will commence building of a co-located UCC following the three year pilot period. Delays in capital redevelopment were attributed to a range of factors including the availability of sufficient funds to complete renovations or redevelopments, the need to relocate other services prior to UCC clinic construction, or the need to accommodate broader planning for ED redevelopment.

Other factors reported to influence the success of UCCs operations included; the availability of dedicated funding to implement the Service Delivery Model, the capacity to designate waiting areas and treatment rooms, the availability of staff with sufficient skills and experience, and the timely availability of diagnostic tests and the time waiting for clinical consultations from inpatient specialists. Suggestions to improve future service delivery included; improved access to GP services, the availability of additional staff to handle rises in UCC demand, clarification or expansion of the UCC scope of practice, and increasing current UCC operating hours.

4.1 Key processes involved in establishing the UCC pilots

A NSW Health Implementation Toolkit recommended a four-phased process for introducing a UCC pilot (Appendix 3). Key processes reported by the five sites implementing a collocated UCC model (Model 1) were consistent with these phases and included key activities focusing upon:

identifying the case for change and making a business case to demonstrate the need for UCC services;

identifying the Service Delivery Model that best suited the local environment, e.g. co-located within ED, and how the streaming process will work in the local ED environment;

developing protocols relating to the scope of services to be provided to UCC patients (inclusion and exclusion criteria);

establishing clinical pathways for use by UCC staff – for example, the nature of standing orders used by the ED for Advanced Clinical Nurses which outline approved radiology and pathology ordering and nurse initiated pharmacology based on the nurse’s level of skill and credentialing;



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recruitment of staff with sufficient seniority, clinical experience and autonomy to work in the UCC from existing ED staff and/or external sources; and

education and training of staff associated with the UCC and communication with all staff involved in ED and UCC functions.

It is anticipated that additional activities would be required by facilities deciding to convert their ED to a UCC (Model 2), as outlined in the case study below.

Wauchope

Wauchope Hospital is the only pilot site selected to convert their exiting ED into an Urgent Care

Centre (UCC). In addition, Wauchope is the first UCC to be implemented in a regional setting.

The existing ED has three cubicles and a telehealth camera. The waiting area is the corridor

outside the treatment cubicles and there is no triage facility. The hospital itself has 26 beds.

Historically the ED has been run by GPs and a registered nurse with remote access to

consultants via telehealth. The ED has a small capacity for pathology and has access to plain x-

rays only.

The decision to convert the existing ED at Wauchope was triggered by three factors:

the existing facility was in poor condition and required significant capital investment;

a pattern of acute presentations requiring inter-hospital transfer for appropriate management; and

difficulties with GPs maintaining ED coverage, particularly after hours.

A formal review of ED utilisation indicated that maintaining a safe and effective ED at Wauchope was not sustainable.

Wauchope needed to provide an alternative and better model for the community, whilst being sensitive to the relationships with GPs and managing community expectations. The UCC conversion provided a suitable alternative that has been accepted by the community following an extensive period of public awareness raising, community consultation, education and key stakeholder management.

The conversion to a UCC model will enable emergency care to be provided at Port Macquarie –15 minutes away - whilst Wauchope retains capacity to deliver urgent care to the community. The new arrangement will mean that ambulances will not to present to Wauchope for acute cases. However, ambulances will be available to transfer “walk-ins” requiring more acute emergency management.

The Wauchope redevelopment will include $2.4M for new palliative care beds, funding for improvements to radiology ($220K), a new kitchen ($200K) and $560K for a UCC. The UCC will include an acute bay, two sub-acute bays, a waiting room, patient toilets and a reception area.



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4.2 Time taken to implement the UCC Service Delivery Model

Each of the pilot sites commenced UCC operation between December 2010 and February 2011. Initial Service Delivery Model implementation focused upon protocol-based identification, streaming, assessment and treatment of patients within the existing infrastructure of hospital EDs. Existing ED treatment areas were re-configured to create designated UCC treatment and waiting areas at two sites (Sydney Children’s Hospital and Campbelltown Hospital). Two of the remaining pilot sites (Children’s Hospital at Westmead, and Westmead Hospital) completed construction of dedicated UCC treatment and waiting areas in mid to late 2013 – more than two years after initial Service Delivery Model implementation. One hospital (Wyong) is yet to build a dedicated physical infrastructure to support UCC service delivery. Where physical infrastructure was unable to be implemented to support the UCC, existing ED resources were managed to segregate patient waiting areas and treatment spaces for non-complex, low acuity presentations.

Key timelines for Service Delivery Model implementation and the development of physical infrastructure at each pilot site are presented in Table 4-1.

Table 4-1: Commencement of UCC/KCC model and infrastructure

PILOT SITE COMMENCEMENT OF SERVICE

DELIVERY MODEL

INFRASTRUCTURE

Campbelltown Hospital Converted Fast-Track to UCC in December 2010

Co-located within ED – renovated existing space

Children’s Hospital Westmead February 2011 Completed September 2013

Sydney Children’s Hospital February 2011 Co-located with ED with dedicated space. Currently being reconsidered in context of ED redevelopment.

Westmead Hospital UCC Model replaced Fast Track November 2010

Completed April 2013

Wyong Hospital December 2010 located within House Doctor area

Under construction

Major reasons for delays in infrastructure development at individual pilot sites were reported to include:

insufficient funding from NSW Health (through the UCC pilot program) to support stand-alone infrastructure development, without the need for additional financing from other sources (e.g., Wyong Hospital);

“The UCC started in 2010 but there was no physical space for it so we located it in the House Doctor space, which meant it was crowded and co-mingled. We

have had to wait for specific additional funding to completely rebuild the hospital ED and UCC area to provide the space for a UCC as it was intended, with



39

separate waiting areas and treatment areas. Hopefully, we will have it in the first half of 2014.” [UCC]

delays associated with broader ED infrastructure planning and re-development, to accommodate multiple changes in physical layout of a range of different services areas, including but not limited to UCC treatment spaces (e.g., Westmead Hospital);

“(We only got the) separate UCC in April 2013. The delay in getting the UCC was physical limitations. We needed to find additional funds to make all the necessary changes to the ED to set up the UCC as a separate area.” [UCC]

delays associated with re-housing of other clinical and administrative services situated adjacent to the ED, prior to the availability of suitable space for UCC construction (e.g., Children’s Hospital at Westmead).

“(The) funding received related to dollars for a project officer and $700K for infrastructure but (we) needed to consolidate other sources of funding to cater

for the flow -on impacts of UCC development on other parts of the hospital such as relocating the admin area” [KCC].

Efficiencies in UCC implementation were reported by the two children’s hospitals. Operating as network, each hospital implemented the Service Delivery Model under a common governance arrangement. Other efficiencies associated with UCC implementation were unable to be identified from the available data.

4.3 Significant factors influencing UCC operations

Consultations with staff involved in pilot site implementation identified five key factors influencing the successful operation of UCCs, relating to:

the provision of additional funding to support Service Delivery Model operations;

designated waiting areas and treatment spaces;

dedicated staff with sufficient knowledge and skills to manage an autonomous caseload;

timely access to diagnostic services (x-ray/pathology services); and

timely access to specialist consultations where required.

4.3.1 DEDICATED FUNDING TO SUPPORT SERVICE OPERATIONS

Limited information was available to ascertain the funding allocations to each hospital participating in the pilot. Sites were reportedly provided with $1,000,000 per annum for three years to develop and implement a pilot UCC. Capital funding was also reported to be made available, as priority capital work funding, according to the infrastructure redevelopment needs of individual hospitals. Estimates of funding allocations to each of the pilot sites are presented in Table 4-2 below. Thus it is estimated that around $16.46 million dollars has



40

been allocated to the UCC pilot program. It is noted that there is proposed capital works at Wyong Hospital which is anticipated to be in the order of $1.5 million12.

Table 4-2: Capital and recurrent allocation by NSW Health

HOSPITAL CAPITAL ALLOCATION

FROM NSW HEALTH

RECURRENT FUNDING FOR

PILOT ($1M PER ANNUM) TO

DECEMBER 2013

TOTAL $ FOR PILOT

PER SITE

Campbelltown Hospital

$210,000 $3.0M $3.21M

Children’s Hospital Westmead

$350,000 $3.0M $3.35M

Sydney Children’s Hospital

$300,000 $3.0M $3.3M

Westmead Hospital $600,000 $3.0M $3.6M

Wyong Hospital $3.0M $3.0M

TOTAL $1.46M $15M $16.46M

The provision of specific funding to undertake capital re-development as part of participation in the UCC pilot and support Service Delivery Model development was reported to be a significant incentive for hospitals to participate in the UCC pilot.

“The Service Delivery Model was a good fit for what was being proposed, as the UCC pilot and the dollars involved proved attractive to progress the Service

Delivery Model which the Network was trying to improve. UCC funding has helped created dedicated space and dedicated additional staff for the ED/UCC

pool.” [UCC]

“The decision to adopt the UCC model was prompted by funding on offer and is recognition of the need to segregate two types of patients, “horizontal patient versus the walk-ins”. Until there was the offer of funds under UCC pilot we

never had the resources or space to do so.” [UCC]

Other clinicians working at the pilot hospitals were generally unaware of the nature or importance of UCC funding for ongoing Service Delivery Model operations (Figure 4-1).

12 Based on funding advice provided to each pilot site.



41

Figure 4-1: Dedicated funding to support day-to-day operations of UCC (n=169)

The extent to which specific funding has been used to cross-subsidise other ED services at individual hospitals could not be reliably ascertained from the available information. Similarly, the future sustainability of UCC operation without ongoing recurrent funding was unable to be determined from information made available to the evaluation consultants.

4.3.2 DEDICATED SPACE FOR UCC PATIENTS

Historical approaches to the management of non-emergency patients within the ED were reported to create two key problems for staff:

misperceptions of unfair prioritisation for treatment amongst patients in the ED waiting area; and/or

the use of dedicated low-acuity treatment areas for management of more acute patients.

Given the longer waiting times experienced by less acute patients, misunderstandings arise when patients arriving at a later time are streamed into care ahead of those who are already waiting. Where UCCs have operated without dedicated waiting areas, these problems have continued to place additional burden on front of house staff.

“(The) biggest problem with Fast Track was the shared waiting area for ED. Pulling patients out for Fast Track was seen as cherry-picking people and

created enormous tension.” [UCC]

“Whilst the UCC is in the ED it is causing problems for triage staff as UCC patients who have recently arrived are getting called before patients who have been waiting for ages. Patients do not make the distinction between ED and

UCC and get upset and complain.” [UCC]

Other sites have implemented a range of different strategies to manage patient expectations about timely access to treatment, and reported these approaches to have a positive influence upon the ‘waiting room climate’, including (but not limited to):

designated chairs or partitioning within the existing waiting area space;

early information to patients about their priority for treatment and estimated waiting time;



42

ticketing systems that allow patients or their carers to monitor their place in the queue for treatment; and

electronic pagers that allow patients to leave the waiting area and return for treatment when services become available.

“….(The) patient can be given a pager while waiting to be seen by a doctor so they can have a walkabout if desired, and this way can also be paged back

when the doctor is ready to see them.” [Non UCC]

Notwithstanding, the capacity (infrastructure permitting) for a separate, dedicated UCC waiting area was considered to be a significant advantage of the Service Delivery Model.

“We now have 2 waiting rooms, different Service Delivery Models for ED and UCC patients, shared reception and triage and patients are directed to either ED or UCC waiting area which has made a big difference to our clerical staff

who wear the brunt of patient frustrations.” [UCC]

“Keys to UCC success as perceived by [hospital] include dedicated space and staff, designated waiting area and sound streaming of patients” [UCC]

A segregated treatment area associated with the UCC Service Delivery Model has also been important. Separate and dedicated space has reduced the tendency to use low-acuity treatment areas for ‘overflow’ management of more acutely unwell patients – particularly at times of peak demand.

“Having UCC in another area has its benefits and disadvantages, in that it has a separate area means there is less hindrance from ED but there is also support from other staff and resources in ED that is very easily available being in ED.”

[UCC]

“Prior to physical redevelopment UCC was used as overflow for ED patients but since dedicated space for UCC cases only and it works better.” [UCC]

“It is difficult to maintain the UCC treatment stream separate from that for House Doctor patients. … (The UCC) is presently under construction adjacent to ED.

This unit will have its own waiting, reception and treatment areas. When commissioned in mid-2013 it is expected that UCC activity will increase and this

treatment stream will be successfully and appropriately separated from more acute treatment streams.” [UCC]

“Neither of the Children’s hospitals use UCC as spill over for ED - CHW initially shared area with ED but redevelopment has provided separate area which is

now dedicated KCC.” [KCC]

4.3.3 DEDICATED STAFFING TO TREAT UCC PATIENTS

One of the most critical success factors for UCCs was consistently reported to be the availability of dedicated staff with sufficient experience and seniority that allows them to work autonomously.



43

“The success of the UCC is related to dedicated staff, dedicated location and increased skill set of the workforce. Extra funding has allowed rostering of more

senior staff.” [UCC]

“Dedicated staff and space are key components to success of the UCC.” [UCC]

The availability of separate treatment areas for UCC staff was also reported to reduce the incidence of clinical reallocation to more acutely unwell patients within the ED.

“Ability to dedicate staff and areas has been crucial. Previously with no additional staff, Fast Track worked only if there was spare capacity, which

wasn't that frequent. Dedicated staff works much better.” [UCC]

“For the UCC to work efficiently it must have a full complement of staff, particularly nursing staff who have the necessary skills required to work in UCC. This does not always happen as nursing staff are deployed from UCC to work in

the other areas of the Emergency Department.” [Non UCC]

4.3.4 TIMELY ACCESS TO DIAGNOSTIC SERVICES

There was consensus amongst all clinical stakeholders that the overall efficiency and effectiveness of UCC care was directly related to timely access to diagnostic services. Accordingly, local models of care tended to stream patients requiring basic diagnostic services (e.g., ultrasound, plain film X-ray). Clinicians indicated that the majority of plain film X-rays were obtained within 60 minutes of the initial request regardless of the time of day (Figure 4-2). Pathology results by their nature were observed to take a longer period of time.



44

Figure 4-2: Usual time for diagnostic services (n=169)

Requests for medication that was not readily available in the ED or UCC were also reported to take in excess of 60 minutes to obtain (Figure 4-3).



45

Figure 4-3: Time to receive medication orders (n=169)

4.3.5 TIMELY ACCESS TO SPECIALIST CONSULTATIONS

Timely access to specialist consultation, when required, was reported to remain one of the most significant impacts upon patient management in both the ED and the UCC. Feedback received during site visits and from clinical staff via survey indicated that the time to receive a consultation from an ED registrar or consultant did not impede the flow of patients through the UCC (Figure 4-4).

Figure 4-4: Time for ED registrar/consultant review (n=169)



46

Figure 4-5: Time to obtain specialist consultation/review (n=169)

"' ... c Cll

"CC c 0 Q.

"' Cll ... .... 0 ... c Cll u ... Cll Cl.

"' .. c Cll

"CC c 0 Q.

"' Cll ... .... 0 .. c Cll u ... Cll Cl.

"' .. c Cll

"CC c 0 Q.

"' Cll ... .... 0 .. c Cll u ... Cll Cl.

~ aspex consulting

~

60%

50%

40%

30%

20%

10%

0%

70%

60%

50%

40%

30%

20%

10%

0%

80%

70%

60%

50%

40%

30%

20%

10%

0%

• Business hours • After hours 54%56%

0% 0%

< 5 mins < 15 mins < 30mins < 60 mins > 60 mins Don't know Missing

Time to obtain a review from another hospital unit registrar/consultant following request

0% 0%

< 5 mins

1% 0%

• Business hours • After hours

63%63%

< 15 mins < 30 mins < 60 mins > 60 mins Don't know

Time to obtain a review from a surgical registrar/consultantfollowing request

• Business hours • After hours

68%

0%

< 5mins < 15 mins < 30mins < 60 mins > 60 mins Don't know

Time to obtain a review from psychiatry registrar/consultant following request

Missing

Missing



47

By contrast, significant delays in obtaining a specialist consultation from other areas of the hospital were considered to be an ongoing source of frustration.

“The biggest hold up for both ED and UCC services is getting setting up a specialist consult – getting an X-ray takes approximately 60 minutes and bloods can be done between 30-60 minutes, but an opinion call to specialist is longest

wait.” [UCC]

“Waiting for specialists is still an issue and is a source of delay.” [UCC]

“The UCC has improved ED and waiting times, time to treat is better but waiting time for specialist consults is still problematic.” [UCC]

“This is sometimes made worse during long waiting periods for speciality registrar review or ward beds/ Operating Theatre (OT) transfer.” [Non UCC]

The majority of requests for inpatient specialist review was reported to take more than 60 minutes, regardless of the type of specialist involved (Figure 4-5).

4.4 Suggested improvements to enhance UCC operations

A number of specific suggestions to improve the efficiency of UCC operations were provided by clinical staff at the pilot hospitals. Suggested areas for further development of UCCs mainly related to:

improved access to GP services, to minimise the likelihood of low complexity, low-acuity presentations to the ED;

“Have a GP-type service attached to or as a part of the ED/ Hospital.” [KCC]

“Need greater access to primary health facilities in GP clinics.” [Non UCC]

further clarification, if not broadening, of the criteria for UCC referral;

“Improving the criteria for categorizing patients as UCC.” [Non UCC]

“Clear pathways for care to make the processes smoother and more efficient.” [Non UCC]

“They need to increase their scope of practice from just fractures, foreign bodies and lacerations. If they have a greater scope of practice than this, then we need to be referring these patients to KCC as well (i.e. gastro).” [Non UCC]

“Yes, broader inclusion of illnesses and injuries.” [Non UCC]

increases in the level of staffing to accommodate peak periods of demand in the ED;

“Increase staff numbers at busy times.” [KCC]

“More staff available in busy times.” [Non UCC]



48

“More nurse practitioners would help, especially on busy evenings.” [KCC]

“Some extra medical cover when very busy or when new MOs or those inexperienced in these presentations are covering KCC.” [Non UCC]

“Physiotherapy services on the weekend during sports season have been found to be helpful in the management of sporting injuries that do not require

specialist review.” [Non UCC]

increased availability of UCC services throughout the day; and

“Extend hours of operation. Increase staff numbers at busy times.” [KCC]

“I feel that the service is under-utilised, that it could operate for longer hours e.g. 1000 to 2400; therefore taking the pressure of ED and facilitating better NEAT

times for non-urgent, non-complex cases.” [KCC]

“Longer hours e.g. 12.00 to 24.00 as paediatric non-urgent, non-complex patients present in the evening. If workload too great, centre closes 22.30,

these patients revert to general waiting list.” [KCC]

“It should be opened for longer hours; it is currently run from 1200-2200. But usually there are a lot of non-urgent patients that could be seen through the centres and after 2200 there remain a lot of patients that have to be seen

through emergency. So suggest the centre run from 1000-2400.” [Non UCC]

“Opening the UCC [should be] for 24hrs.” [Non UCC]

“The time of starting the urgent care is 12pm but would like to see it extended to midnight. [It] would benefit more people and the waiting list.” [Non UCC]

introduction of outpatient clinics.

“An outpatient clinic categorized by department to be attended by teams will be a good option to be available in the hospital not in Emergency Department.”

