Using Transprofessional Care in the Emergency Department to Reduce Patient Admissions

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Journal of Interprofessional Care
ISSN: 1356-1820 (Print) 1469-9567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijic20
Using transprofessional care in the emergency
department to reduce patient admissions: A
retrospective audit of medical histories
Julia Morphet, Debra Lee Griffiths, Kimberley Crawford, Allison Williams,
Tamsin Jones, Belinda Berry & Kelli Innes
To cite this article: Julia Morphet, Debra Lee Griffiths, Kimberley Crawford, Allison Williams,
Tamsin Jones, Belinda Berry & Kelli Innes (2016) Using transprofessional care in the emergency
department to reduce patient admissions: A retrospective audit of medical histories, Journal of
Interprofessional Care, 30:2, 226-231, DOI: 10.3109/13561820.2015.1115394
To link to this article: http://dx.doi.org/10.3109/13561820.2015.1115394
Published online: 08 Mar 2016.
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ORIGINAL ARTICLE
Using transprofessional care in the emergency department to reduce patient
admissions: A retrospective audit of medical histories
Julia Morpheta , Debra Lee Griffiths a , Kimberley Crawfordb , Allison Williams b , Tamsin Jonesa , Belinda Berryc ,
and Kelli Innes a
a
School of Nursing and Midwifery, Monash University, Frankston, Victoria, Australia; b
School of Nursing and Midwifery, Monash University, Clayton,
Victoria, Australia; c Hospital Admission Risk Program (HARP), Peninsula Health, Frankston, Victoria, Australia
ABSTRACT
The demand for emergency department (ED) services has increased significantly, due to our increasingly
ageing population and limited access to primary care. This article reports outcomes from a transprofes-
sional model of care in an ED in Victoria, Australia. Nurses, physiotherapists, social workers, and
occupational therapists undertook additional education to increase the range of services they could
provide and thereby expedite patient flow through the ED. One hundred patients who received this
service were matched against 50 patients who did not. The most common reasons for patient admission
were limb injury/limb pain (n = 47, 23.5%) and falls (n = 46, 23.0%). Transprofessional interventions
included applying supportive bandages, slings, zimmer splints and controlled ankle motion (CAM) boots,
and referral to new services such as case management and mental health teams. The rate of hospital
admissions was significantly lower in the transprofessional group (n = 27, 18.0%) than in the reference
group (n = 19, 38%, p = 0.005). This group also had a slightly lower re-presentation rate (n = 4, 2.7%)
than patients in the reference group (n = 2, 4.0%). There are many benefits that support this model of
care that in turn reduces ED overcrowding and work stress. A transprofessional model may offer a
creative solution to meeting the varied needs of patients presenting for emergency care.
ARTICLE HISTORY
Received 30 May 2014
Revised 16 August 2015
Accepted 29 October 2015
KEYWORDS
Collaboration; emergency
department; patient
outcomes; teamwork;
transprofessional
Introduction
Emergency departments (EDs) globally are experiencing an
ever-increasing demand on services (Lowthian et al., 2012;
Trzeciak & Rivers, 2003). This increase is attributed to a
growing and increasingly aged population (AIHW, 2011;
Pallin, Allen, Espinola, Camargo, & Stephen Bohan, 2013)
and increasing chronic illness (NSW Health, 2007;
Productivity Commission, 2005). Limited access to primary
care results in many people attending EDs as a way to access
healthcare (NSW Health, 2007). Another factor contributing
to service demand in the ED is access block. Access block is a
state in which ED patients awaiting admission are unable to
be transferred to the wards within a reasonable time frame, as
there are no available beds (Australasian College for
Emergency Medicine, 2009). Access block has been well-docu-
mented to contribute to ED overcrowding, which has negative
implications for both patients and staff. ED overcrowding
results in delays to treatment, increased errors and increased
mortality (Kulstad & Kelley, 2009; Kulstad, Sikka, Sweis,
Kelley, & Rzechula, 2010; Pines et al., 2007; Sills, Fairclough,
Ranade, & Kahn, 2011; Sprivulis, Da Silva, Jacobs, Frazer, &
Jelinek, 2006). ED overcrowding also contributes to work
stress and job dissatisfaction for ED staff (Pines et al., 2007).
Given the ageing population, and increase in chronic illness,
global demand on EDs is expected to continue to grow,
increasing the workload for ED staff.
Many strategies have been introduced to address the grow-
ing service demand on EDs. Typically, these strategies aim to
improve patient flow and reduce access block and overcrowd-
ing. Examples of such strategies include waiting room nurses,
streaming, rapid assessment teams, short stay units and care
coordination programs (Crawford et al., 2014). A recent
reform to emergency care in Australia aimed at improving
patient flow was the introduction of a key performance indi-
cator (KPI) based on patient length of stay in the ED. The
National Emergency Access Target (NEAT) requires that 90%
of patients be discharged from or transferred out of the ED
within 4 hours of arrival (Department of Health and Ageing,
2012). Finally, another strategy to address growing ED service
demand is a transprofessional care model, which has been
introduced in the ED of a Victorian (Australia) health service
(Innes et al., 2015).
A transprofessional group consists of members drawn
from a range of professions (Rosenfield, 1992; Thylefors,
Persson, & Hellström, 2005), in this case, occupational ther-
apy, physiotherapy, nursing and speech pathology.
Transprofessional teams are a unique way of drawing together
the skills of different professions into a cohesive unit who
work together toward a common goal (Rosenfield, 1992;
Thistlethwaite, Jackson, & Moran, 2013; Thylefors et al.,
2005). In a multiprofessional model, individuals from varied
professions work in parallel to perform profession-specific
CONTACT Julia Morphet [e-mail] School of Nursing and Midwifery, Monash University, PO Box 527, Frankston, VIC 3199, Australia.
