Project EPIC-START
The five-year project “Implementation evaluation of the Emergency nurse Protocol Initiating Care—Sydney Triage to Admission Risk Tool (EPIC-START) model of care” is supported by an Medical Research Future Fund (MRFF) grant.
EPIC is a clinical framework to support the earlier delivery of standardised evidence-based nurse-initiated treatment by emergency nurses for over 70 of the most common emergency department (ED) adult and paediatric presentations.
START is a validated early decision support/risk tool to support decisions for disposition from ED.
Together with a clinical deterioration alert system they make up EPIC-START model of care.
The primary objective of EPIC-START is to implement EPIC-START and evaluate its system implications across 30 EDs/multi-purpose services in NSW, and the secondary objectives are to determine the implementation of EPIC-START on:
- Increase in proportion of patients receiving care within national triage timeframes
- Decreased patient length of stay in the ED
- Faster time to analgesia
- Better patient experience
- Overall treatment costs reduced
- Clinician uptake
About the project
Led by Professor Kate Curtis, this $2,847,592 project will implement and evaluate EPIC-START with frontline clinicians at 30 EDs to give our patients better access to early evidence-based treatment pathways.
EPIC-START seeks to improve patient outcomes through earlier decisions, delivery of care, and detection of clinical deterioration by front-line ED clinicians and is founded on a significant body of work undertaken by our team and partner organisations over the past five years.
We are working closely with NSW Agency for Clinical Innovation to ensure EPIC protocols will be in line with the NSW state implementation.
ACTRN: ACTRN12622001480774p
The problem
The millions of Australians seeking care in our emergency departments (ED) each year are often confronted by overcrowded waiting rooms, ambulance ramping, and long wait times.
Current models of care in ED are not designed to help patients move through ED efficiently in these situations. An ED patient may needs hospital admission, but there are no in-patient ward beds available.
Thus, the patient requiring admission is stranded in the ED, and ED capacity to care for incoming patients is compromised, further influencing the cycle.
The EPIC-START model of care will help this situation in 30 NSW EDs. The Early nurse Protocol Initiated Care—Sydney Triage to Admission Risk Tool by implementing data analytic tools and evidence-based clinical pathways specifically designed to improve patient flow in ED.
The model focuses on the three "D principles" of patient flow:
- earlier decision-making,
- delivery of care, and
- detection of clinical deterioration.
Validated decision support tools will be deployed at triage to stream patients to various parts of the hospital, with treatments commenced earlier using standardised nurse-initiated pathways across all common illnesses presenting to ED.
Those who deteriorate despite early interventions will be flagged to senior doctors using electronic alerts based on data in the electronic medical records, with an aim to improve efficiency and safety in ED.
Sam's Story - an example of EPIC-START
Sam arrives by ambulance to the local ED after suffering at home for two days with nausea and lower abdominal pain.
Sam is a 78 year-old person with diabetes and chronic heart disease.
It is a busy night in the ED with many patients waiting to be seen.
Sam has a low-grade fever (37.8C), a normal blood pressure and pulse, and is allocated a triage category three that is, to receive treatment within 30 minutes.
Two hours after triage (not 30min), Sam - who is now anxious, upset and in more pain - is finally seen by the Resident Medical Officer (RMO) who, because of ED overcrowding, was unable to attend sooner.
Sam is suspected of having a urinary tract infection, so the RMOa takes blood and urine tests, and orders analgesia.
The plan is to wait for the results of the pathology tests before discussing treatment with the ED Consultant.
Three hours after Sam's arrival, Sam is still waiting for treatment: the pain has intensified, and dizziness has set in. Sam reports this to a nurse.
Sam's blood tests indicate severe sepsis, an outcome that could have been avoided had Sam been treated sooner.
Four hours after Sam's arrival, intravenous antibiotics are administered: but Sam has deteriorated and is rushed to the Intensive Care Unit at another hospital that can deal with the crisis.
Sam spends a further month in hospital for ongoing rehabilitation.
Sam's total length of stay in the ED was eight hours.
