Rapid triage: award-winning action plan slashes four-hour target breaches

How an emergency nurse practitioner team transformed an under-pressure eye casualty service

Before Taurai Matare spearheaded the transformation of eye casualty at Whipps Cross University Hospital in London, the department was repeatedly breaching the four-hour standard, raising concerns about patient safety.

‘There were 118 breaches in the first three months of 2015 – something had to change,’ says Ms Matare, advanced nurse practitioner and matron for ophthalmology. ‘There were only one or two triage nurses and an eye casualty doctor and no pathways for patient follow-ups or inpatient referrals.

New model of care

‘Inappropriate attendances were a problem, with no system to quickly identify and redirect patients with non-urgent conditions. Patient attendances were high and increasing; managers were alerted when breaches took place, but there was no action plan to manage those breaches.’

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The answer was a new model of care, co-designed and implemented by Ms Matare (also known as Tara), who was crowned RCN Nurse of the Year at the RCNi Nurse Awards 2019 after winning the Leadership category for her work transforming ophthalmology services at Whipps Cross.

A core team of emergency nurse practitioners (ENPs) – Salifu Ibrahim, Sarah Lagudah and Mazvita Chigavazira – was empowered to lead the five key areas of the rapid triage pathway, supported by a multidisciplinary team.

Knock-on effect for the ED

‘My business cases for ENPs kept being thrown out,’ says Ms Matare. ‘So consultant Sudeshna Patra and I cancelled our clinics for one week, seeing and discharging patients and implementing pathways. We did not breach the four-hour standard at all, which had a knock-on effect on the breach rate for the main A&E.

‘Our argument was accepted and we got two ENPs. People were asking why we hadn’t done it before. And we have maintained this over two years, despite an increase in the number of patient arrivals by 77 per month.’

‘One third of all eye casualty attendees were seen, treated and discharged by the ENPs without seeing a doctor’

Taurai Matare, RCN Nurse of the Year 2019

Last year the ENPs audited the service they provided to 10,545 patients attending eye casualty. The ENPs provided vision tests, dilating eye drops and scans prior to the patient seeing a doctor, delivered advice over the phone, managed urgent inpatient referrals and monitored the four-hour standard. They also provided patient education, advice and minor treatments.

‘One third of all eye casualty attendees were seen, treated and discharged by the ENPs without seeing a doctor, with 27% referred to alternative pathways such as GPs,’ says Ms Matare. ‘They have reduced the number of four-hour breaches to 0.4 per week.

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‘People travel to come to us’

‘Patients have benefited from spending less time in eye casualty and the performance figures have a positive impact on the overall Whipps Cross A&E performance.

‘But most importantly, eye casualty is achieving safe, effective and prompt care for patients, ENP colleagues feel valued and staff morale is high.’

ENP Ms Lagudah credits Ms Matare for the impressive figures. ‘Tara is the real force in the unit and makes sure it is noticed and appreciated,’ she says. ‘It can be very challenging being a small district hospital offering eye casualty.

‘In one sense we are a victim of her success because people travel to come to us because they know the standard of care we now offer is as good as Moorfields [eye hospital], and we are receiving increasingly complex cases.

‘But as a leader Tara is so, so supportive and everyone knows they are always welcome in her office. You can always go to her. She is very passionate about training and gives everyone that attention.’

All the winners from the RCNi Nurse Awards 2019