Myths versus facts in emergency department overcrowding and hospital access block

Demand for hospital emergency departments: a conceptual understanding

BACKGROUND

Emergency departments (EDs) are critical to the management of acute illness and injury, and the provision of health system access. However, EDs have become increasingly congested due to increased demand, increased complexity of care and blocked access to ongoing care (access block). Congestion has clinical and organisational implications. This paper aims to describe the factors that appear to influence demand for ED services, and their interrelationships as the basis for further research into the role of private hospital EDs.

DATA SOURCES

Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) and relevant journals were searched using terms related to EDs and emergency health needs. Literature pertaining to emergency department utilisation worldwide was identified, and articles selected for further examination on the basis of their relevance and significance to ED demand.

RESULTS

Factors influencing ED demand can be categorized into those describing the health needs of the patients, those predisposing a patient to seeking help, and those relating to policy factors such as provision of services and insurance status. This paper describes the factors influencing ED presentations, and proposes a novel conceptual map of their interrelationship.

CONCLUSION

This review has explored the factors contributing to the growing demand for ED care, the influence these factors have on ED demand, and their interrelationships depicted in the conceptual model.

[Use of emergency departments in rural and urban areas in Spain]

OBJECTIVES

Describe the use of emergency departments (ED), and analyse the differences in use between residents in rural and urban areas.

MATERIAL AND METHODS

Using data from the National Health Survey of 2006 and 2011, the profiles of patients with ED visits by population size of place of residence were obtained. The variables associated with making one visit to the ED were also evaluated, in order to determine the effect of the population size of place of residence.

RESULTS

A higher use of ED is observed in persons with a higher frequency of use of Primary Care and hospital admissions, and increases with worse self-perceived health and functional status, with more chronic diseases, in people from lower social classes, and younger ages. Adjusting for the other variables, residents in larger cities have a higher use of ED than residents in rural areas, who show a higher use of public and non-hospital based ED, than residents in urban areas.

DISCUSSION

There is a higher use of ED by inhabitants of urban areas that cannot be justified by a worst health status of that population. This tends to indicate that the use of ED is not under-used in rural areas, but overused in urban areas.

[Treatment duration of trauma and orthopedic patients in an emergency department]

INTRODUCTION

The majority of emergency patients are admitted to hospital via the emergency department. Overcrowding in emergency departments results in dissatisfied patients, increased complication rates, and negative medicoeconomic consequences. To overcome these problems, sufficient personnel strength should be available depending on treatment duration and the patients' characteristics.

MATERIALS AND METHODS

First, trauma and orthopedic patients were classified into six categories: ABT (history, findings, and therapy), RABT (X-ray and ABT), WABT (wound care and ABT), WRABT (wound care and RABT), STAT (hospital admission), and SR (trauma life support). Furthermore, the duration of medical treatment was correlated with the physicians' educational level (specialist or physician in training after or during the common trunk period). Not included were waiting periods and nursing care measures. After analyzing the frequency of each category, the mean duration of treatment for an"average patient" was determined.

RESULTS

The duration of treatment of 900 patients was recorded. The average times were 9.5 min (ABT), 13.8 min (RABT), 17.3 min (WABT), 24.5 min (WRABT), 38.4 min (STAT), and 84.2 min (SR). The frequencies for the different categories were: ABT 18.8%; RABT 50.2%; WABT 14.5%; WRABT 4.4%; STAT 10.6%, and SR 1.4%. Thus, an average duration of medical treatment of 17.6 min was calculated. Especially in the RABT category, significant differences between specialists and physicians in training were evident. In children and adolescents, the duration of treatment was 12.5 min.

CONCLUSION

The duration of treatment of an average trauma and orthopedic patient depends on the level of care of the hospital and the qualification of the physician in charge. In order to avoid negative consequences of overcrowding in emergency departments, adequate personnel strength is essential. Personnel strength should be calculated based on the average duration of medical treatment of about 18 min.

Evaluating implementation of the emergency severity index in a Belgian hospital

INTRODUCTION

Triage aims to categorize patients based on their clinical need and the available departmental resources. To accomplish this goal, one needs to ensure that the implemented triage system is reliable and that staff use it correctly. Therefore this study assessed the ability of Belgium nurses to apply the Emergency Severity Index (ESI), version 4, to hypothetical case scenarios after an educational intervention.

METHODS

An ESI educational intervention was implemented in accordance with the ESI manual. Using paper case scenarios, nurses' interrater agreement was assessed by comparing triage nurse ESI levels with the reference answers noted in the implementation manual. Interrater agreement was measured by the percentage of agreement and Cohen's κ coefficient using different weighting schemes.

RESULTS

Overall, 77.5% of the scenario cases were coded according the ESI guidelines, resulting in a good interrater agreement (κ = 0.72, linear weighted κ = 0.84, quadratic weighted κ = 0.92, and triage-weighted scheme = 0.79). Interrater agreement varied when evaluating each ESI level separately. Undertriage was more common than overtriage. The highest misclassification range (37.8%) occurred in ESI level 2 scenarios, with 99.2% of the misclassifications being undertriaged.

DISCUSSION

Implementation of the ESI into a novel setting guided by a locally developed training program resulted in suboptimal interrater agreement. Existing weighted κ schemes overestimated the interrater agreement between the triage nurse-assigned ESI level and the reference standard. By providing an aggregated measure of agreement, which allows partial agreement, clinically significant misclassification was masked by a misleading "good" interrater agreement.