[Non UCC]

“Encourage further education for patients to see LMO and use specialist doctors as outpatients instead of ED.” [Non UCC]



49

5 Effectiveness of the Service Delivery Model

Data received from the pilot sites relating to the ‘actual’ characteristics of KCC/UCC-type patients was used to create a profile of those attending for treatment through the pilot service delivery model. Profiling captured 77% of all KCC-type presentations and 81% of all UCC-type presentations. These profiles were subsequently applied to more than 7,800,000 presentations to pilot sites and their peer group hospitals between 2006/07 to 2012/13 in order to understand the nature of KCC/UCC-type presentations over the reporting period.

By 2012/13, KCC/UCC-type presentations accounted for approximately 23% of all triage 4-5 presentations to the specialist children’s hospitals, around 69% of the same group of presentations to tertiary referral hospitals, and around 70% of all triage 4-5 presentations to major metropolitan hospitals. Significant reductions in overall length of stay in the ED were observed for KCC/UCC-type patients treated by hospitals participating in the pilot. In the main, these differences were attributed to improved time to clinician assessment for patients streamed to the KCC/UCC model of service delivery.

Unfortunately, improvements in ED flow for KCC/UCC-type patients were not unique to the pilot hospitals sites (compared with their hospital peers), especially when the overall length of stay for all triage category 4 and 5 patients were considered. Staff were accepting and generally satisfied with the pilot model of service delivery and perceived the model to have a positive impact upon patient outcomes and satisfaction.

Analysis of available clinical outcome data revealed that, whilst changes in the proportion of UCC-type patients discharged home (vs admitted to hospital) were observed at some of the pilot hospital sites, these gains were not consistent across similarly grouped pilot hospitals, nor significantly better than other peer hospitals who did not participate in the pilot model of service delivery.

The proportion of patients referred to their GP following treatment at the pilot hospital sites varied significantly from 0% to around 95%. Changes in clinical outcomes relating to GP referral, after implementation of UCCs, also varied in a similar manner to those observed for other peer group hospitals who did not participate in the pilot service delivery model.

Examination of patient re-presentations for treatment within 48 hours of discharge from the KCC/UCC revealed that: There was no significant difference in the proportion of patients re-presenting to the pilot sites within two years of UCC implementation; of those who did re-present, there were no differences in overall ED length of stay or clinical outcomes, with the exception of community referrals to GPs which increased for two sites (Westmead Hospital and Wyong Hospital); and that in general, pilot site performance was not significantly better or worse than other peer group hospitals



50

Finally, overall comparisons of the average price for UCC-type patients revealed that they were generally comparable to the revenue generated for all triage category 4 and 5 patients treated by the same sites, and mirrored the pattern of overall differences in revenue generated for all triage category 4 and 5 patients between pilot sites and their peer group hospitals.

5.1 Types of patients receiving UCC services

Hospital systems data reported by each of the UCC pilot sites was analysed to identify the profile of a typical ‘UCC-type’ patient. Key patient characteristics and profiles were identified separately for:

Kids Care Centre (KCC) presentations to specialist children’s hospitals; and

Urgent Care Centre (UCC) presentations to other health services.

5.1.1 CHARACTERISTICS OF PATIENT PRESENTATIONS

Key characteristics of KCC presentations to the two children’s hospital pilot sites were similar, and are presented in Table 5-1.

Table 5-1: Key characteristics of KCC presentations

KCC PATIENT CHARACTERISTICS CHILDREN’S HOSPITAL WESTMEAD

SYDNEY CHILDREN’S HOSPITAL

Reported date of KCC commencement Feb 2011 Feb 2011

KCC data reported (months of reported data)

1 Jul 12 - 31 May 13 (11 months)

1 Jul 11 - 31 May 13 (23 months)

Number of cases reported 7,275 13,101

Hours of presentation 0900-2200 hrs (business) 2201-0859 hrs (after hours)

100% 99% 1%

100% 99% 1%

Sex Male Female

100% 58% 42%

100% 58% 42%

Age 0-15 years 16-60 years 61 years and older

100% 100% 0% 0%

100% 100% 0% 0%

Triage category Emergency (2) Urgent (3) Semi-urgent (4) Non-urgent (5)

100% 0% 5% 93% 2%

100% 0% 1% 91% 8%

Admission status Did not wait/left at own risk Non-admitted Admitted to ED Admitted to hospital

100% 6% 89% 0% 5%

99% 2% 91% 4% 2%



51

KCC PATIENT CHARACTERISTICS CHILDREN’S HOSPITAL WESTMEAD

SYDNEY CHILDREN’S HOSPITAL

Major diagnostic category (ICD10-AM) Injury, poisoning Other factors influencing health Other symptoms and signs Skin and subcutaneous tissue Musculoskeletal and connective Infectious or parasitic Eye and adnexa Ear and mastoid Digestive system Respiratory system

99%

80% 6% 4% 3% 2% 1% 1% 1% 1% 1%

99%

80% 1% 2% 2% 6% 1% 1% 2% 1% 1%

The majority of KCC patients were under the age of 16 years, presented between the hours of 0900 and 2200hrs for the management of injuries,

were classified as triage category 4 or 5 upon arrival, and were not admitted following treatment in the KCC.

Characteristics of UCC presentations to the remaining pilot sites are presented in Table 5-2. In general, patient characteristics were similar across the three UCC pilot sites.

The majority of UCC patients were between 16 and 60 years of age, also presented between the hours of 0900 and 2200hrs for the management of injuries, non-specific symptoms and signs, or musculoskeletal problems, were also classified as triage category 4 or 5 upon arrival, and were not

admitted following treatment in the UCC.

Table 5-2: Key characteristics of UCC presentations

UCC PATIENT CHARACTERISTICS WESTMEAD HOSPITAL

CAMPBELLTOWN HOSPITAL

WYONG HOSPITAL

Reported date of UCC commencement Nov 2010 Dec 2010 Dec 2010

UCC data reported (months of reported data)

1 Jul 11 - 12 Feb 12 (9 months)

1 Jul 11 - 31 May 13 (23 months)

1 Jul 11 - 31 May 13 (23 months)

Number of cases reported 16,345 22,259 13,141

Hours of presentation 0900-2200 hrs (business) 2201-0859 hrs (after hours)

100% 77% 23%

100% 89% 11%

100% 94% 6%

Sex Male Female

100% 49% 51%

100% 56% 44%

100% 53% 47%

Age 0-15 years 16-60 years 61 years and older

100% 1% 89% 10%

100% 29% 60% 11%

100% 8% 74% 18%

Triage category Emergency (2)

99% 2%

100% 1%

98% 1%



52

UCC PATIENT CHARACTERISTICS WESTMEAD HOSPITAL

CAMPBELLTOWN HOSPITAL

WYONG HOSPITAL

Urgent (3) Semi-urgent (4) Non-urgent (5)

16% 49% 32%

13% 51% 35%

5% 41% 54%

Admission status Did not wait/left at own risk Non-admitted Admitted to ED Admitted to hospital

98% 20% 58% 8% 14%

98% 3% 87% 1% 8%

98% 3% 90% 0% 7%

Major diagnostic category (ICD10-AM)

Injury, poisoning Other symptoms and signs Musculoskeletal and connective Genitourinary system Digestive system Respiratory system Eye and adnexa Skin and subcutaneous tissue Infectious or parasitic Pregnancy/childbirth/ puerperium Circulatory system Other factors influencing health Ear and mastoid Mental and behavioural Nervous system

99%

24% 20% 11% 10% 7% 5% 5% 5% 4% 2% 2% 2% 1% 1% 1%

99% 59% 5% 11% 1% 2% 2% 2% 6% 2% 2% 1% 4% 1% 1% 0%

98% 45% 9% 8% 3% 5% 6% 2% 9% 3% 1% 2% 2% 2% 1% 1%

Some differences were observed between the three hospitals, most notably:

a higher proportion of patients presented between 2201 and 0859 hours, and were admitted to hospital following treatment in the UCC at Westmead Hospital; and

a higher proportion of younger patients (under the age of 16 years) presented for treatment at Campbelltown hospital.

5.1.2 THE PROFILE OF KCC AND UCC-TYPE PATIENTS

Examination of the general characteristics of presentations to the pilot sites revealed a different profile of patients streamed for treatment to the KCC and UCC, necessitating separate ongoing analysis of the different patient cohorts. Additional analysis was then undertaken to identify specific patient characteristics associated with streaming to the KCC/UCC (as opposed to the ED) for assessment and management at each of the pilot sites.

Data from each of the five pilot sites were extracted and examined in two groups (pooled KCC and UCC presentations) to identify:

the date of commencement (or first date of KCC/UCC data reporting);

the hours of operation (taken as between 0900 and 2200 hours);

the estimated acuity for the majority of presentations (triage category 4 and 5); and



53

the typical age group of UCC presentations (<16 years for KCC, 16-60 years for UCC).

Diagnostic codes for each presentation were then examined to determine whether they were more likely to be streamed to the KCC/UCC or to the ED for assessment and management. Patients were classified as a ‘KCC/UCC-type’ if more than two in every three presentations with a specific diagnostic code were streamed to the KCC or UCC for ongoing care. Based upon this approach, it should be noted that the percentage of patients streamed to the KCC/UCC may represent an upper limit of all patients able to be identified in the general hospital data13.

Major diagnostic groups and conditions comprising KCC-type presentations are outlined in Table 5-3 Up to 77% of all paediatric triage category 4 and 5 presentations in the data sample were more likely to be streamed to the KCC rather than the ED. These presentations were grouped into major ICD10-AM diagnostic categories relating to:

Injury or poisoning (69%); involving:

burns (26%);

contusions (14%);

fractures (8%);

dislocations (5%); and

injuries to specific parts of the body (4%).

Other factors influencing health status (3%), such as:

attention to surgical dressings and sutures (1%); and

attention to other artificial openings of digestive tract (1%).

Musculoskeletal system and connective tissue disorders (3%), including:

joint pain (1%); and

limb pain (1%).

The derived diagnostic profile accounted for three in every four KCC presentations to the two paediatric pilot hospital sites (75%). Specific diagnostic codes associated with each group are presented in Appendix 5.

13 It is noted that the sampling periods available for some sites (e.g. Children’s Hospital Westmead, and Westmead

Hospital) are substantially shorter than other pilot site hospitals (e.g., around three quarters of one financial year). Exact sampling periods were selected to maximise the fidelity (sensitivity and specificity) of the obtained profiles. These profiles were subsequently applied to longer periods (e.g., a full financial year) in order to estimate the likely number (or percent) of UCC type presentations (under the conditions specified above).



54

Table 5-3: ICD10-AM grouped profile of KCC presentations

DIAGNOSTIC PROFILE OF PAEDIATRIC/KCC PATIENTS (AGE 0-15 YRS, TRIAGE CATEGORY 4-5)

PERCENT OF AVAILABLE SAMPLE (PAEDIATRIC

PATIENTS)

CUMULATIVE PERCENT

Injury or poisoning 68.71% 69%

Other factors influencing health status 2.82% 72%

Musculoskeletal system and connective tissue 2.79% 74%

Symptoms, signs and abnormal findings NOS 0.51% 75%

Eye and adnexa 0.51% 75%

Digestive system 0.49% 76%

Infectious and parasitic 0.39% 76%

Ear and mastoid process 0.37% 77%

External causes 0.28% 77%

Skin and subcutaneous tissue 0.26% 77%

Genitourinary system 0.13% 77%

Neoplastic disease 0.04% 77%

Endocrine, nutritional and metabolic 0.03% 77%

Mental and behavioural 0.02% 77%

Nervous system 0.02% 77%

Congenital 0.02% 77%

Circulatory system 0.01% 77%

Respiratory system 0.01% 77%

Grand Total 77.4%

Major diagnostic groups and conditions comprising UCC-type presentations are outlined in Table 5-4. Up to 81% of all adult triage categories 4 and 5 presentations in the sample were more likely to be streamed to the UCC rather than the ED. These presentations were grouped into major ICD10-AM diagnostic categories relating to:

injury or poisoning (38%); involving:

injuries to specific parts of the body (14%)

fractures (9%); and

open wounds (9%).

musculoskeletal system and connective tissue disorders (9%), including:

joint pain (3%);

limb pain (2%);

unspecified dorsalgia (1%); and

low back pain (1%).



55

skin and subcutaneous tissue disorders (7%), such as:

cellulitis (4%); and

cutaneous abscess (1%).

other previously unspecified symptoms, signs and abnormal findings (6%), such as:

unspecified abdominal pain (2%); and

chest pain (1%).

Table 5-4: ICD10-AM grouped profile of UCC presentations

DIAGNOSTIC PROFILE OF ADULT/UCC PATIENTS (AGE 16-60 YRS, TRIAGE CATEGORY 4-5)

PERCENT OF AVAILABLE SAMPLE (ADULT PATIENTS)

CUMULATIVE PERCENT

Injury or poisoning 38.1% 38%

Musculoskeletal system and connective tissue 9.4% 48%

Skin and subcutaneous tissue 6.7% 54%

Symptoms, signs and abnormal findings NOS 6.3% 61%

Digestive system 3.9% 64%

Genitourinary system 2.8% 67%

Respiratory system 2.6% 70%

Eye and adnexa 2.2% 72%

Other factors influencing health status 2.1% 74%

Infectious and parasitic 1.9% 76%

Pregnancy, childbirth and puerperium 1.6% 78%

Ear and mastoid process 1.5% 79%

Circulatory system 0.8% 80%

Mental and behavioural 0.5% 80%

External causes 0.3% 81%

Nervous system 0.2% 81%

Endocrine, nutritional and metabolic 0.1% 81%

Neoplastic disease 0.1% 81%

Blood and immune system 0.0% 81%

Grand Total 81.0%

The derived diagnostic profile accounted just under three in every four UCC presentations to the two remaining pilot hospital sites (71%). Specific diagnostic codes associated with each group are presented in Appendix 6.



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5.2 Demand for emergency and urgent care type services

The total number of ED presentations to specialist children’s (Figure 5-1), other tertiary referral and major metropolitan hospitals across NSW (Figure 5-2) has increased significantly over the past 6 years.

Figure 5-1: Overall trends in number of ED presentations for specialist children’s (A2) hospitals (2006/07-2012/13)

Peer group comparison of the two children’s hospitals reveals a higher overall level of emergency demand at Westmead (Evaluation Site 1), compared with Sydney Children’s Hospital (Evaluation Site 2). Examination of tertiary referral hospitals across NSW reveals that Westmead Hospital (Evaluation Site 3) has experienced moderate levels of emergency department demand compared with other similarly grouped hospitals. By contrast, Campbelltown (Evaluation Site 4) and Wyong (Evaluation Site 5) have experienced significantly higher levels of emergency demand compared with other major metropolitan hospitals over the seven year comparison period.

Given that the majority of KCC/UCC patients were identified within triage category 4 and 5 presentations, an analysis of demand by triage category grouping was also conducted and is presented in Appendix 7. Around 50% of all presentations to tertiary referral hospitals involved patients categorised as triage categories 4 and 5 (4/5). A higher proportion of category 4/5 patients were observed for the specialist children’s hospitals (70%) and for other major metropolitan hospitals across NSW (6%).



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Figure 5-2: Overall trends in number of ED presentations for other tertiary (A1) and major metropolitan (BM) hospitals (2006/07-2012/13)



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More specific analysis was undertaken to identify demand for ‘KCC/UCC-type’ presentations within triage category 4 and 5 occurring during the hours of 0900-2200 (Figure 5-3). Significant increases in the number of KCC/UCC type patients were observed across all hospitals, particularly for tertiary referral and major metropolitan facilities since 2010/11.

On average, at least 30% of all triage category 4 and 5 patients presenting to specialist children’s hospitals were deemed eligible for streaming to the

KCC. For other hospitals, at least 70% of all triage category 4 and 5 presentations were deemed eligible for treatment in a UCC type setting.

Figure 5-3: Percent of ‘KCC/UCC-type’ presentations (0900-2200 hours)



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When examined as a whole against broader ED demand over the past three years, the total number of KCC/UCC type patients is estimated to be at least:

52% of all triage category 4 and 5 presentations between the hours of 0900 to 2200;

17% of all emergency presentations between the hours of 0900 to 2200 hours; and

13% of all emergency presentations to tertiary referral and major metropolitan hospitals.

Overall estimates and significant differences in demand over time are presented in Appendix 7. General demand for KCC/UCC type emergency treatment was observed to peak between:

the months of March-May during the year for children’s hospitals, and December-January for the other pilot sites;

Saturday-Monday during a typical week for all pilot hospitals; and

the hours of 1400-1900 during a typical day for children’s hospitals, and 0900-1400 for the other pilot sites.

In relation to the overall demand it is currently estimated that there are around 158,649 UCC presentations per annum (in 2012/13), spread across:

16,871 (estimated) presentations per annum for the specialist children’s hospitals;

76,558 presentations to other tertiary referral hospitals; and

65,220 presentations to other major metropolitan hospitals.

5.3 Impact upon patient flow in the emergency department

Given the different levels of influence that KCC/UCC patient presentations have upon overall emergency demand, the impact of pilot site operations was examined separately for each peer group of hospitals and compared according to three patient categories/types:

UCC-type patients presenting between 0900 and 2200 hours;

all triage category 4 and 5 patients presenting between 0900 and 2200 hours; and

all patients presenting between 0900 and 2200 hours.

5.3.1 ED PATIENT FLOW FOR SPECIALIST CHILDREN’S HOSPITALS

Overall (median) length of stay for patient types attending the children’s hospitals is presented in Figure 5-4.



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Figure 5-4: Median ED length of stay for patient groups presenting to specialist children’s hospitals

Panel A: All KCC type patients (presenting between 0900-2200 hrs)

Panel B: All Triage Category 4 and 5 patients (presenting between 0900-2200 hrs)

Panel C: All ED patients (presenting between 0900-2200 hrs)

Note: Reference bars are matched to the lower 95% CIs of the baseline year (2010/11) to assist interpretation of significant (non-overlapping) differences.

Figure 5-4 reveals that:

a significant reduction in overall length of ED stay for KCC-type patients occurred in the year following introduction of the pilot program (2011/12), and continued at both children’s hospitals for another financial year (2012/13) thereafter;

however, when all triage category 4 and 5 patient presentations were considered (during the same hours of presentation), significant improvements in overall length of ED stay, which occurred in 2011/12, returned to the same levels as the baseline period of data collection after two years (2010/11);

analysis of all ED patients presenting over the same hours of UCC-equivalent operation revealed that initial reductions in length of stay following the introduction of the KCC also returned to levels previously observed prior to commencement of the KCC pilot.

Thus, whilst KCC-type patients experienced and maintained a significant reduction in overall length of stay following introduction of the pilot…



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…the overall impact upon treatment time in the ED has not been significant after two years of KCC pilot project implementation at both

children’s hospitals sites.

Breakdown of ED patient flow for KCC-type patients at specialist children’s hospitals

Further investigation was conducted to ascertain which components of the ED journey were responsible for the largest reductions in overall length of stay for KCC-type patients following implementation of the pilot (Figure 5-5).

Analysis of the data revealed that, following introduction of the KCCs there was:

no significant difference at either site in the time to triage for KCC-type patients;

a significant reduction in time to clinician assessment following triage at one site (Children’s Hospital at Westmead); and

a significant reduction in time to ED separation following clinician assessment at one site (Children’s Hospital at Westmead).

Thus, significant reductions in overall length of stay for the children’s peer group are attributed to reductions in time to assessment and treatment duration at one of the two sites – notably, the site with the largest net

number of presentations for the peer group.