Color versions of one or more figures in the article can be found online at http://www.tandfonline.com/ijic.
JOURNAL OF INTERPROFESSIONAL CARE
2016, VOL. 30, NO. 2, 226–231
http://dx.doi.org/10.3109/13561820.2015.1115394
© 2016 Taylor & FrancisDownloaded by [Library Services City University London] at 18:00 04 April 2016

assessment, planning and delivery of care to address common
goals (Rosenfield, 1992; Smart & Smith, 2013; Thylefors et al.,
2005). Interprofessional teams are more collaborative, work-
ing together to address common goals and sharing commu-
nication, but still working from a profession-specific basis
(Dyer, 2003; Rosenfield, 1992; Thylefors et al., 2005; Tran,
2012). By comparison, transprofessional teams cross the
boundaries of professions (Rosenfield, 1992; Thylefors et al.,
2005), completing training in other professions, which allows
flexibility in workload, or what some have defined as role
blurring (Sims, Hewitt, & Harris, 2015; Thylefors et al.,
2005). Team members have shared responsibilities, and
work collaboratively, sharing knowledge and skills, and sup-
porting each other to solve problems and deliver services
(Dyer, 2003; Thylefors et al., 2005). The transprofessional
skills of team members allow them to provide whichever
services and skills are required at any given time. This is an
important advantage of the transprofessional model, as it
avoids the delays associated with waiting for multiple specia-
lised assessments (Innes et al., 2015; King et al., 2009). Thus,
consulting times are decreased, as duplication is removed
(Thylefors et al., 2005). As a result, discharge from the ED
can be expedited (Innes et al., 2015; King et al., 2009). For
example, instead of waiting for an occupational health assess-
ment, a physiotherapy assessment and a social work assess-
ment, one transprofessional team member can complete a
comprehensive assessment and deliver all required interven-
tions. The use of transprofessional teams has been described
internationally in paediatric disability units (Stepans,
Thompson, & Buchanan, 2002), rehabilitation (Cartmill,
Soklaridis, & Cassidy, 2011; Reilly, 2001) and palliative care
(Daly & Matzel, 2013). However, there is a paucity of research
examining the outcomes of transprofessional teams in
healthcare.
It is hypothesised that the transprofessional team provide
efficient, effective and economic patient care (King et al.,
2009; Thylefors et al., 2005). One study has shown that a
transprofessional team provided an essential service in ED,
ensuring safe discharge and patient follow-up, and improving
ED efficiency (Innes et al., 2015), yet no other formal evalua-
tion of the transprofessional team has been published. This
study aimed to critically evaluate the following important
outcomes arising from the transprofessional model of care
in the ED: patient admission rates; length of stay in the ED
and patient re-presentation rates to the ED following dis-
charge home.
Background
The study was undertaken in a metropolitan hospital in Victoria,
Australia. In 2012, there were 56,286 patient presentations to the
ED (Australian Institute of Health and Welfare, 2013). The
transprofessional team consists of nurses, physiotherapists,
social workers and occupational therapists. Each transprofes-
sional team member completed 20 competencies to increase
their educational preparedness to extend the services and care
they can provide, effectively enabling them to provide health
services which may typically reside within a different professions
(Table 1) (Goonan, 2011). For example, while not traditionally
the domain of a physiotherapist or occupational therapist, grief
counselling is within the skill set of all team members. The
services provided by transprofessional team members is broad,
including physical, cognitive and social assessments, fitting
splints, developing care plans, referrals to internal and external
services and providing care after discharge. The transprofessional
team treats approximately 400 patients per month in the ED
studied (7% of the ED patient population). It is estimated that
more than 40% of patients who are treated by the transprofes-
sional team have complex needs and chronic illnesses such
as diabetes, heart disease, respiratory conditions and renal
impairment (Goonan, 2011).
The transprofessional team is based within the ED. Patients
can be referred to the team by any of the ED staff as well as
community services (the ambulance service, aged care facilities).
The team works closely with all ED staff, and a typical patient
care episode will include review by an ED medical physician
(doctor), ongoing nursing care and team involvement to resolve
physical or social issues (Figure 1). The service is available from
07.30 am to 10.30 pm 7 days a week. This transprofessional care
model allows a single member of the team to autonomously
assess and manage a multitude of patient presentations, thereby
expediting patient flow through the ED.
Table 1. Key competencies completed by the transprofessional team members.
Physiotherapy competencies 1. Slings and splints
2. Gait aids
3. Soft-tissue injuries
4. Fractures
5. Mobility assessments
6. Follow-up physio
Occupational therapy competencies 7. Aids and equipment
8. Wheelchair prescriptions
9. Cognition assessment
10. Functional assessment
11. Patient education (Personal ADLS; Energy
conservation principals; Back care; Hip
precautions; Cognition; Falls prevention)
Nursing competencies 12. Wound care
13. Catheter care
14. Medication management
Social work competencies 15. Psycho-social assessment
16. Homelessness
17. Child at risk/child protection/sexual
assault
18. Family violence
19. Grief and bereavement
20. Aged care/respite/elder abuse/Victorian
Civil & Administrative TribunalPatient assessed& prioritised bytriage nurse.Assessed andmanaged bynursing andmedical teamReferred totransprofessionalteamAssessed andmanaged bytransprofessionalteamDisposition(home, hospitalward)
Figure 1. Typical pattern for engagement of a transprofessional team.
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