ED overcrowding

Question 1

List causes of ED overcrowding

Answer 1

1) Hospital capacity problem
2) Access block
- most common cause in most urban Australian ED
3) increased patient numbers
4) increased patient complexity
5) increased patient evaluation
6) delays in referral
7) delays in other services
- inpatient assessment
- pathology
- radiology
- allied health
8) ED staff factors
- skill
- numbers
9) ED design

Question 2

Discuss consequences of overcrowding

Answer 2

Reduced quality of clinical care

• Reduced quality of customer service
• increased waiting times
• reduced sytmpoms control
• communications problems
• reduced patient perception of quality of clinical care

Question 3

Define access block

Answer 3

Inability to access appropriate beds in a timely manner for emergency patients who require inpatient admission
Quantified as the proportion of patients admitted, transferred to other hospital or who die in the ED who have a total ED time of more than 8 hours

Question 4

Discuss effects of access block

Answer 4

1) Hospital LOS
- increased inpatient stay by 20-25%
- resulting in compounding effect and places further strain on the hospital + financial strain

2) Work load
- approximately 40% of the workload in major hospital ED is caring for inpatient

3) mortality
- approx 30% relative increase in overall mortality if patients are admitted through overcrowed Eds

4) Waiting times
- may cause up to 40% of the ED waiting tim in some hosptial
- increase DNW
- more profound compliance on NEAT than absolute numbers

5) QOC
- delayed time to critical interventions, increased complications
- increased time to antibiotics
- reduced adeqaucey of pain management
- increase medical error
- increased pressure areas
- delirium in the elderly
- increased patient discomfort

6) impact on Staff
- increased risk that responsibility for poviding clinical care may be unclear
- need for increased co-ordination of care
- diminished familiarity of staff with inpatient procedures
- increased handovers
- increased staff stress

7) non clinical
- increased communication load
- increased medical record mixing
- increased complaints
- decreased patient privacy

Question 5

Discuss causes of access block

Answer 5

1) reduced number of acute in-patient beds
2) increasing specialisation of inpatient wards
3) aged care issues
- increasing dependency needs of an ageing population
4) ratio of elective vs emergency activity
5) effective discharge planning
6) no evidence taht access block is caused by
- large number of low acuity or inappropriate patients
- general practice patietns

Question 6

Discuss strategies to improve hospital patient flow

Answer 6

1) aim for hospital bed occupancy of 85%
- provides spare bed capacity essential for emergency admissions and a surge capacity
- allow hospital to function
- allows for normal fluctuations in demand

2) access block is best adressed by
- ensuring early discharge of inpatients from hosptial each day prior to the high admission load from the ED in the afternoon
- increase the number of beds avaibable at all levels of care within the hostpital
- having more inpatient beds and optimising patient flow processes
- over census policies or placing slected patients in non ward areas not disgnated as ward beds
- ward pull concept - ward areas identify patient requiring admission and initiate ward transfer
- improved bed co-ordination
- reduction in long stay monitoring
- dialy ward rounds

3) improve exit from acute hospital
- active monitoring and management of long stay patients
- increased post acute care services
- inpatient ward rouns ( daily, early, by staff empowered to make discharge decisions or criteria led discharge)
- us of transit loung for patient only awaiting transport

4) balancing demand and elective

5) reduce demand for acute hospital services
- rapid access to OPD
- enhanced community based services

6) communications

Question 7

Discuss strategies to improve ED flow

Answer 7

1) patient streaming
-selecting types of patietns to be seen in different areas of the department by different types of practitioners (Nurse practitioner)
-Effectiveness may be improved by concentrating expertise in an area where it is most required e.g resuss
-Streaming necessitates separate queues for each stream - may reduce effieciny if any stream is overwhelmed or under utilised
Streams commonly used are (resus, probable admission, ambuatory care/fast track, mental health, interhospital transfer)

2) Early seniour decision making
- may reduce number of people involved
- this has been implemented in various forms under various names

3) reduce patient movement
- decrease risk of erro and handover
- increase effiency

4) reduce number of people invovled

5) improve timeliness of services
- medical imaging and path
- discharge support
- medical records
- IT systems

6) improve access to next phase of care
- ED empowered to make admission decisions
- use of holding or interum treatment orders for admitted patietn
- formal admission by inpatient occuring in the ward
- suitbly sized short stay/clinical decision making unit
- use of accelerated evidence based protocols
- use of navigator/time keeper role

Question 8

List measures to reduce ED demand

Answer 8

EFFECTIVE

• direct admission to wards of stable transfers in
• rapid access clinics for referral of non emerg cases
• effective use of hospital day care centres (minor procedures, minor surgiers)

Ineffective

• telephone advise lines nurse on call
• increased GP
• disaster management techniques, including ambulance diversion