Gaming National Emergency Access Target performance using Emergency Treatment Performance definitions and emergency department short stay units

OBJECTIVE

To evaluate potential gaming of the 4 h ED length of stay metric known as the National Emergency Access Target (NEAT) in Australia and Emergency Treatment Performance (ETP) in New South Wales (NSW).

METHODS

Descriptive statistical analysis was used to recalculate and compare the scores for NEAT and the NSW ETP using variations in the definitions of their measurement on 32 184 presentations during 2016. A computer simulation using a discrete event model illustrated the effect of the use of ED short stay beds on the ETP scores.

RESULTS

Using the timestamp of the intent to discharge a patient, called, 'ready for departure' instead of the time of a patient physically leaving the department, resulted in an apparent 6% performance improvement. A local interpretation of the NSW state definition of the 'transferred' patient resulted in the ETP for 'admitted' patients improving by 16%. The discrete event model demonstrated that without changing patient length of stay, ETP scores can be improved by optimising the time of the admit decision or increasing the number of ED short stay beds.

CONCLUSIONS

The opportunity of NEAT may be squandered unless gaming of the definitions and use of ED short stay beds is addressed. We argue that the longstanding issue of 'departure time' should be defined as 'physically leaving' the department, in accordance with the Australasian College for Emergency Medicine (ACEM) definition. Patient occupancy is a real measure of ED resource use and NSW and national recommendations should be adjusted. ACEM accreditation of EDs should include review of their application of NEAT definitions to ensure they truly reflect patient flow processes.

Perceptions and experiences of emergency department staff during the implementation of the four-hour rule/national emergency access target policy in Australia: a qualitative social dynamic perspective

Background

The Four-Hour Rule or National Emergency Access Target policy (4HR/NEAT) was implemented by Australian State and Federal Governments between 2009 and 2014 to address increased demand, overcrowding and access block (boarding) in Emergency Departments (EDs). This qualitative study aimed to assess the impact of 4HR/NEAT on ED staff attitudes and perceptions. This article is part of a series of manuscripts reporting the results of this project.

Methods

The methodology has been published in this journal. As discussed in the methods paper, we interviewed 119 participants from 16 EDs across New South Wales (NSW), Queensland (QLD), Western Australia (WA) and the Australian Capital Territory (ACT), in 2015–2016. Interviews were recorded, transcribed, imported to NVivo 11 and analysed using content and thematic analysis.

Results

Three key themes emerged: Stress and morale, Intergroup dynamics, and Interaction with patients. These provided insight into the psycho-social dimensions and organisational structure of EDs at the individual, peer-to-peer, inter-departmental, and staff-patient levels.

Conclusion

Findings provide information on the social interactions associated with the introduction of the 4HR/NEAT policy and the intended and unintended consequences of its implementation across Australia. These themes allowed us to develop several hypotheses about the driving forces behind the social impact of this policy on ED staff and will allow for development of interventions that are rooted in the rich context of the staff’s experiences.

Impact of the National Emergency Access Target policy on emergency departments' performance: A time-trend analysis for New South Wales, Australian Capital Territory and Queensland

OBJECTIVE

To evaluate the impact of the Australian National Emergency Access Target (NEAT) policy introduced in 2012 on ED performance.

METHODS

A longitudinal cohort study of NEAT implementation using linked data, for 12 EDs across New South Wales (NSW), Australian Capital Territory (ACT) and Queensland (QLD) between 2008 and 2013. Segmented regression in a multi-level model was used to analyse ED performance over time before and after NEAT introduction. The main outcomes measures were ED length of stay ≤4 h, access block, number of ED presentations, short-stay admission (≤24 h), >24 h admissions, unplanned ED re-attendances within 7 days and 'left at own risk' (including 'did not wait for assessment').

RESULTS

Two years after NEAT introduction, ED length of stay ≤4 h increased in NSW and QLD (odds ratio [OR] = 2.48 and 3.24; P < 0.001) and access block decreased (OR = 0.41 and 0.22; P < 0.001), but not in ACT (OR = 1.28; P > 0.05). ED presentations increased over time before and after NEAT introduction with a significant increase above the projected trend in NSW after NEAT (mean ratio = 1.07). Short-stay admissions increased in QLD (OR = 2.60), ACT (OR = 1.68) and NSW (OR = 1.35). Unplanned ED re-attendances did not change significantly. Those who left at their own risk decreased significantly in NSW and QLD (OR = 0.38 and 0.67).

CONCLUSION

ED presentations continued to increase over time in all jurisdictions. NSW and QLD, but not ACT, showed significant improvements in time-based measures. Significant increases in short-stay admissions suggest a strategic change in ED process associated with NEAT implementation. Rates of unplanned ED re-attendances and those leaving at their own risk showed no evidence for adverse effects from NEAT.

Why do 'fast track' patients stay more than four hours in the emergency department? An investigation of factors that predict length of stay

OBJECTIVE

Low-acuity 'fast track' patients represent a large portion of Australian EDs' workload and must be managed efficiently to meet the National Emergency Access Target. The current study determined the relative importance and estimated marginal effects of patient and system-related variables in predicting ED fast track patients who stayed longer than 4 h in the ED.