Figure 5-5: Median length of stay for ED components of KCC-type presentations Panel A: Time to triage for all KCC type patients (presenting between 0900-2200 hrs)

Panel B: Time to clinician assessment for all KCC type patients (presenting between 0900-2200 hrs)



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Panel C: Time to ED separation for all KCC type patients (presenting between 0900-2200 hrs)


5.3.2 ED PATIENT FLOW FOR TERTIARY REFERRAL HOSPITALS

Overall (median) length of stay for patient types attending tertiary referral hospitals is presented in Figure 5-6.

Figure 5-6 reveals that:

a significant reduction in overall length of ED stay for UCC-type patients occurred in the year following introduction of the pilot program (2011/12), and continued for another financial year (2012/13) thereafter;

when all triage category 4 and 5 patient presentations were considered (during the same hours of presentation), significant improvements in overall length of ED were also observed to continue for another two financial years following introduction of the pilot; furthermore

analysis of all ED patients presenting over the same hours of UCC-equivalent operation revealed that initial reductions in length of stay following the introduction of the KCC were maintained for at least two financial years.

For the tertiary hospital pilot site, UCC-type patients experienced and maintained a significant reduction in overall length of stay following

introduction of the pilot. This was also observed for triage category 4 and 5 patients, and all patient presentations during UCC operating hours.

In relation to peer group comparisons, it was also observed that:

at least four other similar hospitals had also achieved significant year-on-year reductions in overall length of ED stay for UCC-type patients – without participating in the pilot (Peer Hospitals A, F, I and K);

the same hospitals also achieved significant year-on-year reductions in overall length of stay for all triage category 4 and 5 patients; moreover

a higher number of peer group hospitals (at least 5) had experienced year-on-year reductions in overall length of stay for all patient presentations during the same period – without participating in the pilot (Peer Hospitals A, D, F, I and K).

Thus, the overall impact of improvements in length of ED stay was not unique to the tertiary hospital pilot site - at least 4 other peer group

hospitals demonstrated significant year-on-year reductions in LOS for



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UCC-type, triage category 4/5, and all patient presentations – without participating in the UCC pilot model of service delivery.

It might be argued that the ‘magnitude’ (size) of the reduction in in overall length of stay at the pilot site is larger than other peer group hospitals. Whilst this observation is accurate, it must also be noted that the baseline from which the pilot site was performing was also much worse (i.e. longer waiting times) than their peers. It is easier to demonstrate greater magnitude of change from the lowest point in a distribution of scores (floor effects), than others operating in the middle or the top range (ceiling effects) of the same distribution. Therefore, the significant performance of other hospital peers should be interpreted as ‘harder’ to achieve than the pilot site in this context.

Breakdown of ED patient flow for UCC-type patients at tertiary referral hospitals

Further investigation was conducted to ascertain which components of the ED journey were responsible for the largest reductions in overall length of stay for KCC type patients following implementation of the pilot (Figure 5-7).

Analysis of the data revealed that, following introduction of the UCCs:

the time to triage for UCC-type patients had not changed at the pilot site. At least three other peer group hospitals had demonstrated and maintained significantly lower times to triage (Peer Hospitals E, G, and J);

there was a significant reduction in time to clinician assessment following triage at the pilot site. However, at least 4 other peer group hospitals had also demonstrated significant reductions in the time to initial assessment by a clinician (Peer Hospitals D, F, I and K); and

there was a significant increase in the time to separation following clinician assessment at the pilot site in the financial year following the introduction of the pilot service delivery model. This was contrasted with significant year-on-year reductions in time to separation which were observed in at least 4 other peer group hospitals (Peer Hospitals A, F, I and K).

Significant reductions in overall length of stay for the tertiary pilot hospital were attributed to improvements (a decrease) in time to be seen by a

clinician within the ED.

However, at least 4 peer group hospitals also demonstrated significant reductions in time to be seen by a clinician within the ED – without

participating in the UCC pilot model of service delivery.



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Figure 5-6: Median ED LOS for UCC-type (top), triage category 4/5 (middle), and all presentations (bottom) to tertiary referral hospitals

Panel A (top) = Time to triage for all UCC type patients (presenting between 0900-2200 hours); Panel B (middle) = Time to clinician assessment for all UCC type patients (presenting between 0900-2200 hours); Panel C (bottom) = Time to ED separation for all UCC type patients (presenting between 0900-2200 hours). Note: Reference bars are matched to the lower 95% CIs of the baseline year (2010/11) to assist interpretation of significant (non-overlapping) differences.



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Figure 5-7: Median ED LOS for time to triage (top), assessment (middle) and separation (bottom) for UCC-type presentations




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5.3.3 ED PATIENT FLOW FOR MAJOR METROPOLITAN HOSPITALS

Overall (median) length of stay for patient types attending major metropolitan hospitals is presented in Figure 5-8, which reveals that:

a significant reduction in overall length of ED stay for UCC-type patients occurred for one of the pilot sites (Wyong Hospital) in the year following introduction of the pilot program (2011/12), and continued for another financial year (2012/13) thereafter. For the other pilot site (Campbelltown Hospital), an initial improvement in overall ED length of stay in the first financial year following implementation of the pilot, returned to baseline levels by the second financial year of pilot service delivery implementation;

when all triage category 4 and 5 patient presentations were considered (during the same hours of presentation), the same pattern of performance was observed between each of the two pilot sites; however

analysis of all ED patients presenting over the same hours of UCC-equivalent operation revealed that initial reductions in length of stay following the introduction of the UCC were maintained for the first pilot site, and a significant reduction in overall length of stay was observed for the second pilot site (after an initial increase), in the second year following pilot UCC implementation.

For one of the major metropolitan hospital pilot sites, UCC-type patients experienced and maintained a significant reduction in overall length of

stay following introduction of the pilot. This was also observed for triage category 4 and 5 patients, and all patient presentations during UCC

operating hours.

For the other pilot site, initial gains in overall length of stay for UCC-type and all triage category 4 and 5 patients returned to baseline levels by the

second financial year following implementation of the pilot.

In relation to peer group comparisons, it was also observed that:

at least one other peer group hospital had also achieved significant year-on-year reductions in overall length of ED stay for UCC-type patients – without participating in the pilot (Peer Hospital C);

at least three other peer group hospitals had also achieved significant year-on-year reductions in overall length of stay for all triage category 4 and 5 patients (Peer Hospitals C, D, H); moreover

at least one other peer group hospital had experienced year-on-year reductions in overall length of stay for all patient presentations during the same period – without participating in the pilot (Peer Hospital H).

Thus, the overall impact of improvements in length of ED stay were not unique to one of the major metropolitan hospital pilot sites - at least 1

other peer group hospital demonstrated significant year-on-year reductions in LOS for UCC-type, triage category 4/5, and all patient

presentations – without participating in the UCC pilot model of service delivery.



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Here, it might be argued that the ‘magnitude’ (size) of the reduction in in overall length of stay at the pilot sites is harder to achieve than other peer group hospitals - given that both hospitals sit ‘mid-range’ to their peer group counterparts. This argument merits consideration and might be taken into account when assessing the overall performance of pilot sites within this group. This would result in a ‘suspended judgement’ about the likelihood that at least one hospital has achieved meaningfully significant improvements in performance since commencement of the pilot (Wyong), pending the availability of future performance data.

Breakdown of ED patient flow for UCC-type patients at major metropolitan hospitals

Further investigation was conducted to ascertain which components of the ED journey were responsible for the largest reductions in overall length of stay for UCC type patients following implementation of the pilot (Figure 5-9).

Analysis of the data revealed that, following introduction of the UCCs:

the time to triage for UCC-type patients had not changed at both pilot sites;

there was a significant reduction in time to clinician assessment following triage at both pilot sites in the financial year following pilot implementation (2011/12). However, only one site maintained this improvement (Wyong) in the subsequent financial year (2012/13). In addition, significant reductions in time to clinician assessment were also observed over the same period in at three other peer group hospitals that had not participated in the UCC pilot (Peer Hospital C, D and H).

there was no significant change in the time to separation following clinician assessment at both pilot sites. By contrast, at least eight peer group hospitals demonstrated significant reductions in time to separation from the ED (in 2012/13) without participating in the pilot (Peer Hospitals A, b, C, D, E, F, H and I).

Significant reduction in overall length of stay for one of the major metropolitan pilot hospitals was attributed to improvements (a decrease) in

time to be seen by a clinician within the ED.

However, at least 3 peer group hospitals also demonstrated significant reductions in time to be seen by a clinician within the ED – without

participating in the UCC pilot model of service delivery.



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Figure 5-8: Median ED LOS for UCC-type (top), triage category 4/5 (middle), and all presentations (bottom) to major metro hospitals




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Figure 5-9: Median ED LOS for time to triage (top), assessment (middle) and separation (bottom) for UCC-type presentations




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5.3.4 STAKEHOLDER PERCEPTIONS OF UCC IMPACT ON PATIENT FLOW

A number of pilot sites indicated that the UCC service and its precursors, such as Fast Track, had facilitated patient flows within EDs. In some facilities, the introduction of the UCC model has resulted in better meeting of the four hour targets amongst other government policy objectives.

“It has helped manage the less urgent ED presentations with less wait, but the overall outcome is unclear other than shorter wait.” [Non UCC]

“(UCC) has good links with ED. Service quality dependant on medical staff in attendance. This has to be balanced between need for service versus (the)

need to expose/educate.” [UCC]

“The UCC is an extension of the emergency department, not a separate entity and is staffed by the ED. It is only for non-urgent cases and would not be expected to see emergency/medical patients unless there were no UCC

patients to be seen or the ED was extremely busy.” [Non UCC]

However, most of the pilots reported operating only a ‘partial UCC model’ due to the lengthy delays associated with implementing the physical infrastructure associated with the model of service delivery. This in turn has resulted in a range of negative perceptions of the impact of the UCC model on the ED.

“It will work more efficiently when not combined with an adjoining department as staffing resources allocated to UCC are currently being used by ED Fast track. Once the department is a stand along building, the doctor will have

his/her own allocated nurse to provide faster treatment.” [UCC]

“Whilst UCC is in ED – (it is) causing problems for triage staff as patients who have recently arrived (UCC patients) are getting called before ED patients who have been waiting for ages. Patients make do distinction between ED and UCC

and get upset and complain.” [UCC]

5.4 Impact upon staff satisfaction and perceived quality of care

5.4.1 STAFF SATISFACTION

Staff satisfaction with key operational elements of the UCC service delivery model are presented in Figure 5-10, which reveals that staff were significantly more satisfied14 with:

the clarity of criteria for referral to the UCCs (72%);

the level of training received (70%);

14 Significant differences from a median overall level of 50% satisfaction were identified. Satisfaction based upon net

agreement scores (‘strongly agree’ + ‘agree’). 95% confidence interval of ± 8% at p=.50.



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the level of support to manage patients treated in the UCC (66%); and

the level of support to manage medical emergencies (62%).

Figure 5-10: Perceptions on set up and operation of UCC – all respondents (n=169)

Whilst levels of training to work in the UCC were the most highly rated area of operational satisfaction, not all staff agreed. Those who worked in the UCC without training were particularly dissatisfied.

“(I) don't like working in urgent care when I am untrained, as I feel useless. Staff are very understanding and excellent with what they can provide.” [Non

UCC]

Others thought that the overall level of training could be further improved.



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“Nursing staff not well trained (some don't do casts for e.g.)” [KCC]

“Assessment skills of nursing staff could be improved.” [KCC]

Significantly higher levels of staff dissatisfaction15 were reported in relation to:

the design of the UCC for staff (27%);

the design of the UCC for patients (22%); and

the sufficiency of clinical equipment to meet the needs of UCC patients (19%).

Levels of dissatisfaction were consistent with previous stakeholder feedback indicating frustration where pilot sites had a lack of clearly designated physical space and infrastructure.

Figure 5-11: Perceptions of satisfaction – all respondents (n=169)

15 Significant differences from a median overall level of 11% dissatisfaction were identified. Dissatisfaction based upon net

disagreement scores (‘strongly disagree’ + ‘disagree’). 95% confidence interval of ± 8% at p=.50.



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Staff satisfaction with professional roles and responsibilities following implementation of the UCC service delivery model are model are presented in Figure 5-11, and indicated that:

Staff were significantly more satisfied16 with:

links between the UCC and the ED (68%); and

the complexity of patients seen in the ED after UCC implementation (62%);

Significantly higher levels of staff dissatisfaction17 were reported in relation to the ongoing workload in the ED (32%).

5.4.2 PERCEIVED QUALITY OF PATIENT CARE

Survey respondents were asked to indicate their perceptions about the standard of care and waiting times experienced by patients treated within the UCC. Approximately 70% of respondents ‘agreed’ that patients received the same standard of care in the UCC as they do in the ED. There was also net agreement (in excess of 50%) that patients in the UCC spent less time waiting, less time being treated, and were generally satisfied with the services provided to them in the UCC (Figure 5-12).

“I think it works well, the patients who don't have complex issues, for example lacerations, and seen and sent home quicker.” [Non UCC]

“High patient satisfaction with the waiting time & efficiency of treatment in the UCC.” [Non UCC]

“It shortens their length of stay in our department and has a positive impact on the view parents, guardians and patients have on our department.” [Non UCC]

Figure 5-12: Perceptions of standard of care and waiting times – all respondents (n=169)

16 Significant differences from a median overall level of 47% satisfaction were identified. Satisfaction based upon net

agreement scores (‘strongly agree’ + ‘agree’). 95% confidence interval of ± 8% at p=.50. 17 Significant differences from a median overall level of 10% dissatisfaction were identified. Dissatisfaction based upon net

disagreement scores (‘strongly disagree’ + ‘disagree’). 95% confidence interval of ± 8% at p=.50.



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5.5 Impact upon patient/client safety and clinical outcomes

5.5.1 PATIENT SAFETY

There were no objective data available to assess the rate of clinical incidents occurring at each of the pilot implementation sites. Notwithstanding, there was general agreement across sites that patient/client safety and clinical outcome were not compromised by the Service Delivery Model. Patients who required more critical care were transferred back to the ED if required.

“We have had no incidents relating to safety and quality. As a test, we would get feedback from fracture clinic provides information on missed fractures.”

[UCC/KCC]

“There have been no incidents since UCC commenced, primarily as it is not a compartmentalised system so (there are) no patient safety issues.” [UCC/KCC]

“We would cease operating UCC if patients became predominantly high acuity and high complexity within presentations at ED.” [UCC/KCC]

5.5.2 CLINICAL OUTCOMES

A limited range of clinical outcome data was available for analysis. Health system information relating to main discharge disposition, referrals at discharge and the number and type of patients re-presenting for treatment were examined as indicators of patient outcomes associated with the UCC model of service delivery.

Main discharge disposition of patients

Around 90% of all KCC/UCC-type patients were discharged to their usual residential accommodation or admitted to hospital following treatment (Table 5-5).

Table 5-5: Discharge disposition of KCC/UCC-type patients by hospital group

DISCHARGE DISPOSITION CHILDREN’S HOSPITALS

TERTIARY HOSPITALS

MAJOR METRO HOSPITALS

Discharged from ED 69% 52% 63%

Admitted to hospital 22% 36% 27%

Other 1% 3% 2%

Did not wait/Left at own risk 8% 9% 8%

Total 100% 100% 100%



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Excluding those that did not wait for treatment18, less than three percent of all KCC/UCC-type patients experienced other types of discharge arrangements.

The percentage of KCC-type (Figure 5-13) and UCC-type (Figure 5-14) patients who were discharged to their usual accommodation following treatment at specialist children’s, tertiary referral and major metropolitan hospitals in NSW are presented below.

Figure 5-13: Percent of KCC-type patients discharged to usual accommodation

Amongst the children’s hospitals, a differing pattern patient discharges was observed following introduction of the KCC:

at Westmead Children’s Hospital, there was no significant change in the proportion of patients discharged home (vs admitted to hospital) in the year following introduction of the KCC (2011/12). However, a significant increase in the proportion of KCC-type patients discharged home (rather than admitted to hospital) was observed in the second year following the introduction of the KCC.

at Sydney Children’s Hospital, there was a significant increase in the proportion of patients discharged home in the year following the introduction of the KCC (2011/12). However, initial gains in the proportion of patients discharged home had disappeared in the second year following the introduction of the KCC, to levels that were not significantly different from the baseline year of comparison.

Amongst the tertiary referral hospitals, the pilot evaluation site (Westmead Hospital) had a significantly lower proportion of UCC-type patients discharged to their usual residential accommodation than virtually all other peer group hospitals (except Peer Site F). Whilst significant increases in the proportion of patients discharged home were observed following the introduction of the UCC, significant improvements were also observed in other hospitals who had not participated in the pilot model of service delivery (Peer Sites A, G and I).

18 Recall that those who did not wait or left at own risk were excluded from KCC/UCC-type profiling as no diagnosis code

was available for patient classification. Thus figures remaining in this section relate to the total percentage of patients excluding presentations in these categories (i.e. DNW/LOR).



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Figure 5-14: Percent of UCC-type patients discharged to usual accommodation Panel A: Percentage of patients discharged from tertiary referral hospitals

Panel B: Percentage of patients discharged from major metropolitan hospitals




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Amongst the major metropolitan hospitals, different trends in discharge disposition were observed amongst the pilot hospital sites:

Wyong Hospital (Evaluation Site 4) had experienced significantly higher levels of home discharge compared to almost all other peer group hospitals. Unsurprisingly, there was little change in the proportion of UCC-type patients discharged home following introduction of the pilot model of service delivery (due mostly to ceiling effects in ED performance).

Campbelltown Hospital (Evaluation Site 5) had experienced similar levels of home discharge for UCC-type patients to the majority of their hospital peers. These levels had not changed significantly in the first year following introduction of the UCC, and had then decreased to significantly lower levels of home discharge in the second year following introduction of the pilot model of service delivery (2012/13). Significant reductions in the proportion of home discharges were also observed at three other peer group hospitals who did not participate in the pilot (Peer Sites B, E and F). By contrast, two other peer group hospitals demonstrated significant improvements in the same measure without participating in the pilot (Peer Sites D and G).

Thus, whilst changes in the proportion of UCC-type patients discharged home (vs admitted to hospital) were observed at some of the pilot hospital sites, these gains were not consistent across similarly grouped pilot hospitals, nor significantly better than other peer hospitals who did not participate in the pilot model of service delivery.

Community referrals for UCC-type patients

For those KCC/UCC-type patients discharged home, the proportion of referrals made to different community services was also examined (Table 5-6).

Table 5-6: Community referrals for KCC/UCC-type patients by hospital group

DISCHARGE DISPOSITION CHILDREN’S HOSPITALS

TERTIARY HOSPITALS

MAJOR METRO HOSPITALS

General Practitioner (GP/LMO) 10% 77% 80%

Hospital Outpatient or Other Specialist 9% 11% 5%

Review in ED 5% 2% 3%

Other <0% 6% 7%

Not Referred 76% 4% 5%

Total 100% 100% 100%

For the children’s hospitals, the majority of KCC-type patients (76%) were not referred to any community service provider following discharge from the ED. By contrast, the majority of UCC-type patients seen by tertiary referral hospitals (77%) and major metropolitan hospitals (80%) were referred for follow-up to their local GP following treatment.



