Responses to access block in Australia: Royal Perth Hospital

Access block and ED overcrowding

Prospective and retrospective access block hospital intervention studies from 1998 to 2008 were reviewed to assess the evidence for interventions around access block and ED overcrowding, including over 220 documents reported in Medline and data extracted from The State of our Public Hospitals Reports. There is an estimated 20-30% increased mortality rate due to access block and ED overcrowding. The main causes are major increases in hospital admissions and ED presentations, with almost no increase in the capacity of hospitals to meet this demand. The rate of available beds in Australia reduced from 2.6 beds per 1000 (1998-1999) to 2.4 beds per 1000 (2002-2007) in 2002, and has remained steady at between 2.5-2.6 beds per 1000. In the same period, the number of ED visits increased over 77% from 3.8 million to 6.74 million. Similarly, the number of public hospital admissions increased at an average rate of 3.4% per year from 3.7 to 4.7 million. Compared with 1998-1999 rates, the number of available beds in 2006-2007 is thus similar (2.65 vs 2.6 beds per 1000), but the number of ED presentations has almost doubled. All patient groups are affected by access block. Access block interventions may temporarily reduce some of the symptoms of access block, but many measures are not sustainable. The root cause of the problem will remain unless hospital capacity is addressed in an integrated approach at both national and state levels.

Understanding interdepartmental and organizational work in the emergency department: an ethnographic approach

Social scientific and nursing studies, and the experiences of emergency department staff, have attested to the complex organisational and communicative work that accompanies emergency clinical work. Yet, little attention has been paid to developing a research framework to examine and develop communicative and organisational work in emergency departments (EDs). This paper explores the role of nurses in plugging gaps in the care of ED patients, and summarises the findings of a large, 3-year ethnographic study comprising 12 months of ethnography in two EDs in Sydney, Australia, and 2 years of analysis. The findings of the large study are summarised and exemplified here as part of a broader conceptual argument for the importance of ethnographic research in EDs. Ethnography involves capturing the moment-to-moment action of life when and where it happens, and in the context of, reflecting and amending, broader social patterns. The findings report on the relationship of communication, organisational and, in particular, interdepartmental and interorganizational work, to emergency clinical work and demonstrate that nurses play an important role in articulating and reconciling patients' and medical staff activities. The paper concludes that emergency nurses are well placed to use ethnographic research to advance the understanding and delivery of emergency care.

Whole-of-hospital response to admission access block: the need for a clinical revolution

The major problem of access block to acute hospital admissions in Australia needs a more radical response than a focus on increasing inpatient beds, as suggested recently. Australia needs to take on board recent changes in United Kingdom hospital systems, which have revolutionised patient flow during acute admissions and dramatically improved efficiency, clinical quality and outcomes. Accident and emergency departments in the UK became recognised as part of acute hospital dysfunction. Now, increasingly, patients needing admission are directed as soon as possible to an acute medical assessment and admission unit (AMAAU), thus freeing accident and emergency staff for re-defined core priorities. AMAAUs require supervision by a new style of acute general physician, who drives timely management of acute medical patients, defines patient needs, estimates the likely date of discharge, and selects the most appropriate inpatient clinical stream. These reforms are staff-intensive and expensive, but cost-effective and patient-focused. They highlight the need for an adequate scale for acute clinical services and defined streams of care within individual hospitals, as well as explicit networking at a regional level to guarantee specialist acute services when needed.

Myths versus facts in emergency department overcrowding and hospital access block

Overcrowding occurs when emergency department (ED) function is impeded, primarily by overwhelming of ED staff resources and physical capacity by excessive numbers of patients needing or receiving care. Access block occurs when there is excessive delay in access to appropriate inpatient beds (> 8 hours total time in the ED). Access block for admitted patients is the principal cause of overcrowding, and is mainly the result of a systemic lack of capacity throughout health systems, and not of inappropriate presentations by patients who should have attended a general practitioner. Overcrowding is most strongly associated with excessive numbers of admitted patients being kept in the ED. Excessive numbers of admitted patients in the ED are associated with diminished quality of care and poor patient outcomes. These include (but are not limited to) adverse events, errors, delayed time-critical care, increased morbidity and excess deaths (estimated as at least 1500 per annum in Australia). There is no evidence that telephone advice lines or collocated after-hours GP services assist in reducing ED workloads. Changes to ED structure and function do not address the underlying causes or major adverse effects of overcrowding. They are also rapidly overwhelmed by increasing access block. The causes of overcrowding, and hence the solutions, lie outside the ED. Solutions will mainly be found in managing hospital bedstock and systemic capacity (including the use of step-down and community resources) so that appropriate inpatient beds remain available for acutely sick patients.

Interface between residential aged care facilities and a teaching hospital emergency department in Western Australia

OBJECTIVE

To estimate the appropriateness of emergency department (ED) presentations by people aged>or=65 years living in residential care facilities.

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort study of older residents of residential care facilities who presented to the ED of the Royal Perth Hospital, Western Australia, between January and June 2002. Data were reviewed by an expert clinical panel.

MAIN OUTCOME MEASURES

Appropriateness of ED presentation, presenting complaint, involvement of a general practitioner/locum doctor prior to transfer, proportion of patients admitted to hospital from the ED, survival to discharge.

RESULTS

541 residents aged>or=65 years were transferred by ambulance to the ED, comprising 8.3% of all ED presentations of people in this age group. The mean age of the study cohort was 83.7 years (SD, 7.0 years), of which 68% were women. Of the 541 presentations, 326 (60%) resulted in hospital admission, and of these, 276 (85%) survived to hospital discharge. Musculoskeletal disorders accounted for 25% of all presentations, and 22% were falls-related; pneumonia (11% of presentations) was the single largest presenting complaint. ED attendance was deemed "inappropriate" for 71/541 cases (13.1%; 95% CI, 10.5%-16.2%); in only 25% of ED presentations was a GP/locum doctor involved prior to transfer.

CONCLUSIONS

The majority of ED presentations by aged care residents were considered to be appropriate, but there was scope for improvement in coordinating care between the hospital ED and residential care institutions.