METHODS

Data for ED presentations between 1 July 2014 and 30 June 2015 were collected from a large regional Australian public hospital. Only 'fast track' patients were included in the analysis. A gradient boosting machine was used to predict which patients would have an ED length of stay greater or less than 4 h. The performance of the final model was tested using a validation data set that was withheld from the initial analysis. A total of 27 variables were analysed.

RESULTS

The model's performance was very good (area under receiver operating characteristic curve 0.89, where 1.0 is perfect prediction). The five most important variables for predicting length of stay were time-dependent and system-related (not patient-related); these were the amount of time taken from when the patient arrived at the ED to: (i) order imaging; (ii) order pathology; (iii) request admission to hospital; (iv) allocate a clinician to care for the patient; and (v) handover a patient between ED clinicians.

CONCLUSIONS

We identified the most important variables for predicting length of stay greater than 4 h for fast track patients in our ED. Identifying factors that influence length of stay is a necessary step towards understanding ED patient flow and identifying improvement opportunities.

Two Hour Evaluation and Referral Model for Shorter Turnaround Times in the emergency department

OBJECTIVE

The objective of this study was to assess the implementation of a novel ED model of care, which combines clinical streaming, team-based assessment and early senior consultation to reduce length of stay.

METHODS

A pre-post-intervention study was used to compare ED performance following an extensive clinical redesign programme. Clinical teams and work sequences were reconfigured to promote the role of the staff specialist, with a focus on earlier decisions regarding disposition. Primary outcome measures were ED length of stay and National Emergency Access Target (NEAT) compliance. Secondary outcomes included referral and workup times, wait times by triage category, ambulance offload times, ward discharges and unit transfers within 24 h of admission, representation within 48 h, and Medical Emergency Response Team (MERT) calls within 24 h of admission.

RESULTS

Two seasonally matched 26 week intervals were compared with adjustment for demographics, triage category and arrival by ambulance. Overall, there was an 18.4% rise in NEAT performance (95% confidence interval (CI): 17.7-19.1) while ED length of stay decreased by a total of 86.8 min (95% CI: 83.6-90.1). Time series analysis did not suggest any preexisting trends to explain these results. The average time to referral decreased by 74.7 min (95% CI: 69.8-79.6) and waiting times decreased across all triage categories. Rates of MERT activation and unplanned representation were unchanged.

CONCLUSION

A facilitated team leader role for senior doctors can help to reduce length of stay by via early disposition, without significant risks to the patient.

Changing paediatric emergency department model of care is associated with improvements in the National Emergency Access Target and a decrease in inpatient admissions

OBJECTIVE

To assess the impact on patient flow as noted by the National Emergency Access Target (NEAT), with the introduction of a new Paediatric ED (PEM ED) model of care.

METHODS

This longitudinal observational study was conducted at the Logan Hospital, a 344 bed public hospital in metropolitan Brisbane, which opened a physically separate, dedicated PEM ED on 14 October 2014, incorporating approximately 30% more staff, limited changes in processes and no changes in governance. De-identified data of the entire clientele from the ED Information System were compared 365 days before and after the opening of the PEM ED.

RESULTS

Although the number of children presenting to ED increased by 23% (pre 18 142, post 22 391), the median length of stay decreased substantially from 152 min to 138 min, resulting in a 7.75% rise in presentations that met the NEAT target (pre 77.41%, post 85.16%; P < 0.0001). Admission to the ED Short Stay Unit rose by 16.48% (pre 5.38%, post 21.86%; P < 0.0001), whereas final disposition to the inpatient paediatric unit fell by 2.30% (pre 11.43, post 9.13%; P < 0.0001). The clinical presentations were similar pre and post across age, sex, ethnicity, referral and arrival mode, Australasian Triage Scale category, presenting problem and discharge diagnosis.

CONCLUSION

NEAT times improved after changing the PEM ED model of care. Further studies may assist identifying which of the specific features within the new model are most effective for improving patient flow.

Redesigning emergency patient flow with timely quality care at the Alfred

OBJECTIVES

The 4 h National Emergency Access Target was introduced in 2011. The Alfred Hospital in Melbourne implemented a hospital-wide clinical service framework, Timely Quality Care (TQC), to enhance patient experience and care quality by improving timeliness of interventions and investigations through the emergency episode and admission to discharge in 2012. We evaluated TQC's effect on achieving the National Emergency Access Target and associated safety and quality indicators.

METHODS

Retrospective analysis with piecewise regression of 215 125 ED attendances before/after implementation, November 2009 to August 2013; with comparison of proportions of patients discharged, admitted or transferred from ED within 4 h of arrival; left at risk; unplanned ED re-attendances up to 28 days; ED length of stay; and in-hospital mortality.

RESULTS

The percentage of patients admitted, discharged or transferred within 4 h rose from 60% in 2010, to 74% in 2013. Median ED length of stay decreased significantly. Rate of unplanned ED re-presentations decreased by 27%, 22% and 17% within 24 h, 48 h and 7 days, respectively; and patient numbers leaving at risk halved from 8% to 4%. Mortality for admitted patients declined from 3.5% to 2.2%. All results were statistically significant.

CONCLUSIONS AND FUTURE DIRECTIONS

TQC resulted in improvement in timeliness of care for emergency patients without compromising safety and quality. Success is attributed to effective engagement of stakeholders with a hospital-wide approach to redesigning the care pathway and establishing a new set of principles that underpin care from the time of ED arrival.