Sam's triage nurse calculates a Sydney Triage to Admission Risk Score (START) that identifies a very likely hospital admission. This is automatically flagged to the hospital bed manager who begins the process of sourcing a hospital bed.
At the same time, the emergency nurse commences and Emergency Nurse Protocol Initiated Care (EPIC) protocol for a patient with abdominal pain.
WIthin 30 minutes of ED arrival, Sam has an intravenous cannula inserted, urine and blood tests are conducted, is given analgesia: Sam is now calmer.
By the time the RMO sees Sam (typically two hours after triage), Sam's pain is much better, and blood test results have returned.
At that consultation, it is decided that Sam should have broad spectrum antibiotics, because the initial blood test results indicated severe sepsis.
Sam is placed in a monitored area of the ED, given further intravenous fluids and antibiotics, and Sam's urine output is monitored.
After three hours, Sam's clinical condition has improved, despite the initial blood test results, and is reviewed by the admitting team over the phone who agree with the management plan.
An in-patitient ward bed had already been assigned to Sam based on the initial triage START assessment.
Orderlies take Sam to the medical ward at the same hospital, where Sam spend a further seven days under the geriatric service. Sam's family is relieved.
Sam's total ED length of stay was less than four hours.
The study
This project will evaluate the EPIC-START model of care in four Local Health Districts in NSW: Southern NSW LHD, Western Sydney LHD, Northern NSW LHD and Sydney LHD in four phases:
- Pre-implementation: collect baseline comparison data and identify barriers to implementation
- Implementation strategy: develop site-specific implementation strategies based on stage 1
- Implementation
- Evaluate the implementation: patient, health service, implementation outcomes (cost, fidelity, usability)
Partnering institutions
Our leading team of clinician researchers, consumers and partners ensures representation of key agencies that deliver or support emergency care in Australia. They include:
- seven universities:
- University of Sydney
- University of Technology Sydney
- Macquarie University
- Deakin University
- Queensland University of Technology
- University of Wollongong
- Royal Melbourne Institute of Technology
- eight health districts:
- Illawarra Shoalhaven
- Northern NSW
- Southern NSW
- Sydney
- Western Sydney
- NSW Health
- NSW Agency for Clinical Innovation (NSW ACI)
- NSW Emergency Care Institute
- Australian Commission on Safety and Quality in Health Care
- the Australian College of Nursing
- the College of Emergency Nursing Australasia
- the College of Emergency Medicine Australasia.
We are working closely with NSW Agency for Clinical Innovation to ensure EPIC protocols will be in line with the state implementation of EPIC protocols.
The team led by Professor Kate Curtis and is based at the University of Sydney.
- Associate Professor Michael Dinh, SLHD
- Dr Amith Shetty, WSLHD
- Professor Margaret Fry, UTS
- Professor Timothy Shaw, University of Sydney
- Dr Thomas Lung, University of Sydney
- Dr Margaret Murphy, WSLHD
- Associate Professor Ling Li, Macquarie University
- Dr Hatem Alkhouri, ACI
- Professor Julie Considine, Deakin University - Eastern Health
- Dr Sarah Kourouche (study coordinator), University of Sydney
- Dr James Hughes, QUT
- Professor Ramon Shaban, University of Sydney
- Wayne Varndell, SESLHD
- Associate Professor Christina Aggar, NNSWLHD
- Saartje Berendsen Russell, SLHD
- Kylie Smith, NSW Agency for Clinical Innovation
- Dr Radhika Seimon, SLHD
- Dr Mary Lam, RMIT
- Louise Casey, Southern NSW LHD
- Alfa D’Amato, Ministry of Health
- Dr Trevor Chan, Australian College for Emergency Medicine
- Professor Julia Morphet, College of Emergency Nursing Australasia
- Laura Griffin, NSW Agency for Clinical Innovation
- Kerrianne Ryan, NSW eHealth
- Margerita Murgho, Australian Commission on Safety and Quality in Health care
- Associate Professor Judy Mullan, University of Wollongong