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Further analysis of community referrals following discharge from the children’s hospitals was undertaken (Figure 5-15), which revealed that:

all KCC-type patients seen at The Children’s Hospital Westmead (Evaluation Site 1) were formally recorded by the hospital as “not referred” to any community service provider following discharge from the ED.

for Sydney Children’s Hospital (Evaluation Site 2), around 40% of KCC-type patients were referred to their GP following treatment in the ED. There was no significant change in the proportion of GP referrals following implementation of the KCC pilot. By contrast, around 25% of referrals were made to hospital outpatient departments prior to the introduction of the KCC. Whist the proportion of outpatient referrals decreased significantly in the year immediately following introduction of the pilot model of service delivery, they had subsequently increased (in 2012/13) to levels that were not significantly different from baseline (2010/11).

Figure 5-15: Types of community referral for KCC-type patients discharged from specialist children’s hospitals Panel A: Percentage of patients not referred to any service following discharge

Panel B: Percentage of patients referred to GP/LMO following discharge

Panel C: Percentage of patients referred to hospital outpatient departments following discharge



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Additional analysis undertaken on community referral data from tertiary referral hospitals (Figure 5-16) indicated that the majority (90%+) of UCC-type patients discharged from the ED at Westmead Hospital (Evaluation Site 3) were referred to their GP for further follow-up, and that this had increased significantly by the second year following implementation of the pilot service delivery model. Significant improvements in the proportion of UCC-type patients was also observed at five peer group hospitals who were not involved in the pilot model of service delivery (Peer Sites C, D, E, G and J).

The proportion of referrals to hospital outpatient departments at Westmead Hospital was amongst the lowest of all peer group hospitals and had significantly reduced even further following implementation of the UCC. A variable pattern of performance was observed for other peer group hospitals, with some showing significant reductions in the proportion of community referrals for UCC-type patients over the same period (Peer Sites C and I), and others experiencing significant increases in the proportion of community referrals for the same patient cohort (Peer Sites A and B).

For major metropolitan hospitals (Figure 5-17), between 75%-80% of all UCC-type patients were referred to their GP following treatment at the pilot evaluation sites. Whilst the proportion of GP referrals had increased significantly at Wyong Hospital (Evaluation Site 4) within two years of implementation of the UCC, it had decreased significantly at Campbelltown Hospital (Evaluation Site 5). Significant decreases in the proportion of GP referrals were also observed at three other peer group hospitals over the same three year period (Peer Sites B, E and I). However, four other peer hospitals demonstrated significant improvements in the proportion of UCC-type patients referred to GPs following treatment without participating in the pilot service delivery model.

Referrals to hospital outpatients at Wyong Hospital were not significantly different within two years of UCC implementation. Outpatient referrals at Campbelltown had increased significantly within two years of the UCC pilot.

Thus, the proportion of patients referred to their GP following treatment at the pilot hospital sites varied significantly from 0% to around 95%. Changes in clinical outcomes relating to GP referral, after implementation of UCCs, also varied in a similar manner to those observed for other peer group hospitals who did not participate in the pilot service delivery model.



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Figure 5-16: Tertiary hospital UCC-type patient referrals to no-source (top) GP (middle) or hospital outpatients (bottom) after discharge

Panel A (top) = Referrals to No-source for all UCC type patients (presenting between 0900-2200 hours); Panel B (middle) = Referrals to GP/LMO for all UCC type patients (presenting between 0900-2200 hours); Panel C (bottom) = Referrals for Outpatients for all UCC type patients (presenting between 0900-2200 hours). Note: Reference bars are matched to the lower 95% CIs of the baseline year (2010/11) to assist interpretation of significant (non-overlapping) differences.



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Figure 5-17: Major metro UCC-type patient referrals to no-source (top) GP (middle) or hospital outpatients (bottom) after discharge

Panel A (top) = Referrals to No-source for all UCC type patients (presenting between 0900-2200 hours); Panel B (middle) = Referrals to GP/LMO for all UCC type patients (presenting between 0900-2200 hours); Panel C (bottom) = Referrals for Outpatients for all UCC type patients (presenting between 0900-2200 hours). Note: Reference bars are matched to the lower 95% CIs of the baseline year (2010/11) to assist interpretation of significant (non-overlapping) differences.

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2010111 ( "UCC Start Dec.") 2011/12 2012113

I I

BM PeerE BMPeerF BMPeerG BM Peer H BMPeer l

2010/11 201 1/12 2012113



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Representation of UCC-type patients to the ED/UCC within 48 hours of discharge

Patients who re-presented to the ED within 48 hours of discharge (and were subsequently discharged home) were examined. Results are presented in Table 5-7. Detailed re-presentation data are presented for closer scrutiny in Appendix 8.

Analysis revealed that:

there was no significant difference in the proportion of patients re-presenting to the pilot sites within two years of UCC implementation.

of those who did re-present, there were no differences in overall ED length of stay or clinical outcomes, with the exception of community referrals to GPs which increased for two sites (Westmead Hospital and Wyong Hospital).

in general, pilot site performance was not significantly better or worse than other peer group hospitals



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Table 5-7: Representation characteristics between commencement and 2 years following KCC/UCC implementation19

Representation characteristics Children’s Hospitals Tertiary Referral Hospitals Major Metropolitan Hospitals

Evaluation sites

(and peer group hospitals where relevant)

A2

Evaluation

Site 1

A2

Evaluation

Site 2

A1

Evaluation

Site 3

A1 Peer

Group Better

(sig < .05)

A1 Peer

Group Worse

(sig <.05)

BM

Evaluation

Site 4

BM

Evaluation

Site 5

BM Peer

Group Better

(sig < .05)

BM Peer

Group Worse

(sig <.05)

Percentage of patients 2.6% (ns) 2.5% (ns) 3.8 (ns) 1 (E) 4 (B,C,I,J) 6.3 (ns) 5.8 (ns) 3 (B,D,F) 0

Hour of day (majority %) 0900-1000hrs 0900-1100hrs 0900-1100hrs

Day of week (majority %) Fri & Sun Sat - Mon Fri, Sun-Mon

Month of year (majority %) Dec-Jan Dec-Jan Dec-Jan

Overall Median LOS in ED (ns) (ns) (ns) 2 (I,J) 0 (ns) (ns) 0 4 (D,G,H,I)

Median time to triage (ns) (ns) (ns) 1 (C) 1 (D) (ns) (ns) 4 (E,G,I) 2 (A,F)

Median time to clinician assessment (ns) (ns) (ns) 2 (J,K) 2 (B,C) (ns) (ns) 2 (F,I) 0

Median time to patient separation from ED (ns) (ns) (ns) 2 (C,I) 0 (ns) (ns) 0 0

Percent discharged to usual accom. (ns) (ns) (ns) 0 0 (ns) (ns) 0 0

Percent discharges ‘not referred’ (ns) (ns) (ns) 0 3 (B,J,K) (ns) (ns) 3 (E,H,I) 0

Percent discharges referred to GP (ns) (ns) (*) 0 10 (ALL) (*) (ns) 3 (B,D,H) 1 (I)

Percent discharges referred OP/Specialist (ns) (ns) (ns) 0 8 (A-E,I-K) (ns) (ns) 6 (A-C,E-F,H) 0

19 Changes denoted as either non-significant ‘(ns)’, significantly improved ‘(*)’, or significantly deteriorated ‘(*)’ from baseline period of comparison in 2010/11 (first financial year of UCC pilot

commencement). Peer Group comparisons denoted as number of sites significantly ‘Better’ or significantly ‘Worse” than evaluation sites within their peer group. Majority % for time of presentation denotes times when the largest single proportion of patients re-presented for treatment. Length of stay and time to triage/assessment/separation denotes time in minutes. Percentage figures and time estimates pertain only to those directly discharged from the KCC/UCC or ED to their usual residential accommodation (i.e., excludes those admitted to hospital for further treatment.



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5.6 The level of resource utilisation achieved over time at each UCC

5.6.1 REPORTED BUDGETARY ALLOCATIONS AND PILOT SITE EXPENDITURES

It is estimated that aggregate operating funding to the pilot sites since the inception of the program has totaled $15M (Table 4-2); or $3M at each of the five pilot site over the three years. In addition, there was another $1.46M in capital funding across four pilot sites, with a further $1.5M anticipated to be allocated to Wyong Hospital in this current financial year. These figures are based on advice from NSW Health. There has been no separate reporting of actual program costs at the pilot sites. The lack of actual (patient-level) cost data for the pilot has inhibited any reliable assessment of:

cost-effectiveness (i.e. the actual cost per unit of output); or any

cost-comparison between the UCC pilot sites and other comparator sites (i.e. the relative cost per unit of available clinical outcomes between pilot and peer group sites).

Therefore, cost differences between alternative service models cannot be determined from the data made available. The only insights are derived from a description of the relative funding devoted to the UCC pilot.

1.1.2 REVENUE FOR KCC/UCC-TYPE PATIENTS

Revenue associated with treatment of UCC-type patients was compared with all triage category 4 and 5 patients treated by the pilot and peer group hospitals (where available).

Children’s hospitals

Typical (average) revenue for UCC-type patients and all category 4 and 5 patients treated by children’s hospitals is presented in (Figure 5-18).

Analysis of available data revealed that:

revenue per patient treated for KCC-type patients at The Children’s Hospital Westmead (Evaluation Site 1) were significantly different than for KCC-type patients treated at Sydney Children’s Hospital (Evaluation Site 2). The basis for the differences in revenue per patient treated appears to be due to service volumes.

revenue per patient treated for all KCC patients were then compared to the overall treatment of all triage category 4 and 5 patients, which revealed;

higher than the revenue otherwise generated from all category 4 and 5 patients combined at The Children’s Hospital Westmead; but

lower than the revenue otherwise generated from all category 4 and 5 patients combined at Sydney Children’s Hospital.



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Figure 5-18: Average revenue for KCC-type (top) vs all category 4-5 (bottom) patients treated at the children’s hospitals

Panel A: Average revenue generated for KCC-type patients (presenting between 0900-2200 hrs)

Panel B: Average revenue generated for all triage category 4-5 patients (presenting between 0900-2200 hrs)

Tertiary referral hospitals

Typical (average) revenue for UCC-type patients and all category 4 and 5 patients treated by tertiary referral hospitals is presented in (Figure 5‑ 19).

Analysis of available data suggests that:

revenue per patient treated for UCC-type patients at Westmead Hospital (Evaluation Site 3) was the same as all triage category 4 and 5 patients treated by the pilot site.

when compared to other peer group hospitals;

revenue per patient treated for (at least) three hospitals who did not participate in the pilot were significantly lower for UCC-type (and all triage category 4 and 5) patients (Peer Sites B, I and J); and

revenue per patient treated at four other hospitals that did not participate in the pilot program were significantly higher for UCC-type (and all triage category 4 and 5). (Peer Sites A, D, F and G).



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Figure 5-19: Average revenue for UCC-type (top) vs all category 4-5 (bottom) patients treated at tertiary referral hospitals Panel A: Average revenue generated for UCC-type patients (presenting between 0900-2200 hrs)




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Figure 5-20: Average revenue for UCC-type (top) vs all category 4-5 (bottom) patients treated at major metropolitan hospitals Panel A: Average revenue generated for UCC-type patients (presenting between 0900-2200 hrs)




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Major metropolitan hospitals

Typical (average) revenue for UCC-type patients and all category 4 and 5 patients treated by major metropolitan hospitals is presented in (Figure 5‑ 20).

Analysis of available data suggests that:

revenue per patient treated for UCC-type patients at Wyong Hospital (Evaluation Site 4) was lower than for all triage category 4 and 5 patients treated; and that

revenue per patient treated for UCC-type patients at Campbelltown Hospital (Evaluation Site 5) generated the same revenue per patient as for all triage category 4 and 5 patients treated.

The revenue per patient generated at both pilot major metropolitan hospitals was the same as at least one other peer group hospital (Peer Site E) for UCC-type and all triage category 4-5 patients. However, the revenue generated per patient at eight other peer hospitals for UCC-type was lower than for all triage category 4-5 patients. (Peer Sites A-D, F-I).

Overall, the revenue per patient (or average price) for UCC-type patients were generally comparable to the revenue per patient generated for all triage category 4 and 5 patients treated at the same pilot sites. Similarly, revenue per patient differences mirrored the pattern of overall differences in revenue per patient generated for all triage category 4-5 patients between pilot sites and their peer group hospitals.

Any future evaluation would significantly benefit from the availability of activity costing at pilot and comparator (peer) sites.

5.6.2 STAKEHOLDER PERCEPTIONS ABOUT RESOURCE UTILISATION OF UCCS

On the basis of both site visits and survey results, appears to be a level of ambivalence amongst ED personnel as to the return of investment that has been achieved by the UCC service delivery model. Many noted that similar outcomes would have been achieved through increased investment on ED services as currently structured.

“Unfortunately the amount of resources (manpower) provided to UCC does not outweigh the benefit that the UCC brings to the rest of the ED.” [Non UCC]

“The UCC Service Delivery Model is excellent in terms of providing a senior doctor with adequate nursing and clerical backup, but deeply flawed in that it is

difficult to triage patients into 2 streams (ED and house doctor), let alone 3 streams. The money would have been far better spent on providing the house

doctor section of the ED with adequate staffing and facilities.” [UCC]

“[It is] beneficial to have a fast track area, particularly for injuries. It would be a shame if the area was no longer available for whatever reason, whether that be financial/political etc as I feel it is a good service to the community.” [Non UCC]

“Close UCC and improve House Doctor” [UCC]

“More funding. More doctors.” [KCC]



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5.7 Acceptability of the UCC service delivery model

Staff working at the pilot sites were generally unclear about the perceptions of the UCC held by external stakeholders as outlined in Figure 5-21.

Figure 5-21: Perceptions of community impact – all respondents (n=88)

Staff who were more directly responsible for clinical management and administration of the pilots, considered that the introduction of a UCC service model at pilot sites had a positive impact on the nature and quality of service for non-emergency patients. This included perceptions of patients spending a shorter time spent within the ED overall and less time waiting for review and treatment.

“The UCC has allowed non-urgent patients, whom would otherwise wait long periods of time to be seen, have a medical review and treatment initiated

quickly. It shortens their length of stay in our department and has a positive impact on the view parents, guardians and patients have on our department.”

[Non UCC]

“I think it works well. The patients who don't have complex issues and for example lacerations are seen and sent home quicker.” [Non UCC]

This in turn was thought to impact positively upon overall ED workload.

“It has beneficial to have a fast track/UCC area, particularly for injuries.” [Non UCC]

“It has certainly decreased the workload on the department, having an experienced doctor with a dedicated nurse to help.”

Other expressed a more sceptical view about the overall impact of the UCC on the ED – pending the availability of additional data.

“It has helped manage the less urgent ED presentations with less wait, but the overall outcome is unclear other than a shorter wait.” [Non UCC]



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6 Summary of findings

6.1 Overall summary

A substantial amount of background work has been conducted by NSW Health to investigate methods of better streamlining non-urgent, non-complex patients for care in public sector EDs. An ‘urgent care centre’ model of service delivery was selected for piloting in NSW, given the reported success of similar approaches in other overseas jurisdictions. Following initial analysis of potential patient profiles and overall demand across NSW public hospitals, an expression of interest resulted in the selection of five sites for implementation of a ‘UCC’ approach to managing non-urgent, non-complex patients presenting to their hospital EDs.

Funding was provided to each pilot site to achieve two aims: First, to build a separate physical infrastructure, co-located with each ED, to segregate and treat the targeted patient cohort; Second, additional recurrent funds were provided on an annual basis to support operational implementation of the new service delivery model. Each site commenced planning and implementation in a manner consistent with the NSW Health UCC Implementation guidelines. Pilot service delivery models commenced between December 2010 and February 2011. Physical infrastructure re-developments have been slower to follow. Two sites managed to re-structure existing ED infrastructure at an earlier period of the pilot service delivery model, two sites managed re-development towards the end of the three year pilot period, and one site is yet to commence building and operation of a segregated UCC patient treatment area.

Analysis of major outcomes relating to ED patient flow, and patient disposition and referrals for ongoing care following KCC/UCC treatment have revealed that: In general, whilst KCC/UCCs have benefited the cohort of patients for whom they were designed to treat, any net improvement in outcome cannot be ascertained above those observed for peer group hospitals implementing other models of care. Differences in outcome reduce further when the impact of KCC/UCCs upon all category 4 and 5 patients are considered.

Accordingly, it is concluded that:

the KCC/UCC model of care may offer advantages in the hospitals within which it is implemented, for the treatment of this specific patient cohort; however

these ‘benefits’ do not appear in the broader treatment of all triage category 4 and 5 patients treated within the same periods of time each day; moreover

other hospitals who have not implemented the pilot model of service delivery demonstrate equal or better outcomes to the KCC/UCC pilot sites for the specific patient cohort, and the broader cohort of triage category 4 and 5 patients who present for treatment; furthermore

multiple models of ED service streaming exist in the pilot and peer group hospital sites. The current data is unable to disaggregate the impacts of the range of different ED models of service delivery at each of the pilot (or other peer group hospital) sites. For example, it is impossible to conclude whether co-existing models for ‘front of house’ or ‘house doctor’ assessment by senior medical practitioners has enhanced, inhibited or otherwise influenced UCC streaming after triage and thus the outcomes that have



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otherwise been observed in the systems data relating to ED patient flow or consumer outcomes.

Thus, on the basis of the available information, there is no evidence that a KCC/UCC model of care is any better or worse than other models for streamlining and treating patients within NSW public hospital EDs.

Moreover, there is sufficient evidence to indicate that a number of other single (or multiple) models of ED streaming and treatment may produce

superior outcomes for ED performance and patient outcomes for the same types of patients treated in UCCs. These should be actively investigated in order to understand the service delivery models underlying what has been

identified as system-wide better practice.



