SortED’s Investigation (Ix) recommendations

One of the main objectives for SortED was to move away from triage to a process more like Rapid Assessment and Treatment (RAT) where a doctor gets investigations and early treatments (Rx) underway during the initial assessment.

 

The control arm of our ED study showed that serial processing still prevails, usually with 4 waits before treatment is given.

 

Arrive –1–> triage — 2 –> clinician evaluation –3–> Ix ordered–4–> Rx ordered

 

For example, the median time to request an ECG  was 46.5 minutes after arrival. With SortED the ECG was ‘requested’ at triage < 2 minutes after first seeing the patient.

 

During the ‘Sort’ process SortED triggers an Ix list of investigations and an Rx list with treatments and procedures (like IV access). I’ll deal with Rx later.

 

The sub-set of Ix displayed for each presentation:

 

• must not be too long a list (we want a speedy process)
• must not encourage over investigation or irrelevant tests
• should allow missing items to be entered, but ideally contain every likely Ix

 

SortED, due to its Graphic User Interface (GUI), is able to use many more presentations than the MTS approach. For example, we added ‘Suspected sepsis’ and ‘Dizziness & vertigo’  neither well covered in MTS 2 or 3.

 

The advantage of building prototypes is you test, refine and retest learning a lot in the process. The disadvantage is that you generate huge amounts of data to be analysed!

 

Were the investigations selected appropriate?

 

The first 157 patients had the ‘steam-hammer’ approach to analysis. That is a consultant examining the patients’ SortED record and classifying each Ix selected on SortED as either appropriate or unnecessary, also recording any omitted investigations.

 

983 Ix were selected for this cohort (6.3 Ix per patient) of which 964 (98.1%) were deemed by the consultant who reviewed each patient’s ED record as appropriate and only 19 (1.9%) were inappropriate. The median number of Ix proffered on these lists was 12 suggestions, so the nurses were clearly selective in what they chose and did not simply use the whole list.

 

There were only 67 relevant investigations which had been omitted (0.4 per patient). Further analysis of the omitted Ix could now take place in Somerset and Jacqui Garland checked each record to determine which presentation had been used and then whether the omitted Ix was or was not on the displayed list. Of 67 omitted items 28 had been omitted by the nurse and 39 had been left off the relevant list.

 

No chance of continuing such a labour intensive process in the winter months! Also, one might argue that this approach relies on a single ED consultant’s opinion.

 

Gillie Francis – Oct 2017