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Appendix 1 Performance Indicators

IMPLEMENTATION INDICATORS FOR GOVERNMENT

KEY ACTIVITY INDICATOR DATA SOURCE

IDENTIFY AREAS OF COMMUNITY CONCERN

Type and level of evidence about rising demand for emergency department services

Documentation of emerging evidence

ASSESS CONCERNS AGAINST GOVERNMENT POLICY AND ESTABLISH A PROGRAM RESPONSE

Number and type of government priorities established for addressing service demand

Number of government programs identified to develop a response to rising demand

NSW and Australian Government policy documentation

INVESTIGATE AREAS OF INCREASING SERVICE DEMAND

Number of patients with specified clinical conditions presenting to Emergency Departments

NSW Health Needs Analysis

IDENTIFY VARIATION IN DEMAND ACROSS HEALTH SERVICES

Number of patients presenting to individual health services (including, triage categories, age bands, discharge disposition etc)

NSW Health Needs Analysis

IDENTIFY CLINICAL EVIDENCE FOR EFFECTIVE INTERVENTIONS

Number and type of established approaches to addressing demand

Literature review

IMPLEMENT STAKEHOLDER CONSULTATION PROCESS TO DISCUSS KEY ISSUES AND INTERVENTIONS

Number and range of stakeholders consulted

Number and range of key issues identified through consultation

Report on stakeholder consultations

DETERMINE AN APPROPRIATE GOVERNMENT RESPONSE

Number and range of interventions to be implemented

Service Delivery Model document

IDENTIFY RESOURCES TO IMPLEMENT INTERVENTION

Amount and duration of funding provided to support program implementation

State and federal budgetary allocations

DEVELOP STATEWIDE AND LOCAL IMPLEMENTATION PLANS

Number of health services targeted for implementation

Statewide and local implementation plans

MONITOR PROGRAM OPERATION, IMPACT AND SUSTAINABILITY

Number and range of key activities and outcomes for ongoing measurement

NSW Health Evaluation Framework



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IMPLEMENTATION INDICATORS FOR HEALTH SERVICES


ESTABLISH COMMITMENT TO IMPLEMENT NEW PROGRAM INITIATIVES

Number of MoU between participating health services and NSW Health

NSW Health documents

CONFIRM LOCAL NEED, PATIENT ELIGIBILITY AND REFERRAL CRITERIA

Number and type of eligible patients by diagnostic group and acuity

Number and range of clinical activities undertaken prior to referral for treatment in the UCC

Local needs assessment

Local Service Delivery Model documentation

ESTABLISH GOVERNANCE ARRANGEMENTS

Number and range of clinical governance arrangements implemented


IDENTIFY OPERATIONAL ARRANGEMENTS

Number and range of opening hours

Number and range of staff required

Time to complete staff recruitment

Funding allocations, determined budgets and actual expenditure of operations, and capital development


ESTABLISH PHYSICAL INFRASTRUCTURE

Number and type of consulting spaces (capacity)

Time to travel (configuration) from

ED to UCC waiting area

UCC to ED consulting spaces

UCC to Medical Imaging


ESTABLISH EQUIPMENT AND LINKS TO HOSPITAL SERVICES

Number and range of clinical equipment provided

Number and type of protocols/arrangements for obtaining:

Medical Records

Pathology Tests

Medical Imaging Studies

Pharmaceutical Products


Audit of equipment

Staff consultation

Protocol review

IMPLEMENT IT AND COMMUNICATION SYSTEMS

Number of IT terminals installed

Number/range of telecommunications provided

Time to access electronic information

Time to contact ED staff

Time to contact other hospital staff


Audit of equipment

Staff consultation

Staff survey



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IMPLEMENT EVALUATION AND MONITORING SYSTEMS

Number of fields recorded

Type of fields recorded

Percentage of missing data

Frequency of reporting

Data extracts and hard copy reports from health services

REGISTER AND TRIAGE PATIENTS

Number of patients registered by triage category Data extracts from health services

NSW Health EDDC

ALLOCATE PATIENTS TO APPROPRIATE TREATMENT STREAM (ED VS UCC)

Number of patients allocated to ED (by Triage Category)

Number of patients allocated to UCC (by Triage Category)

NSW Health EDDC

Data extracts from health services

ASSESS PATIENTS Number of patients assessed (by type of health professional)


NSW Health EDDC

PERFORM DIAGNOSTIC TESTING AND RE-ASSESSMENT

Number of diagnostic tests by type Data extracts from health services

NSW Health EDDC

IMPLEMENT APPROPRIATE TREATMENTS

Number and type of treatments provided per patient Data extracts from health services

NSW Health EDDC

DISCHARGE PATIENT (OR TRANSFER TO APPROPRIATE CARE)

Number of patients transferred to ED

Number of patients discharged to usual accommodation

Number of referrals for ongoing care (by provider type)


NSW Health EDDC



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OUTCOME INDICATORS – SHORT TO MEDIUM TERM (WITHIN 6 TO 12 MONTHS)

KEY OUTCOME INDICATOR DATA SOURCE

IMPROVED STREAMLINING OF PATIENTS FOR CARE

Monthly number of patients triaged to category 3, 4, and 5.

Percentage of eligible category 5 patients referred back to a GP for assessment and management

Percentage of eligible patients referred for UCC management (by triage category)

Hospital MDS

NSW Health EDDC

DECREASED TIME TO ASSESSMENT FOR PATIENTS

Percentage of UCC patients seen within performance benchmarks (by time of day, day of week, month of year)

Percentage of ED patients seen within performance benchmarks (by time of day, day of week, month of year)

Hospital MDS

NSW Health EDDC

DECREASED TIME SPENT IN TREATMENT BY PATIENTS

Average duration of treatment by diagnostic group and triage classification

Average wait for:

Medical records (by time of day)

Pathology results (by time of day)

Medical imaging results (by time of day)

ED consultation (by time of day)

Hospital consultation (by time of day)

Pharmaceutical products (by time of day)

Hospital MDS

NSW Health EDDC Staff consultation/ survey

INCREASED EFFECTIVENESS OF SERVICE DELIVERY

Percentage of UCC patients experiencing an adverse event (including arrest)

Percentage of UCC patients transferred to the ED for ongoing management

Percentage of UCC patients admitted to hospital for care (by short stay/observation unit, assessment unit, general ward, other)

Length of stay in UCC/ED for patients admitted to hospital (as proxy impact of bed block)

Length of stay in hospital for patients admitted from UCC/ED (by same day, overnight but less than 24 hours, multi-day stays) Percentage of UCC patients re-presenting to the ED within 48 hours

Hospital MDS and other local data

NSW Health EDDC

NSW Health APD

SATISFACTION WITH SERVICE DELIVERY

Percentage of staff satisfied with clinical/administrative roles, responsibilities, case mix

Staff survey



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and workload

Percentage of patients who Did Not Wait for treatment

Percentage of patients satisfied with key elements of service delivery (as per local survey domains)

Hospital MDS

NSW Health Patient Appraisal Survey

OUTCOME INDICATORS – MEDIUM TO LONGER TERM (WITHIN 12 TO 24 MONTHS)


INCREASED

EFFICIENCY OF

HOSPITAL SERVICES

Decreased time spent waiting for assessment

Decreased time spent in treatment

Decreased demand for ED services from the UCC

Decreased demand for hospital services from the UCC

Decreased admission to hospital from the UCC

Decreased demand for specialist outpatient clinics from the ED/UCC

Hospital MDS and

other local data

NSW Health EDDC

NSW Health APD

IMPROVED

UTILISATION OF

COMMUNITY

TREATMENT

OPTIONS

Increased satisfaction with ED/UCC services from community

providers

Increased number and range of community referrals by UCC

Decreased referrals for potentially preventable conditions by

community practitioners

Decreased presentations for potentially preventable conditions by

individual patients

Hospital MDS and

other local data

NSW Health EDDC

NSW Health APD

DECREASED COST

OF SERVICE

DELIVERY

Average cost per patient episode of care by diagnostic group, triage

category, and discharge disposition (for ED vs UCC) Statewide NWAU

data



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Appendix 2 Staff Surveys

UCC Staff Survey



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----------------------------------------------------------------------------Some information about the people responding to the survey

* 1. What is the name of your health service?

carnpb •ow11 H~~<&p!lal

Sydney c l:lrern; Hoopllal

w estmea.<! Ctlllllren's HDSpllal

w estmea.<! ttOJEpllal



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----------------------------------------------------------------------Some information about the people responding to the survey

* 2. What is your professional occupation (tick one box only}?

AJI E<l Healtll

Hor;plt Adrnlnllitrat:on

CIEf!Cal



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-------------------------------------------------------------------------Some information about the people responding to the survey

3. What is your curre nt level of profession:ll employment (tick one box only)?

Medical Admlnl~lra.Uon

cornallimt

Medical omcer

Medical studt:lll

Otller (ple.ase spECII')')



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4. Whst is your current leve:l of profe.ss~ion31 employment (ti c'k one box only)?

roe Ma:naoger Enrolled Nun;e

'Uroe Pl<ictll!oner



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5. Which Allied He,alth profession do you 'belong to ,(tick one box onl;y)?

Social Wort

occ~au:onal Tllerapy



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6. What is your current level of :professional employment (ti ck one box only)?

AI ed H e-al'lh Manager

SeniOr Clllk:fan (Grade 3 or ~)

Grade 2 Cllnlcfan

Grade 1 Cllnlcran

Stlldent Cllnld'illl



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Some information about the people responding to the survey

7. How many years have you been working at. your current level of professional employment (t ick one box only)?

5 m 10 )"ears

More tnan 1 o y-ears



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------------------------------------------------------------------Some information about the people responding to the survey

8. In which area of the hospital do you currently work (t ick all t hat apply}?

!Emergency DepiiT.mEflt

urgEl!lt care cer~tre

Other M?.a of lM H05i!ll



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-----------------------------------------------------------------------


9. Where do you spend MOST of your time working (tick one box only)?

Em!!t'9Ef1C)' Depar.ment (ED)

1If92ni care c~ (UCC)

::q~~al ume sperti 111 :11~ E I> illld ucc



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-----------------------------------------------------------------------------------Your feedback about services provided to the ED and Urgent Care Centre

1 0'. During business hours (0900~-1700hrs) how long does it USUAU Y take you to do the following activities. FOR A NON-URGENT PATIENT?

Obtilln an exls:Jn9 medical record

Obtain an appoli'ltment tor an lma.g glradiOIDg)' prDcellllre

.Receive :n.e reruns ~"l!!r an lmag:llg proced..-e

OMaln procJIIC1& or aellllce a om IIO&pltll pl'l<ll!llac.y

Speaa wltll a cHnlctan from (lie ED

.Recewe a ~·1£1t.•consulta::Jon nom tile- En When re~1re11

Speaa wltll a c a.n 111 Dlha aoeas or tile tl[)spllal

.Receive a ~·151t'constfla1Jo frOm otller melll'cal ~116 ~~onen reqLCecJ

L~ lllan 5 Les& ~.111 Le~» :11an l~ tr1al1 More tr.an

mJnllie& 15 mDlutes JO mlilvl!!s6D mlmnes EiJ 111ilvtes



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-----------------------------------------------------------------------------------Your feedback about services provided to the ED and Urgent Care Centre

11. AFTER business hours (0900-1700hrs) how long does it USUALLY take you to do the following actM ties- FOR A NON URGENT PATIENT?

Obtain an exle.:ln9 medical record

Obtain an appallltmMt ror an lmiJ9 gl'radiOIDgy prl)ce®re

Receive :he results alter an lrnaglllg procedLWe

ReceiVe the resi.C:';I; af.er a pattoD(ogy re1111est

Ob1alll prodl.IC1s or a!JVIce :tom tlospltiil ptlannac;y

Spea• with a CliniCian from :he ED

Receive a 'i'ISIIlc:onSIJita:loo :rom ttle E 0 when required

Speal . i¥1111 a en c lan tn ootiEJ areas or the tle&pClal

Receive a 'l'lsiL'consli'laUon from o111er rnellcal I.Wllts 1111'1M reqltled

l~ ttoan S LeSi llan leli& ~ l~ llla:1 ~ore tl'lan

m lnl1'1es 15 m!rlutesJO mlrtutes6D mlm.llet;ED rrtnutes



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--------------------------------------------------------------------------------------------Your feedback about the day-to-day operation of the Urgent Care Centre

12. Please indicate the extent to which you agree or disagree with the following

statements

111ere ill'e Clear crttena ror reremng pat:en11; to the ucc

lllere iil1!! clear crt ala for reremng paltenl& to a GP ra:ller ;:Jun the

ucc~~

starr nave S<Jl!ICIE!nt tralrtln.g ~o prD""ollCie :reat~nt to pal!en~S

at!ellellng the ucc

Stall' nave wme1em Stlpport to martag~> patiEilts treateo In me ucc

Stalr r.ave &Lilllcll!flt wpport to manage medical emagencles In :he

ucc

Stall' na-.·e 'Ciea:r crt1erta ror re•emng pa~en11; ~cl to the ::o It reqlfreCI

The ucc has &ll1'11Cient 1nrorma11on tecnnOlogy a;nd communication

equipment

The ucc r.as <JedlcateCI1\ml!:'llg to S'4Jp011 Clay-to-oay operatrons

The ucc has sufliCient clinical eqLCprnertllo m~>e1 the neells of

patiE111s

lllere are clear a t ata ror rerm al bact to a GP oiiii'Afng treatrnertl Ill (he ucc

lllere are Clear crtterta ror rererral to comrramlty &'4'poct seM ces arter

:reatment In the ucc

llle ucc rs ..,. ~slgrteCI TOr sla'JT

llle ucc Is wen des~eCI •or patlenls

s:roogl)'

~sagree Disagree

Neli:ral or

Don"l Know Agree

s:rongry

Agree



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----------------------------------------------------------------------------------------Your feedback about the impact of the Urgent Care Centre

The impact U/>Ofi d aff ...

13. Please indicate the extent t.o wflich you agree or disagree wit h the following

statements

r&es are $al:l&11e.d 'AI::llll1e!r p~esslonal roles aoo le6pOnliiiiiiiU:es tl

:ne ucc

Doctor& are ~;aU6tled wttllllielr professional rcies ami respoos!biiiUes

lll O!eUCC

Allied He-aiUI stan' ilfe $il:J&I[ed Willi :Jielr pro1esslonal roles and

respooslbJIIUes In llie ucc

a:encall stal! are ~;aJI!iCed Willi :heir prlll'e6S:on roles and

respooslbJIIUes In llie ucc

Inks 11erween 1111!' ucc and 1111!' S D are easily malntalni!'d

s tarr are sall:61ted ~~~o111i tilE' com.Jl(enly or pa:ll!flis admitted tor carl? In

:he uoc

s tarr are sall'61ted Willi till! comp(enly or pa:JI!fl:s admitted tor carl? In

:lie EO

Stal'l" a reo R:lli~ed Wltll the workload undenaJ:en In tile UCC

Dl&agree Nei.lral or

001111 KnOYI Agree



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----------------------------------------------------------------------------------Your feedback about the Impact of the Urgent Care Centre

The impact upon p3lienfs ...

14. Please indicate the extent to which you agree or disagree with the following statements

Hon-urgenl pa:!Eflts rE<:eWe :liE! same stamlanl Ill care In tile ucc as

1t1e-y ao In tile ED

on-urgeni pii:IEflJ:s spm<l l~s tme walling to be .a~ In :liE!

ucc 'comparea w1111 :ne : D

on-urgent pauen.:s speml less tme llelng i reate<l ln :liE! ucc compare<! wtll tile ED

on-urgeni pii:IEfll:s are sa:J511ell Wlttl the servlcespllMdell by tile

ucc

s:rongry II'sagre.:

DISagree Nellral or

Don1 Krtow Agree

s:rongry agre.:



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--------------------------------------------------------------------------------------Your feedback about the impact of the Urgent Care Centre

The impact upon community health providers __ _

Note !hat the most comm on "Polentially preventable cond'itions" include patients presenting with COPO, dehydration or gastroenteritis, UTis or pyelonephritis, dental cond'rtions, cen~itis, asthma, CHF, ear/nose/throat infections, convu lsxms d'ue to epilepsy. or diabetic complfcations .

15. Please indicate the extent to which you agree or disagree with the following

statements

l ocal GP$ are WPfJortlore of ttu: ucc model of can:

other canm.ut:.iy sEPI1ces are EUPfJOrtlore of 111e ucc model or care

Tile number or pilllen.:s preserulng to :ne ucc w1tll potEflC'a;:;

preva~taDI~ con.cmrons tlas aecreasea

The nurrtler of GP referral& to (lie U<:C ror patlerus ltlltl po:Efltrany preva~table 'con.dlt!ons tlas aecreasea

s:roogty !Xsagree

DISagree Neltral or Do~ Knclw

Agree s:roogty ·"-9rl:e



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------------------------------------------------------------------Other suggestions for improvement

I

16. Do you have any other comments about the Urgent Care Centre at your hospital? If

so, please outline briefly below.

17. Do yo'u have any suggestions :~~bout how c31re for non-c,omplex, low :~~cu ity, p:~~tients

could be improved?



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KCC Staff Survey

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NSW HeaHh: Evaluation of Urgent Care Centres

Introduction

The foDowing questians have been designed ID ga:her your feedback aboul lhe Urgem Care Cenue opera1ing at your

heallh seNice.

The 5-llrvey will take about 10 mittute s of your ti me to complete

Once comple<ed, your answers w iD be pi'OVided to an indeependent company m at has. been commissioned to

eva1ua:e the Urgent Care Centres in NSW.

Atty feedltack y ou provide will be treated cottficlentially

If you require any ad!fitional information or assistance in completing me survey, p lease contact Aspex Consulting

on 1800 300 802 '(free call) or send an em ail t.o survey@aspexconsulong,.com.au .

If yo u have any concerns or c omplaints a bout th'is survey, yoo may address them to a nominated representative> at

NSW Healih on 02 6625 5091.

Thank you for taking a few mjnu~s to provide your feedback abou1 the Urgent C are Centre at your hospiilal.



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NSW Health: Evaluation of Urgent Care Centres


*1. What is the name of your health se rvice?

Sydney Children's Hospital

Westmead Children's Hospiu l



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* 2. Wh:~t is your 1professionsl occup:~tion (tick one box only)?

Medical

Nursi:ng

Allied Heal1h

Hospital Administration

Clerical

011her '(please specify)

I

Respondents to this item will be automatically re-directed to 03

Respondents to this item wm be automatically re-directed to 04

Respondents to this item Will be automatically re-directed to 05

Respondents to this item wiD be automatically re-directed to 07

Respondents to this item wiD be automatically re-directed to 07

Respondents to this item will be automatically re-directed to 07



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3. What is your current level of professional employment (t ick one box only)?

Medical Ad ministration

Consultant

Registrar

Medical Officer

Medical Student

Other '(please specify)

I

Resportdeflts to this item will be automatically re-diJected to 07



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4. What is your current level of professional employment (t ;ick one box only)?

Nursing Administration Registered Nurse

Nu:rse Manat~er Enrolled Nurse

Nurse Practitioner Stu dent Nurse

Nurse Consultant

Other (please specify)

Respondents to this item will be automatically re-dlrected to 07



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5. Which Allied Health profession do you belong to (tick one box only)?

Physiotherapy

Social Work

NulritionJDi etetics

Speech P athoJogy

Occu;padonal Therapy

Other (please specify)

I



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6. What is your current level of professions'! employment (t ick one box only)?

Allied Health Man~er

Senior Ol inician (Grade J or 4)

Grade 2 Clinician

Grade 1 Clinician

Srudent CGnician

Other (please specifY}

I

Respondents to this item will be automatically re-cfrected to 07



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NSW Heatth: Evaluation of Urgent Care Centres


7. How many yea'rs have you been working at your current level of professional employment (tick one box only)?

0 to 3 years

3 to 5 years

5 to 10 years

More than 1 0 years



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8. In which :ne3 ·of the hospit31 do you currently work (t,ick 311 th3t 3pply)?

Em ergency Depa11ment

Urgen t C.Sre Centre

Other Area o• the Hospital



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9. Where do you spend MOST of your time working (tick one box only)?

Em ergency Deparunent (ED)

Urgent Care Centre (UCC)

Equal lime spem in the ED and UCC

Other areas of the hospital (please specify)

I



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NSW Heatth: Evaruation of Urgent Care Centres

Your feedback about services provided to the ED and Urgent Care Centre

10. During business hours (0900-1700hrs) how long does it. USUALLY tske for the following :~~ctivities to occur . with A NON-COMPLEX, NON,.URGENT PATIENT?

T ime to receive a plain film X-Ray (e.Q'-· limb} after it has

been requested

T im e to r-eceive a pathology result (e.g ., blood test) after a

specimen has been sent

T im e to r-eceive medications from the hospi&al pharmacy

after they have been ordered

T ime to ·Obtain a re-view from an ED

regi strar/consu llant/tellow after it has been requested

T ime to obtain a rev iew from a medical unit

regi strar/consu llant after it has been requested

T ime to ob!ain a review from a su:rgjcal

regi strar/consullant after it has been requested

T ime to obtain a re view from a psychiatry

regi strar/consullant after it has been requested

Less Less Less le.ss. More

than 5 than 15 than 30 than 60 than 60 kflow or

m inute.s minutes minutes minutes m inutes N/A



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Your feedback about services provided to the ED and Urgent Care Centre

11. AFTER business hou1rs (0900-1700hrs) how long does it USUALLY take for the following activities to occur- with A NON-COMPLEX, NON~URGENT PATIENT?

Time to ,.ea!ive a plain film X-Ray (e.g., limb} alter it tlas

been re<~ues:ted

Time to re-ceive a pathology resuh (e.g .. blood test) after a

specimen has been se-nt

Time to re-ceive medications from ttle hospital pharmacy

aftet" they have been ordered

Time to obtain a review from an ED

registmr/oonsul;antffellow afier it tlas been requested

Time to obtain a re'liew from a medical unit

registrar/oonsullant aft.er it has been requested

Time t.o obtain a rev iew from a SUlll.ical

,registrar/oonsulunt afi.er it has been requested

Time to obtain a review from a psycmatty

registrar/oonsulunt after it tlas been requested

l ess l ess Less l ess More Don'i

than 5 lhan 15 ihan 30 than 60 than 60 know or

minutes minu!.es minutes minutes minut es N/A



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Your feedback about the day-to-day operation of the Urgent Care Centre

12. Please indicate the ext ent to which you agree or dis3gree with the following st3tements

Tttere are clear criteria for refemnglstreaming ~lien ts to

the UGC

Staff have sufficien~ uain ing to provide lreatment to

patients attending the UCC

Staff have sufficient support to manage patients treated

in the UCC

Staff have sufficient support to manage medical

emergencies in the UCC

Staff have clear criteria for handing pat ients back to lhe

ED if requtred

The UCC has sufficien t information teclmology and

communication e<JUipment

The UCC has dedicated funding to support day-io-day

operat ions

The UGC has sulf"tcient clinical equipment to meet the

need's of ~tients

There are d ear criteria for referral back to a GP foD.owing

trealJTlent in the UCC

There are clear criteria for referral to comm unity support

seN ices after treatment in the UCC

Thee UCC is w ell designed fur staff

The UCC is wel l desi gned for ~lients

Strongly

disagree

Neutral orr Disagree Agree

Don't :Know

Strongly

Agree



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Your feedback about the impact of the Urgent Care Centre

The impact upon staff ..

13. Please indicate the extent to which you agree or disagree with the following statements

Nurses are satis1ieod wi1h their pro•essional roles and

responsibilities in the UCC

Doctors are satisfied with lhe;ir pro ·essional roles and

responsibilities in lhe UCC

Allied Heallh scalf are satisfied wittllheir professional

roles and responsibilrues in the UCC

Clerical su ff are satisiied with their professional roles

and respons ibil'ities in m e UCC

Links bemeen the UCC and !he ED are easily

maintained

Sta are satis fied with the complex ily of pat ients seen in

the UCC

Staff are satisfied with the complex ily of patients seen in

the EO

Staff are satisfied wi1h the workload undertaken in lhe

ucc

Staff are satisfied wi1h the workload undertaken in the

ED

Strongly

disagree

Neutral or Disagree Agree

Don't Know

Strongly

agree



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Your feedback about the impact of the Urgent Care Centre

The impact upon patients ...

14 .. Please indicat e the extent to which you 3gree or dis3gree with the following st3tements

lllon-oom plex. non-\Jrgent patien ts rec!!Ne th e s.ame

standard of care in ttl€ UCC as lhey do rn the ED

lllon-oom plex. non -urgent p.alie llis spend less time

waiting' to be assessed in the UCC compared w ith the

ED

Ncm-oom plex. norHJrgent patients spend less time bein~

treated in the UCC compared with tne ED

lllcm-oom plex. non-urgen t palients are salisfied wim the

sei'Vices provided by the UCC

Strongly

d'isagree

Neutral or Dtsagree Agree

Don't Know

Strongly

.ogree



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Other suggestions for improvement

15. Do you have any other comments about the Urgent Care Centre at your hospit al? If so, please outline briefly below.

.o:. l

,:J

16. Do you have any suggestions about how care for non-complex, low acuity, patients could be improved?

I

.. 1

~



130

Appendix 3 NSW Health UCC implementation stages

PHASE ACTIVITIES EVIDENCE OF COMPLIANCE

IDENTIFIED FROM PILOT

SITES

Phase 1 – Initiate and Assess

By end of Phase 1 the following should be achieved:

Implementation project aims are clearly stated;

The project has strong clinical engagement ;

Team members are meeting regularly and understand respective accountabilities;

There is agreement on the preferred Service Delivery Model, the scope of services to be provided, and estimated patient volume and workforce capacity required;

In the case of co-located and conversion models, the delivery location has been identified;

In the case of conversion and standalone models, interim arrangements to deliver UCC services have been developed; and

The Gateway checklist 1 has been completed and sent to NSW Health.

Phase 2 – Develop

By the end of Phase 2, the following should be achieved:

The Project Team understands how the UCC will operate on a day-to-day basis and has produced required operational documents and training material;

Recruitment activities, where required, have commenced;

The Implementation Plan reflects the dependent and critical activities required to Go Live;

Risks and issues are being managed and escalated as required; and

The Gateway checklist 2 has been completed and sent to NSW Health.

Phase 3 – Mobilise


Hard and soft facilities (building and contents) are ready to provide clinical services;

Documented agreements, contracts, and management reporting arrangements are in place and ready to support the governance of the UCC;

Staff have been transitioned and are ready to start providing services;

Patients, practitioners, clinicians and other stakeholders are aware of the UCC, its purpose, how they can access it, and when it will begin providing



131

PHASE ACTIVITIES EVIDENCE OF COMPLIANCE

IDENTIFIED FROM PILOT

SITES

services; and

The “Go Live” Gateway checklist 3 has been completed and sent to NSW Health.

Phase 4 - Deliver and Monitor


Patients are presenting and being referred to the UCC, and are receiving appropriate treatment;

Capacity has been adjusted to reflect demand, and actions are in place to address demand if there is significant variation from forecast;

Data and feedback has been collected to determine the impact and success of the service; and

NSW Health has completed the pilot evaluation and reported back to the service accordingly.



132

Appendix 4 Survey findings

Survey respondents by pilot site (n=169)

Professional occupation (n=169)

Type of nursing respondents (n=84)



133

Type of medical respondents (n=67)

Years working (n=169)

Areas worked most often across hospital (n=169)



134

Usual time for to receive X-ray results (n=169)

Usual time for to receive pathology results (n=169)

Usual time for to receive medications following ordering (n=169)



135

Time to obtain a review from ED registrar/consultant/fellow following request (n=169)

Time to obtain a review from another hospital unit registrar/consultant following request (n=169)

Time to obtain a review from a surgical registrar/consultant following request (n=169)



136

Time to obtain a review from psychiatry registrar/consultant following request (n=169)

Perceptions on set up and operation of UCC – all respondents (n-169)



137

Perceptions on set up and operation of UCC – non UCC (n=122) versus UCC (n=44) respondents



138

Perceptions on set up and operation of UCC - Nursing (n=84) versus Medical (n=67) respondents

~ aspex consulting -,. Medical Fisher's Z p ("sig] Nursing

Criteria for ED transfer 0.41 0.738 Criteria for ED transfer 23%

Criteria for Strearring 13% -0.34 0.846 Criteria for Strearring 14% t · Criteria for transfer to ronm .mity -2.17 0.041" Criteria for transfer to rorrm.mity 31%

Criteria for transfer to GP 0.44 0.736 Criteria for transfer to GP 35%

Dedeated tundilg 1% 187 0.084 Dedeated tundilg 51%

Designed for patients 174 0.095 Designed for patients 18%

Designed for staff % 0.91 0.394 Designed for staff 15%

ErrergenOJ Sup~rl 0.73 0.588 ErrergenOJ Sup~rl 15%

Steil trainilg -105 0.309 Stet! trainilg 14% I o%

Sufficient equprrent 0% 196 0.062 Sufficient equprrent 17%

Sufficient IT 2.04 0.056 Sufficient IT

Treatrrent Suwort -0.25 0.852 TreatrrentSuwort 14% 1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

1 Strongly Agree • Agree Neutral or Don1 Know • Disagee 1 Strongly dsagree 1 Strongly Agree 1 Agree Neutral or Don1 Know 1 Disagee • Strongly dsag ree

Note: Significance testing denotes differences in levels of 'net agreement' (i.e. strongly agree plus agree) to survey questions by each group of respondents depicted in the above graph.



139

Perceptions on set up and operation of UCC - KCC (n=88) versus UCC (n=81) respondents

~ aspex consulting -,. KCC Fis her's 2 p ("sig ) ucc

Criteria for ED transfer 20% 0.039" 2.14 Criteria for ED transfer

Criteria for strearring 9% 2.34 0.036" Criteria for strearring

-2.37 0.024" Criteria for transfer to rorrmmity

Criteria for transfer to GP 1.48 0.152 Criteria for transfer to GP

Dedicated fundng 0.72 0.511 Dedicated fundng

Designed for patients 0.39 0.750 Designed for patients

Designed for staff -0.51 0.630 Designed for staff

Emergency su~rt 11% 1.82 0.091 Emergency su~rt

Staftrainng 16% 0% -0.14 1.000 Staftrainng

Sufficient equpment 14% 0.69 0.523 Suffraent equpment

Sufficient IT 1.01 0.332 Sufficient IT

10% % 0.81 0.487 Treatment s~.pport

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

• Strongly Agree • Agree Neutral or Don' Know • Disagee • Strongly dsagree • Strongly Agree • Agree Neutral or Don' Know • Disagee • Strongly dsagree

Note: Significance testing denotes differences in levels of 'net agreement' (i e strongly agree plus agree) to survey questions by each group of respondents depicted in the above graph. • Denotes significant differences between groups.



140

Perceptions of satisfaction – all respondents (n=169)

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W011<load in ED 23%

Complexity of patients UCC 27%

Wor1<1oad in UCC 30% 2%

Nurses satisfied 42% 2%

Complexity of patients ED 20% 2%

Links between UCC & ED 15% 1%

Clerical 58% 2%

Allied health satisfied 65% 0%

Doctors satisned 41% 0%

0% 10% 20% 30% 40J/o 50J/o 60J/o 70J/o 80J/o 90J/o 100%

• Strongly Agree • Agree Neutral/Don't Know 1 Disagree 1 Strongly disagree



141

Perceptions of satisfaction – Non UCC (n=122) versus UCC (44)



142

Perceptions of satisfaction – Nursing (n=84) versus Medical (67)

~ aspex consulting -,. Medical Fisher's 2 p ("sig) Nursing

Allied health sclisfied 107 0.334 Allied health sclisfied

Clerical staff satisfied ·0.72 0.575 Clerical staff satisfied

CofTllledy of patients ED ·0.98 0.356 CofTlllexty of patients ED

Cofl'lllexty of patients UCC 16% 0.08 1000 Cofl'lllexty of patients UCC

Doctors satisfied 19% 3.67 0.001" Dodors satisfied

Links between UCC & ED 2.59 0.018" Links between UCC & ED

Nurses sclisfied -4.65 o.ooo· Nurses sclisfied

Wcrkload in ED 0.68 0.505 Wcrkload in ED

Wcrkload in UCC 24% -0.11 1000 Wcrkload in UCC

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

• SlrollJIY Agree • Agree Neutral or Don, Know • Disagee • StrollJIY dsagree • SlrollJIY Agree • Agree Neutral or Don, Know • Disagee • SlrollJIY dsagree

Note: Signiffcance testing denotes differences in levels of 'net agreement' (i.e. strongly agree plus agree) to survey questions by each group of respondents depicted in the above graph. • Denotes significant differences between groups

0%

1%

1%

100%



143

Perceptions of satisfaction – KCC (n=81) versus UCC (88)

~ aspex consulting -,. Fisher's 2 p ("sig) ucc

Allied health sctisfied -0.56 0.582 Allied health sctisfied

ClerK:al 0.07 1000 ClerK:<! I

ColllJiexty of patierts ED 2.54 0.016" ColllJiexty of patierts ED 27%

ColllJiexty of patierts UCC 3.82 o.ooo· ColllJiexty of patierts UCC 38%

Doctors satisfied 197 0.055 Doctors satisfied 48%

Links between UCC & ED 4.22 o.ooo· Links between UCC & ED 23%

Nurses sctisfied 2.23 0.036" Nurses sclisfied 49%

Wakbad inED 3.63 0.001" Wakbad inED

Wakbad in UCC 3.22 0.002" Wakbad in UCC 40%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

• Strorgly Agree • Agree Neutral or Donl Know • Disagee • Strongly dsagree • Strorgly Agree • Agree Neutral or Donl Know • Disagee

Note: Signiffcance testing denotes differences in levels of 'net agreement' (i e. strongly agree plus agree) to survey questions by each group of respondents depicted in the above graph • Denotes significant differences between groups.

• Strongly dsagree

100%



144

Perceptions of standard of care and waiting times – all respondents (n=169)

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Same standard of care

Less time waiting 18% 1%

Less time being treated 22% 1%

Satisfied with U CC 33%

0% 10% 20% 30% 40% 50% 60% 7f'flo 8f'!/o 9f'!!o 100%

• Strongly Agree • Agree Neutral/Don't Know • Disagree • Strongly disagree



145

Perceptions of standard of care and waiting times – Non UCC (n=122) versus UCC (n=44)

Perceptions of standard of care and waiting times – Nursing (n= 84 ) versus Medical (n=67)



146

Perceptions of standard of care and waiting times – KCC (n= 81 ) versus UCC (n=88)

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Fishe,.•s 2 p (""sig )

KCC ucc

Less time beng treated 20% -0.08 1.000 Less time beng treated 24% + Less t ime waitirg Ill% 1% 2.24 0.031" Less t1rre waltirg 26%

Same standard of care 0% % 1.91 0.077 Sarre standard of care 19%

21% 3.41 0.001" Satisfied .,.,;th UCC 44%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

• Strorgly Agree • Agree Neutral or Don' Know • Disag:ee • Strorgly dsagree • Strorgly Agree • Agree Neutral or Don' Know

Note: Significance testing denotes differences in levels of 'net agreement' (i.e. strongly agree plus agree) to survey questions by each group of respondents depicted in the above graph. • Denotes significant differences between groups.

• Disag:ee • Strorgly d sagree



147

Perceptions of community impact – all respondents (n=88)

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69% 1%

Preventable conditions decreased 1° 58% 2%

GP referrals for PPC decreased 63% 3%

GPs supportive 73% 1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

• Strongly Agree • Agree Neutral/Don't Know • Disagree • Strongly disagree



148

Perceptions of community impact – Non-UCC (n=62) versus UCC (n=26)

Perceptions of community impact – Nursing (n=56) versus Medical (n=32)



149

Appendix 5 KCC diagnostic categories and codes

INJURY OR POISONING % OF KCC PROFILE

Open wound of other parts of head 4.66%

Fracture of lower end of both ulna and radius 4.12%

Injury unspecified 3.76%

Fracture of other finger 2.79%

Open wound of lip and oral cavity 2.53%

Fracture of lower end of humerus 2.28%

Open wound of cheek and temporomandibular area 2.02%

Dislocation of elbow unspecified 1.50%

Foreign body in nostril 1.50%

Injury of muscles and tendons of unspecified body region 1.43%

Fracture of forearm part unspecified 1.38%

Sprain and strain of ankle 1.36%

Superficial injury of other parts of head 1.31%

Fracture of clavicle 1.30%

Fracture of lower end of radius 1.28%

Open wound of unspecified body region 1.14%

Unspecified injury of wrist and hand 1.12%

Open wound of finger(s) without damage to nail 1.07%

Foreign body in ear 0.98%

Fracture of tooth 0.98%

Fracture of other toe 0.94%

Fracture of lower leg part unspecified 0.90%

Open wound of head part unspecified 0.89%

Foreign body in alimentary tract part unspecified 0.85%

Open wound of scalp 0.80%

Crushing injury of thumb and other finger(s) 0.71%

Unspecified injury of forearm 0.71%

Fracture of metatarsal bone 0.70%

Contusion of knee 0.69%



150


Fracture of patella 0.68%

Open wound of eyelid and periocular area 0.68%

Unspecified injury of ankle and foot 0.66%

Fracture of shaft of radius 0.61%

Fracture of other metacarpal bone 0.58%

Other superficial injuries of ankle and foot 0.55%

Burn of unspecified degree of wrist and hand 0.53%

Fracture of shafts of both ulna and radius 0.51%

Injury of conjunctiva and corneal abrasion without mention of foreign body 0.50%

Injury of eye and orbit unspecified 0.49%

Sprain and strain of wrist 0.49%

Open wound of knee 0.48%

Open wound of other parts of foot 0.48%

Fracture of navicular [scaphoid] bone of hand 0.47%

Open wound of wrist and hand part part unspecified 0.47%

Fracture of thumb 0.47%

Sprain and strain of finger(s) 0.43%

Fracture of upper end of humerus 0.36%

Open wound of finger(s) with damage to nail 0.35%

Sprain and strain of other and unspecified parts of foot 0.35%

Superficial injury of wrist and hand unspecified 0.34%

Unspecified injury of lower leg 0.34%

Fracture of upper end of ulna 0.32%

Open wound of ear 0.32%

Fracture of lower end of tibia 0.32%

Open wound of lower leg part unspecified 0.31%

Fracture of nasal bones 0.30%

Contusion of elbow 0.29%

Fracture of upper end of radius 0.28%

Multiple fractures of forearm 0.28%

Other superficial injuries of wrist and hand 0.28%

Open wound of nose 0.28%

Infection following a procedure not elsewhere classified 0.26%

Fracture of first metacarpal bone 0.25%



151


Fractures of other parts of lower leg 0.25%

Fracture of upper limb level unspecified 0.25%

Contusion of shoulder and upper arm 0.25%

Open wound of other parts of lower leg 0.21%

Sprain and strain of other and unspecified parts of knee 0.21%

Superficial injury of nose 0.20%

Fracture of lateral malleolus 0.20%

Fracture of shaft of tibia 0.19%

Open wound of toe(s) without damage to nail 0.19%

Superficial injury of unspecified body region 0.18%

Unspecified injury of upper limb level unspecified 0.18%

Fracture of fibula alone 0.17%

Fracture of upper end of tibia 0.17%

Foreign body on external eye part unspecified 0.17%

Dislocation sprain and strain of unspecified joint and ligament of upper limb level unspecified

0.17%

Open wound of toe(s) with damage to nail 0.17%

Fracture of foot unspecified 0.15%

Fracture of other carpal bone(s) 0.15%

Sprain and strain of elbow 0.15%

Multiple superficial injuries of lower leg 0.15%

Foreign body in stomach 0.14%

Other injuries of eye and orbit 0.14%

Burn of unspecified degree of hip and lower limb except ankle and foot 0.13%

Fracture of shaft of ulna 0.13%

Fracture of other parts of forearm 0.13%

Dislocation of finger 0.12%

Fracture of shaft of humerus 0.12%

Superficial injury of scalp 0.12%

Dislocation sprain and strain of unspecified body region 0.11%

Superficial injury of ear 0.11%

Contusion of other parts of wrist and hand 0.11%

Sprain and strain of other and unspecified parts of hand 0.11%

Other superficial injuries of lower leg 0.11%

Contusion of other and unspecified parts of foot 0.10%



152


Burn of unspecified degree of trunk 0.10%

Superficial injury of lower limb level unspecified 0.09%

Fracture of lower end of femur 0.09%

Sprain and strain of shoulder joint 0.09%

Contusion of finger(s) without damage to nail 0.09%

Open wound of elbow 0.09%

Burn of unspecified degree of head and neck 0.08%

Unspecified injury of shoulder and upper arm 0.08%

Multiple fractures of fingers 0.08%

Burn of unspecified degree of ankle and foot 0.08%

Burn of unspecified degree of shoulder and upper limb except wrist and hand 0.08%

Multiple open wounds unspecified 0.07%

Superficial injury of head part unspecified 0.07%

Dislocation of knee 0.07%

Foreign body in pharynx 0.07%

Crushing injury of other and unspecified parts of wrist and hand 0.06%

Unspecified multiple injuries 0.06%

Open wound of lower back and pelvis 0.06%

Contusion of toe(s) without damage to nail 0.06%

Contusion of other and unspecified parts of forearm 0.06%

Fracture of unspecified body region 0.06%

Superficial injury of lower leg unspecified 0.06%

Crushing injury of toe(s) 0.06%

Open wound of upper limb level unspecified 0.06%

Other superficial injuries of forearm 0.06%

Dislocation of shoulder joint 0.05%

Fracture of other and unspecified parts of wrist and hand 0.05%

Contusion of other and unspecified parts of lower leg 0.05%

Burns of multiple regions unspecified degree 0.04%

Injury to multiple structures of knee 0.04%

Contusion of ankle 0.04%

Open wound of ankle 0.04%

Toxic effect Venom of spider 0.04%

Open wounds involving head with neck 0.04%



153


Contusion of eyeball and orbital tissues 0.04%

Dislocation of patella 0.03%

Injury of other pelvic organs 0.03%

Fracture of other tarsal bone(s) 0.03%

Rh incompatibility reaction 0.03%

Multiple open wounds of hip and thigh 0.03%

Superficial injury of upper limb level unspecified 0.02%

Superficial injury of trunk level unspecified 0.02%

Burn of first degree of trunk 0.02%

Other superficial injuries of abdomen lower back and pelvis 0.02%

Dislocation of acromioclavicular joint 0.02%

Fracture of mandible 0.02%

Other superficial injuries of eyelid and periocular area 0.02%

Sprain and strain of toe(s) 0.02%

Dislocation of toe(s) 0.02%

Fracture of shaft of femur 0.02%

Burn of third degree body region unspecified 0.02%

Injury of nerve(s) of unspecified body region 0.02%

Crushing injury of other parts of ankle and foot 0.02%

Traumatic amputation of other single finger (complete)(partial) 0.02%

Ocular laceration without prolapse or loss of intraocular tissue 0.02%

Fracture of neck of femur 0.02%

Fracture of scapula 0.02%

Open wound of forearm part unspecified 0.02%

Open wound with infection 0.02%

Tear of meniscus current 0.02%

Fracture of other and unspecified parts of lumbar spine and pelvis 0.02%

Contusion of thigh 0.02%

Open wound of upper arm 0.02%

Sprain and strain of jaw 0.02%

Open wound of neck part unspecified 0.02%

Contusion of eyelid and periocular area 0.02%

Contusion of toe(s) with damage to nail 0.02%

Contusion of finger(s) with damage to nail 0.02%



154


Multiple superficial injuries unspecified 0.02%

Superficial injury of hip and thigh unspecified 0.02%

Burns of multiple regions no more than firstdegree burns mentioned 0.01%

Dislocation of thoracic vertebra 0.01%

Fracture of lower limb level unspecified 0.01%

Sprain and strain of hip 0.01%

Traumatic rupture of ulnar collateral ligament 0.01%

Superficial injury of lip and oral cavity 0.01%

Superficial injury of neck part unspecified 0.01%

Open wound of other parts of thorax 0.01%

Injury of other specified intrathoracic organs 0.01%

Other superficial injuries of hip and thigh 0.01%

Dislocation of hip 0.01%

Sprain and strain involving (fibular)(tibial) collateral ligament of knee 0.01%

Burns involving less than 10% of body surface 0.01%

Avulsion of eye 0.01%

Fracture of forearm 0.01%

Open wound of breast 0.01%

Crushing injury of face 0.01%

Foreign body in bronchus 0.01%

Fracture of vault of skull 0.01%

Drowning and nonfatal submersion 0.01%

Multiple fractures of metacarpal bones 0.01%

Open wound of thorax part unspecified 0.01%

Burn of eye and adnexa part unspecified 0.01%

Unspecified injury of trunk level unspecified 0.01%

Complication of surgical and medical care unspecified 0.01%

Foreign body in other and multiple parts of genitourinary tract 0.01%

Injury of other and unspecified muscles and tendons at forearm level 0.01%

Toxic effect Toxic effect of contact with unspecified venomous animal 0.01%

Injury of extensor or abductor muscles and tendons of thumb at forearm level 0.01%

Poisoning Other and unspecified agents primarily affecting the cardiovascular system 0.01%

Infection and inflammatory reaction due to other internal orthopaedic prosthetic devices implants and grafts

0.01%



155

OTHER FACTORS INFLUENCING HEALTH STATUS % OF KCC PROFILE

Attention to surgical dressings and sutures 1.22%

Attention to other artificial openings of digestive tract 0.62%

General medical examination 0.32%

Followup examination after treatment for conditions other than malignant neoplasms 0.26%

Attention to gastrostomy 0.09%

Routine child health examination 0.07%

Dental examination 0.06%

Contact with and exposure to other communicable diseases 0.04%

Followup examination after treatment of fracture 0.04%

Examination and observation for unspecified reason 0.02%

Adjustment and management of vascular access device 0.02%

Laboratory examination 0.01%

Other general examinations 0.01%

Routine and ritual circumcision 0.01%

Fitting and adjustment of orthopaedic device 0.01%

Need for immunization against unspecified infectious disease 0.01%

Procedure for purposes other than remedying health state unspecified 0.01%

Followup care involving removal of fracture plate and other internal fixation device 0.01%

MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE % OF KCC PROFILE

Pain in joint 1.46%

Pain in limb 0.77%

Acquired deformity of musculoskeletal system unspecified 0.25%

Dorsalgia unspecified 0.05%

Acquired deformity of limb unspecified 0.04%

Arthritis unspecified 0.03%

Effusion of joint 0.03%

Trigger finger 0.02%

Residual foreign body in soft tissue 0.02%

Deformity of finger(s) 0.02%

Transient synovitis 0.02%

Neuralgia and neuritis unspecified 0.01%



156

MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE % OF KCC PROFILE

Other dorsalgia 0.01%

Rotator cuff syndrome 0.01%

Other meniscus derangements 0.01%

Malunion of fracture 0.01%

Muscle strain 0.01%

Myositis unspecified 0.01%

Scoliosis unspecified 0.01%

Joint disorder unspecified 0.01%

Pyogenic arthritis unspecified 0.01%

Juvenile osteochondrosis unspecified 0.01%

SYMPTOMS, SIGNS AND ABNORMAL FINDINGS NOS % OF KCC PROFILE

Other and unspecified abnormalities of gait and mobility 0.22%

Localized oedema 0.13%

Other general symptoms and signs 0.09%

Other and unspecified disturbances of skin sensation 0.03%

Restlessness and agitation 0.01%

Cyanosis 0.01%

Paraesthesia of skin 0.01%

Pain not elsewhere classified 0.01%

Localized swelling mass and lump multiple sites 0.01%

EYE AND ADNEXA % OF KCC PROFILE

Disorder of eye and adnexa unspecified 0.26%

Acute conjunctivitis unspecified 0.17%

Conjunctival haemorrhage 0.04%

Other specified disorders of eyelid 0.02%

Conjunctivitis 0.01%

Chronic conjunctivitis 0.01%



157

DIGESTIVE SYSTEM % OF KCC PROFILE

Disorder of teeth and supporting structures unspecified 0.20%

Impacted teeth 0.09%

Anal abscess 0.06%

Other specified disorders of teeth and supporting structures 0.06%

Other specified diseases of jaws 0.04%

Unilateral or unspecified inguinal hernia without obstruction or gangrene 0.02%

Anodontia 0.01%

Dyspepsia 0.01%

INFECTIOUS AND PARASITIC % OF KCC PROFILE

Viral warts 0.13%

Other viral agents as the cause of diseases classified to other chapters 0.13%

Enterovirus infection unspecified site 0.03%

Conjunctivitis due to adenovirus 0.02%

Tinea unguium 0.02%

Anogenital herpesviral [herpes simplex] infection 0.02%

Tinea pedis 0.01%

Granuloma inguinale 0.01%

Infestation unspecified 0.01%

Acute hepatitis B without deltaagent and without hepatic coma 0.01%

Other gastroenteritis and colitis of infectious and unspecified origin 0.01%

EAR AND MASTOID PROCESS % OF KCC PROFILE

Disorder of ear unspecified 0.20%

Other infective otitis externa 0.06%

Perforation of tympanic membrane unspecified 0.06%

Perforation of tympanic membrane 0.02%

Nonsuppurative otitis media unspecified 0.02%

Disorder of external ear unspecified 0.01%

Disorder of tympanic membrane unspecified 0.01%



158

EXTERNAL CAUSES % OF KCC PROFILE

Bitten or struck by dog 0.13%

Foreign body or object entering through skin 0.07%

Contact with sharp object undetermined intent 0.03%

Bitten or struck by other mammals 0.01%

Fall involving bed 0.01%

Assault by unspecified means 0.01%

Contact with venomous snakes and lizards 0.01%

Pedal cyclist [any] injured in unspecified traffic accident 0.01%

Pedestrian injured in traffic accident involving other and unspecified motor vehicles 0.01%

SKIN AND SUBCUTANEOUS TISSUE % OF KCC PROFILE

Chronic ulcer of skin not elsewhere classified 0.08%

Sunburn unspecified 0.04%

Other granulomatous disorders of skin and subcutaneous tissue 0.04%

Psoriasis unspecified 0.02%

Other nail disorders 0.02%

Ulcer of lower limb not elsewhere classified 0.01%

Nail disorders 0.01%

Pityriasis rosea 0.01%

Pyogenic granuloma 0.01%

Corns and callosities 0.01%

Pruritus unspecified 0.01%

Pseudofolliculitis barbae 0.01%

Anogenital pruritus unspecified 0.01%

Vasculitis limited to skin unspecified 0.01%

GENITOURINARY SYSTEM % OF KCC PROFILE

Disorder of penis unspecified 0.10%



159

GENITOURINARY SYSTEM % OF KCC PROFILE

Acute vulvitis 0.02%

NEOPLASTIC DISEASE % OF KCC PROFILE

Neoplasm of uncertain or unknown behaviour Neoplasm of uncertain or unknown behaviour unspecified

0.03%

Benign neoplasm Short bones of lower limb 0.01%

ENDOCRINE, NUTRITIONAL AND METABOLIC % OF KCC PROFILE

Coagulation defect unspecified 0.02%

Testicular dysfunction unspecified 0.01%

Insulindependent diabetes mellitus With other specified complications 0.01%

MENTAL AND BEHAVIOURAL % OF KCC PROFILE

Other conduct disorders 0.01%

Mixed specific developmental disorders 0.01%

NERVOUS SYSTEM % OF KCC PROFILE

Epilepsy unspecified 0.01%

Hereditary and idiopathic neuropathy unspecified 0.01%

CONGENITAL % OF KCC PROFILE

Hypospadias unspecified 0.02%



160

CIRCULATORY SYSTEM % OF KCC PROFILE

Rheumatic heart disease unspecified 0.01%

RESPIRATORY SYSTEM % OF KCC PROFILE

Pneumothorax unspecified 0.01%

GRAND TOTAL 77.39%



161

Appendix 6 UCC diagnostic categories and codes

INJURY OR POISONING % OF UCC PROFILE

Injury of muscles and tendons of unspecified body region 4.29%

Open wound of unspecified body region 2.55%

Sprain and strain of ankle 2.39%

Open wound of finger(s) without damage to nail 2.38%

Unspecified injury of wrist and hand 2.08%

Unspecified injury of ankle and foot 1.66%

Superficial injury of unspecified body region 1.47%

Fracture of unspecified body region 1.08%

Open wound of wrist and hand part part unspecified 1.03%

Fracture of other metacarpal bone 1.03%

Unspecified injury of head 0.92%

Unspecified injury of lower leg 0.77%

Fracture of metatarsal bone 0.77%

Fracture of other finger 0.64%

Allergy unspecified 0.58%

Open wound of lower leg part unspecified 0.58%

Fracture of lower end of radius 0.57%

Fracture of other toe 0.51%

Fracture of lateral malleolus 0.50%

Fracture of navicular [scaphoid] bone of hand 0.46%

Open wound of other parts of foot 0.42%

Fracture of other and unspecified parts of wrist and hand 0.40%

Fractures of other parts of lower leg 0.40%

Foreign body in cornea 0.37%

Injury of conjunctiva and corneal abrasion without mention of foreign body 0.37%

Open wound with infection 0.34%

Unspecified injury of forearm 0.33%

Open wound of other parts of head 0.32%

Fracture of shaft of radius 0.32%

Fracture of upper end of radius 0.31%



162


Open wound of forearm part unspecified 0.29%

Crushing injury of thumb and other finger(s) 0.28%

Fracture of foot unspecified 0.27%

Injury unspecified 0.27%

Fracture of other carpal bone(s) 0.26%

Burn of unspecified body region unspecified degree 0.25%

Sprain and strain of wrist 0.25%

Fracture of fibula alone 0.25%

Open wound of head part unspecified 0.24%

Foreign body in ear 0.20%

Other superficial injuries of wrist and hand 0.20%

Fracture of clavicle 0.19%

Other complications of procedures not elsewhere classified 0.18%

Open wound of other parts of wrist and hand 0.18%

Unspecified injury of shoulder and upper arm 0.18%

Dislocation of finger 0.17%

Injury of Achilles tendon 0.17%

Injury of eye and orbit unspecified 0.16%

Other superficial injuries of eyelid and periocular area 0.16%

Fracture of rib 0.16%

Open wound of toe(s) without damage to nail 0.16%

Sprain and strain of shoulder joint 0.15%

Fracture of shaft of humerus 0.14%

Infection following a procedure not elsewhere classified 0.14%

Other specified effects of external causes 0.14%

Open wound of knee 0.13%

Fracture of mandible 0.12%

Fracture of shaft of tibia 0.12%

Fracture of medial malleolus 0.11%

Fracture of lower end of tibia 0.10%

Burn of first degree of wrist and hand 0.09%

Open wound of thigh 0.09%

Fracture of lower end of both ulna and radius 0.09%

Unspecified injury of upper limb level unspecified 0.09%



163


Burn of unspecified degree of wrist and hand 0.08%

Dislocation of thoracic vertebra 0.07%

Dislocation of shoulder joint 0.07%

Fracture of upper end of ulna 0.07%

Injury to multiple structures of knee 0.07%

Contusion of other and unspecified parts of foot 0.06%

Dislocation of acromioclavicular joint 0.06%

Injury of multiple muscles and tendons at lower leg level 0.06%

Superficial injury of head part unspecified 0.06%

Unspecified injury of hip and thigh 0.06%

Burn of unspecified degree of hip and lower limb except ankle and foot 0.06%

Dislocation sprain and strain of unspecified joint and ligament of trunk 0.06%

Fracture of first metacarpal bone 0.06%

Open wound of ear 0.06%

Open wound of elbow 0.06%

Sprain and strain of hip 0.06%

Unspecified injury of lower limb level unspecified 0.06%

Unspecified injury of thorax 0.06%

Burn of unspecified degree of head and neck 0.05%

Crushing injury of other and unspecified parts of wrist and hand 0.05%

Multiple open wounds of lower leg 0.05%

Traumatic rupture of ulnar collateral ligament 0.05%

Effects of electric current 0.05%

Fracture of upper end of tibia 0.05%

Multiple open wounds unspecified 0.05%

Superficial injury of upper limb level unspecified 0.05%

Dislocation of patella 0.04%

Fracture of upper end of humerus 0.04%

Unspecified adverse effect of drug or medicament 0.04%

Multiple fractures of forearm 0.04%

Superficial injury of lower limb level unspecified 0.04%

Tear of meniscus current 0.04%

Burn of first degree of shoulder and upper limb except wrist and hand 0.03%

Foreign body in alimentary tract part unspecified 0.03%



164


Open wound of finger(s) with damage to nail 0.03%

Sprain and strain of toe(s) 0.03%

Toxic effect Other specified gases fumes and vapours 0.03%

Burns of multiple regions no more than firstdegree burns mentioned 0.03%

Burns of multiple regions unspecified degree 0.03%

Contusion of thorax 0.03%

Mechanical complication of urinary (indwelling) catheter 0.03%

Fracture of scapula 0.02%

Injury of extensor muscle and tendon of other finger(s) at forearm level 0.02%

Other superficial injuries of forearm 0.02%

Posttraumatic wound infection not elsewhere classified 0.02%

Superficial injury of wrist and hand unspecified 0.02%

Fracture of lower end of humerus 0.02%

Fracture of neck of femur 0.02%

Mechanical complication of other specified internal prosthetic devices implants and grafts 0.02%

Fracture of lower limb level unspecified 0.01%

Injury of multiple muscles and tendons at ankle and foot level 0.01%

Penetrating wound of eyeball with foreign body 0.01%

Burn of eyelid and periocular area 0.01%

Burn of first degree of head and neck 0.01%

Dislocation sprain and strain of unspecified body region 0.01%

Dislocation sprain and strain of unspecified joint and ligament of upper limb level unspecified

0.01%

Injury of multiple muscles and tendons at shoulder and upper arm level 0.01%

Mechanical complication of intrauterine contraceptive device 0.01%

Open wound of vagina and vulva 0.01%

Superficial injury of lower leg unspecified 0.01%

MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE % OF UCC PROFILE

Pain in joint 3.28%

Pain in limb 1.92%

Dorsalgia unspecified 1.27%



165

MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE % OF UCC PROFILE

Low back pain 1.02%

Cervicalgia 0.39%

Myalgia 0.36%

Sciatica 0.13%

Other specified soft tissue disorders 0.11%

Effusion of joint 0.10%

Arthritis unspecified 0.08%

Chondrocostal junction syndrome [Tietze] 0.08%

Deformity of finger(s) 0.07%

Bursopathy unspecified 0.06%

Gonarthrosis unspecified 0.05%

Lumbago with sciatica 0.05%

Rotator cuff syndrome 0.05%

Other dorsalgia 0.05%

Olecranon bursitis 0.04%

Achilles tendinitis 0.04%

Neuralgia and neuritis unspecified 0.04%

Fibroblastic disorder unspecified 0.03%

Osteomyelitis unspecified 0.03%

Arthrosis unspecified 0.02%

Other enthesopathy of foot 0.02%

Other specified intervertebral disc displacement 0.02%

Spontaneous rupture of unspecified tendon 0.02%

Bursitis of shoulder 0.01%

Lateral epicondylitis 0.01%

Patellar tendinitis 0.01%

Plantar fascial fibromatosis 0.01%

Synovitis and tenosynovitis unspecified 0.01%

Trigger finger 0.01%

Disorder of synovium and tendon unspecified 0.01%

Periarthritis of wrist 0.01%



166

SKIN AND SUBCUTANEOUS TISSUE % OF UCC PROFILE

Cellulitis unspecified 1.98%

Cellulitis of other parts of limb 1.53%

Cutaneous abscess furuncle and carbuncle unspecified 0.57%

Cutaneous abscess furuncle and carbuncle of limb 0.46%

Cellulitis of finger and toe 0.37%

Pilonidal cyst with abscess 0.27%

Local infection of skin and subcutaneous tissue unspecified 0.26%

Urticaria unspecified 0.17%

Cellulitis of face 0.16%

Cutaneous abscess furuncle and carbuncle of buttock 0.15%

Cutaneous abscess furuncle and carbuncle of face 0.12%

Ulcer of lower limb not elsewhere classified 0.12%

Dermatitis unspecified 0.10%

Ingrowing nail 0.09%

Cellulitis of trunk 0.08%

Chronic ulcer of skin not elsewhere classified 0.06%

Follicular disorder unspecified 0.06%

Decubitus ulcer and pressure area unspecified 0.06%

Sunburn unspecified 0.04%

Follicular cyst of skin and subcutaneous tissue unspecified 0.03%

Psoriasis unspecified 0.03%

SYMPTOMS, SIGNS AND ABNORMAL FINDINGS NOS % OF UCC PROFILE

Other and unspecified abdominal pain 2.24%

Chest pain unspecified 0.66%

Nausea and vomiting 0.55%

Other chest pain 0.51%

Headache 0.41%

Dizziness and giddiness 0.23%

Syncope and collapse 0.22%

Pain unspecified 0.19%

Epistaxis 0.18%



167

SYMPTOMS, SIGNS AND ABNORMAL FINDINGS NOS % OF UCC PROFILE

Pain localized to upper abdomen 0.18%

Cough 0.17%

Dyspnoea 0.14%

Localized swelling mass and lump head 0.14%

Fever unspecified 0.10%

Unspecified haematuria 0.10%

Retention of urine 0.06%

Localized swelling mass and lump neck 0.05%

Anaesthesia of skin 0.04%

Pelvic and perineal pain 0.04%

Localized swelling mass and lump trunk 0.04%

Chest pain on breathing 0.02%

Restlessness and agitation 0.02%

Localized oedema 0.01%

Other specified abnormal findings of blood chemistry 0.01%

Finding of alcohol in blood 0.01%

Other and unspecified abnormalities of gait and mobility 0.01%

Other illdefined and unspecified causes of mortality 0.01%

DIGESTIVE SYSTEM % OF UCC PROFILE

Other specified disorders of teeth and supporting structures 0.91%

Periapical abscess without sinus 0.80%

Acute appendicitis 0.31%

Constipation 0.26%

Acute cholecystitis 0.23%

Gastrooesophageal reflux disease without oesophagitis 0.21%

Dental caries unspecified 0.14%

Calculus of bile duct without cholangitis or cholecystitis 0.13%

Unspecified appendicitis 0.13%

Other specified diseases of jaws 0.11%

Gastritis unspecified 0.10%

Acute pancreatitis unspecified 0.08%



168

DIGESTIVE SYSTEM % OF UCC PROFILE

Cholangitis 0.08%

Gastrointestinal haemorrhage unspecified 0.07%

Other specified diseases of anus and rectum 0.05%

Anal fissure unspecified 0.04%

Cellulitis and abscess of mouth 0.04%

Other and unspecified intestinal obstruction 0.03%

Diseases of lips 0.03%

Acute gingivitis 0.02%

Peptic ulcer site unspecified Unspecified as acute or chronic without haemorrhage or perforation

0.02%

Crohn disease unspecified 0.02%

Haematemesis 0.02%

Other specified disorders of gingiva and edentulous alveolar ridge 0.01%

Umbilical hernia with obstruction without gangrene 0.01%

Disease of anus and rectum unspecified 0.01%

Disease of tongue unspecified 0.01%

GENITOURINARY SYSTEM % OF UCC PROFILE

Urinary tract infection site not specified 0.93%

Abnormal uterine and vaginal bleeding unspecified 0.72%

Unspecified renal colic 0.38%

Inflammatory disorders of breast 0.19%

Other specified disorders of male genital organs 0.10%

Acute tubulointerstitial nephritis 0.08%

Other specified abnormal uterine and vaginal bleeding 0.06%

Calculus of kidney 0.05%

Orchitis epididymitis and epididymoorchitis without abscess 0.04%

Excessive and frequent menstruation with regular cycle 0.04%

Irregular menstruation unspecified 0.04%

Other specified noninflammatory disorders of vagina 0.04%

Abscess of vulva 0.03%

Cystitis unspecified 0.03%



169

Dysmenorrhoea unspecified 0.02%

Other specified conditions associated with female genital organs and menstrual cycle 0.02%

Calculus of ureter 0.02%

Mittelschmerz 0.02%

Redundant prepuce phimosis and paraphimosis 0.01%

Disorder of breast unspecified 0.01%

RESPIRATORY SYSTEM % OF UCC PROFILE

Acute upper respiratory infection unspecified 0.65%

Unspecified acute lower respiratory infection 0.42%

Acute pharyngitis unspecified 0.25%

Asthma unspecified 0.24%

Pneumonia unspecified 0.21%

Acute frontal sinusitis 0.17%

Influenza with other respiratory manifestations virus not identified 0.13%

Acute sinusitis unspecified 0.11%

Acute bronchitis unspecified 0.10%

Peritonsillar abscess 0.08%

Other specified respiratory disorders 0.08%

Chronic sinusitis unspecified 0.06%

Lobar pneumonia unspecified 0.04%

Acute maxillary sinusitis 0.02%

Chronic obstructive pulmonary disease with acute exacerbation unspecified 0.02%

Disease of upper respiratory tract unspecified 0.01%

EYE AND ADNEXA % OF UCC PROFILE

Retained (old) intraocular foreign body nonmagnetic 0.89%

Papilloedema unspecified 0.36%

Conjunctivitis unspecified 0.29%

Disorder of eye and adnexa unspecified 0.12%

Hordeolum and other deep inflammation of eyelid 0.11%

Conjunctival haemorrhage 0.09%



170

EYE AND ADNEXA % OF UCC PROFILE

Blepharitis 0.06%

Purulent endophthalmitis 0.06%

Visual disturbance unspecified 0.06%

Other visual disturbances 0.05%

Corneal pigmentations and deposits 0.03%

Mucopurulent conjunctivitis 0.01%

Senile incipient cataract 0.01%

Exophthalmic conditions 0.01%

Herpesviral keratitis and keratoconjunctivitis 0.01%

Other conjunctival vascular disorders and cysts 0.01%

Other retinal vascular occlusions 0.01%

OTHER FACTORS INFLUENCING HEALTH STATUS % OF UCC PROFILE

Procedure not carried out unspecified reason 0.39%

Attention to surgical dressings and sutures 0.30%

Issue of repeat prescription 0.27%

Examination and observation following transport accident 0.21%

Medical care unspecified 0.19%

Other specified medical care 0.19%

Examination and observation following other inflicted injury 0.12%

Need for immunization against unspecified combinations of infectious diseases 0.11%

Laboratory examination 0.07%

Followup examination after unspecified treatment for other conditions 0.06%

Procedure not carried out because of patients decision for other and unspecified reasons 0.05%

Surgical followup care unspecified 0.05%

Contact with and exposure to other communicable diseases 0.02%

Orthopaedic followup care unspecified 0.02%

Counselling unspecified 0.01%



171

INFECTIOUS AND PARASITIC % OF UCC PROFILE

Gastroenteritis and colitis of unspecified origin 0.96%

Viral infection unspecified 0.47%

Zoster without complication 0.19%

Scabies 0.09%

Mumps without complication 0.05%

Varicella without complication 0.04%

Unspecified mycosis 0.03%

Bacterial infection unspecified 0.02%

Enteroviral vesicular stomatitis with exanthem 0.01%

Herpesviral vesicular dermatitis 0.01%

Tinea unguium 0.01%

PREGNANCY, CHILDBIRTH AND PUERPERIUM % OF UCC PROFILE

Mild hyperemesis gravidarum 0.70%

Threatened abortion 0.46%

Spontaneous abortion Complete or unspecified without complication 0.17%

Missed abortion 0.09%

Unspecified infection of urinary tract in pregnancy 0.05%

Blighted ovum and nonhydatidiform mole 0.04%

Pregnancyrelated condition unspecified 0.04%

Maternal care for intrauterine death 0.01%

EAR AND MASTOID PROCESS % OF UCC PROFILE

Otitis media unspecified 0.47%

Otitis externa unspecified 0.34%

Otalgia 0.27%

Acute otitis externa noninfective 0.25%

Abscess of external ear 0.05%

Tinnitus 0.04%

Cellulitis of external ear 0.02%



172

EAR AND MASTOID PROCESS % OF UCC PROFILE

Disorder of ear unspecified 0.01%

Other specified disorders of ear 0.01%

CIRCULATORY SYSTEM % OF UCC PROFILE

Phlebitis and thrombophlebitis of other deep vessels of lower extremities 0.61%

External haemorrhoids without complication 0.08%

Pulmonary embolism without mention of acute cor pulmonale 0.05%

External haemorrhoids with other complications 0.02%

Other forms of acute ischaemic heart disease 0.01%

Atrial fibrillation and flutter 0.01%

MENTAL AND BEHAVIOURAL % OF UCC PROFILE

Depressive episode unspecified 0.11%

Mental disorder not otherwise specified 0.06%

Schizophrenia unspecified 0.06%

Severe depressive episode without psychotic symptoms 0.04%

Mental and behavioural disorders due to use of alcohol Harmful use 0.04%

Unspecified nonorganic psychosis 0.03%

Bipolar affective disorder unspecified 0.02%

Generalized anxiety disorder 0.02%

Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances Dependence syndrome

0.02%

Reaction to severe stress unspecified 0.01%

Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances Withdrawal state

0.01%

Mental and behavioural disorders due to use of cannabinoids Dependence syndrome 0.01%

Mental and behavioural disorders due to use of opioids Withdrawal state 0.01%

Schizoaffective disorder unspecified 0.01%



173

EXTERNAL CAUSES % OF UCC PROFILE

Contact with sharp object undetermined intent 0.24%

Bitten or struck by other mammals 0.08%

NERVOUS SYSTEM % OF UCC PROFILE

Migraine unspecified 0.14%

Bell palsy 0.04%

Tensiontype headache 0.03%

Cluster headache syndrome 0.01%

ENDOCRINE, NUTRITIONAL AND METABOLIC % OF UCC PROFILE

Volume depletion 0.05%

Unspecified diabetes mellitus With multiple complications 0.03%

Insulindependent diabetes mellitus Without complications 0.01%

NEOPLASTIC DISEASE % OF UCC PROFILE

Benign neoplasm Urinary organ unspecified 0.06%

BLOOD AND IMMUNE SYSTEM % OF UCC PROFILE

Anaemia unspecified 0.01%

Coagulation defect unspecified 0.01%

GRAND TOTAL 80.99%



174

Appendix 7 Analysis of ED presentations by triage category



175

~ aspex consulting

~

5%

i 4'l' •

• 3% 5. 0

2%

f ~ 1% .t

0% A2 Evalualion Site 1 A2 Eveluaf10n Site 2

Tri'9' category 1 and 2 pruentalions

• 200&'07 • 2007108 • 2008J09 • 200Sf10 2010111 2011112 2012/ll

35%

~ 30%

25%

" ill 20% 5.

Ci 15%

t 10% !! Ill 5% a..

0% A2 Eva\Jation Slte 1 A2 Evaluation Sije 2

Triage c<~tegOf)' 3 prosentatioos

• 20116f07 • 2007108 • 2008109 2009110 2010111 2011112 2012113

100%

j 80%

-{! ill 60% 5.

Ci & 40%

i .. ~ 20%

a..

0% A2 Evaluation Site 1 A2 Evaluation Sije 2

Triage category 4 and S preuntatione

• 20116f07 • 2.007108 • 2008«)9 2009110 2010111 2011112 2012113



176

j SO%

c: 40% ill !5. 30% 0 i 20% i!!

= 10% Q.

110%

70%

J 60%

1! SO% ill !5. 40% 0 & 30%

~ 20%

• 10% Q.

0%

~ aspex consulting

~

BM Evaluaf.Kln BM Evai~Jation BM Peer A BM Peer B ~ Peer C BM Pi!er D BM Peer E BM Peer F BIA Peer G BIA Pe.., H BM Pi!er I Sile 4 Sije S

Tri'9' category 1 and 2 pruentalions

• 2007108 • 2008J09 2010111 20"11112 201211l

BIA Evaluation ElM Elra\Jalion ~ Peer A ~ Peer B BM Peer C ~ Peer D ElM Peer E BM Peer F BM Peer G BM Peer H BIA Peer I s~e 4 Site 5

Triago e<~tegory 3 preuntationo

• 20116f07 • 2008109 2009110 20"10111 2011112 20"12113

... BIA Evaluation BM EYBiualion BM Peer A BM Peer B ~ Peer C BM Peer D BM Peer E BM Peer f BM Peer G BM Peer H BIA PeEf' I

s~e 4 Sile 5

Triage category 4 and S presentations • 20116f07 • 2.007108 • 2008«)9 2009110 21)10111 2011112 20"12113



177

Appendix 8 Analysis of KCC/UCC re-presentations

Percentage of patients re-presenting

Specialist children’s hospitals (A2)

FINANCIAL YEAR A2 EVALUATION SITE 1 A2 EVALUATION SITE 2 PEER GROUP TOTAL

2006/07 4.60% 2.60% 4.20%

2007/08 4.00% 2.90% 3.70%

2008/09 3.60% 3.20% 3.50%

2009/10 3.40% 2.80% 3.30%

2010/11 3.10% 2.40% 2.90%

2011/12 3.40% 1.90% 3.00%

2012/13 2.60% 2.50% 2.60%

Total 3.60% 2.60% 3.30%



178

Tertiary referral hospitals (A1)

FINANCIAL YEAR A1 EVALUATION

SITE 3

A1 PEER

A

A1 PEER

B

A1 PEER

C

A1 PEER

D

A1 PEER

E

A1 PEER

F

A1 PEER

G

A1 PEER

I

A1 PEER

J

A1 PEER

K

PEER GROUP TOTAL

2006/07 4.20% 4.70% 5.40% 6.10% 5.40% 4.10% 5.60% 6.10% 4.40% 4.00% 5.00%

2007/08 1.70% 3.50% 5.90% 6.70% 5.60% 4.40% 5.70% 6.50% 3.90% 3.60% 5.10%

2008/09 3.70% 4.20% 5.70% 6.80% 4.00% 4.40% 5.00% 5.80% 4.50% 3.00% 4.80%

2009/10 3.90% 3.40% 4.80% 6.20% 3.70% 4.10% 4.70% 6.90% 3.60% 7.10% 3.00% 4.60%

2010/11 3.70% 3.80% 4.80% 6.00% 4.70% 3.30% 4.40% 6.00% 3.20% 5.90% 3.30% 4.40%

2011/12 4.20% 3.90% 5.30% 6.20% 4.60% 2.90% 4.50% 4.30% 3.20% 6.70% 3.50% 4.40%

2012/13 3.80% 4.20% 5.00% 4.30% 2.90% 4.40% 4.00% 9.90% 3.20% 4.80%

Total 3.90% 3.90% 5.20% 6.30% 4.50% 3.60% 4.70% 5.50% 5.30% 6.60% 3.30% 4.70%

Major metropolitan hospitals (BM)

FINANCIAL YEAR BM EVALUATION

SITE 4

BM EVALUATION

SITE 5

BM PEER

A

BM PEER

B

BM PEER

C

BM PEER

D

BM PEER

E

BM PEER

F

BM PEER

G

BM PEER

H

BM PEER

I

PEER GROUP TOTAL

2006/07 7.00% 7.10% 5.80% 5.10% 8.00% 6.40% 15.30% 7.70% 11.40% 15.70% 10.50% 8.90%

2007/08 7.10% 7.30% 6.00% 4.10% 2.20% 4.30% 12.20% 5.70% 13.30% 10.30% 13.80% 7.70%

2008/09 8.10% 4.60% 5.40% 4.90% 10.80% 5.10% 11.80% 5.60% 12.30% 14.60% 11.20% 8.30%

2009/10 11.40% 5.50% 7.20% 3.70% 6.90% 4.40% 13.10% 5.70% 15.60% 11.00% 12.70% 8.30%

2010/11 6.90% 5.50% 7.30% 4.80% 6.70% 4.70% 8.50% 4.60% 10.10% 9.50% 9.70% 6.70%

2011/12 5.60% 6.60% 7.00% 4.50% 6.60% 4.30% 5.40% 5.80% 6.10% 9.00% 6.10% 6.00%

2012/13 6.30% 5.80% 7.10% 4.40% 5.30% 4.70% 6.50% 4.60% 5.90% 6.60% 6.50% 5.80%

Total 7.30% 6.00% 6.70% 4.50% 7.20% 4.80% 9.70% 5.50% 9.90% 11.40% 9.50% 7.20%



179

Percentage of patients re-presenting





180


Hour of patients re-presenting




181





182

Day of patients re-presenting





183


Month of patients re-presenting




184





185

Median ED length of stay for patients re-presenting





186


Median time to triage for patients re-presenting




187





188

Median time to clinician assessment for patients re-presenting





189


Median time to separation for patients re-presenting




190





191

Percentage of patients discharged from the ED following re-presentation





192


Percentage of patients not referred to any sources following re-presentation and discharge from the ED




193





194

Percentage of patients referred to their GP following re-presentation and discharge from the ED





195


Percentage of patients referred to hospital outpatient departments following re-presentation and discharge from the ED




196





197

Appendix 9 List of evaluation and peer group sites

HOSPITAL SITE HOSPITAL NAME

A2 Evaluation Site 1 A207 The Children’s Hospital at Westmead

A2 Evaluation Site 2 C238 Sydney Children’s Hospital

A1 Evaluation Site 3 D224 Westmead Hospital (all units)

A1 Peer A A208 Royal Prince Alfred Hospital

A1 Peer B D209 Liverpool Hospital

A1 Peer C Q230 John Hunter Hospital

A1 Peer D C213 St George Hospital

A1 Peer E B218 Royal North Shore Hospital

A1 Peer F D210 Nepean Hospital

A1 Peer G B202 Gosford Hospital

A1 Peer H P208 Wollongong Hospital

A1 Peer I C208 Prince of Wales Hospital

A1 Peer J A212 St Vincent’s Hospital, Darlinghurst

A1 Peer K A237 Concord Hospital

BM Evaluation Site 4 B206 Wyong Hospital

BM Evaluation Site 5 D215 Campbelltown Hospital

BM Peer A C214 Sutherland Hospital

BM Peer B D227 Bankstown / Lidcombe Hospital

BM Peer C D203 Blacktown Hospital

BM Peer D A202 Canterbury Hospital

BM Peer E B210 Hornsby and Ku-Ring-Gai Hospital

BM Peer F D206 Fairfield Hospital

BM Peer G B214 Mona Vale and District Hospital

BM Peer H D201 Auburn Hospital

BM Peer I B212 Manly District Hospital

evaluation of urgent care centres pilot · 4/2/2014 · final report 2 april 2014 3 ... ucc or...

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