Flexing bed stock: a hospital capacity management case study

As hospitals struggle to meet rising demand for their services, efficient capacity management is critical to the success of their efforts. A popular strategy employed by hospitals to meet the variability in demand for their services is to 'flex' their capacity, i.e. to vary the number of available staffed beds to suit demand on a regular basis. This study uses data from a large tertiary hospital in South Australia to analyze the efficacy of their flexing protocols and the impact of flexing capacity on overcrowding. We also analyze the impact of variation in occupancy on patient flow parameters and compare this to previous studies conducted on similar sized Australian hospitals that do not flex capacity. Our findings reveal that flexing capacity helps the hospital spend less time over critical occupancy levels, and that the hospital does not show the signs of performance decline exhibited by hospitals that do not flex capacity. Areas for improvements in the flexing protocol and possible strategies are also identified. The findings support the use of flexing capacity as an efficient protocol and will serve as a useful guide for services seeking to improve existing capacity management protocols.

Detecting and diagnosing hotspots for the enhanced management of hospital Emergency Departments in Queensland, Australia

BACKGROUND

Predictive tools are already being implemented to assist in Emergency Department bed management by forecasting the expected total volume of patients. Yet these tools are unable to detect and diagnose when estimates fall short. Early detection of hotspots, that is subpopulations of patients presenting in unusually high numbers, would help authorities to manage limited health resources and communicate effectively about emerging risks. We evaluate an anomaly detection tool that signals when, and in what way Emergency Departments in 18 hospitals across the state of Queensland, Australia, are significantly exceeding their forecasted patient volumes.

METHODS

The tool in question is an adaptation of the Surveillance Tree methodology initially proposed in Sparks and Okugami (IntStatl 1:2-24, 2010). for the monitoring of vehicle crashes. The methodology was trained on presentations to 18 Emergency Departments across Queensland over the period 2006 to 2008. Artificial increases were added to simulated, in-control counts for these data to evaluate the tool's sensitivity, timeliness and diagnostic capability. The results were compared with those from a univariate control chart. The tool was then applied to data from 2009, the year of the H1N1 (or 'Swine Flu') pandemic.

RESULTS

The Surveillance Tree method was found to be at least as effective as a univariate, exponentially weighted moving average (EWMA) control chart when increases occurred in a subgroup of the monitored population. The method has advantages over the univariate control chart in that it allows for the monitoring of multiple disease groups while still allowing control of the overall false alarm rate. It is also able to detect changes in the makeup of the Emergency Department presentations, even when the total count remains unchanged. Furthermore, the Surveillance Tree method provides diagnostic information useful for service improvements or disease management.

CONCLUSIONS

Multivariate surveillance provides a useful tool in the management of hospital Emergency Departments by not only efficiently detecting unusually high numbers of presentations, but by providing information about which groups of patients are causing the increase.

The association between time to disposition plan in the emergency department and in-hospital mortality of general medical patients

BACKGROUND

A perceived risk of time-limited emergency department (ED) assessment of patients is inadequate workup leading to inappropriate disposition. The aim of this study was to examine the association of time to disposition plan (TDP) on ED length of stay (LOS) and correlate this to mortality.

METHODS

A retrospective review of data collected from ED information systems at three hospitals was conducted between June 2008 and October 2009. Included patients were admitted to a general medical unit. Patients were excluded if admitted to intensive care, coronary care, a cardiac monitored bed or required surgery in first 24 h or had an expected LOS of <48 h. Multivariate regression analysis was used to identify independent associations with mortality.

RESULTS

A total of 10,107 patient episodes was analysed, of which 6768 patients (67.0%) had an ED LOS of ≥8 h. There was significant effect modification by ED LOS in the association of TDP and mortality. In the setting of longer ED LOS, a TDP of <4 h was associated with significantly higher mortality (OR 1.57, 95% CI: 1.28-1.92, P < 0.001), corrected for age, gender and triage category. This association was not significant when ED LOS was <8 h (OR 0.88, 95% CI: 0.60-1.27, P = 0.49).

CONCLUSIONS

In the setting of prolonged ED LOS, completing ED assessment and management within 4 h of presentation was associated with significantly higher mortality. Further prospective studies are required to understand the relationship between rapid decision making in the ED and patient safety.

Contemporary themes in acute coronary syndrome management: from acute illness to secondary prevention

Acute coronary syndrome (ACS; myocardial infarction and unstable angina) is the leading cause of mortality in Australia, and those who survive one ACS event are at significant risk of experiencing another. Access to evidence-based and optimal ACS management in both the acute and long-term periods is of great importance. Management of ACS should include appropriate timely revascularisation, medical therapy and ongoing secondary prevention. A key consideration in selecting acute antithrombotic therapies is a careful determination of the risk of bleeding versus risk of recurrent ischaemia. Although there is a strong evidence base for the urgency of delivery and the quality of acute care, knowledge translation is suboptimal. There remains a need for ongoing research and policy development aimed at improving ease and equity of access to evidence-based care. Despite universal guideline recommendations for ongoing secondary prevention strategies, research indicates suboptimal use of evidence-based medications, poor adherence to lifestyle recommendations, and low levels of participation in traditional cardiac rehabilitation. Contemporary secondary prevention programs are evolving into flexible, multifaceted interventions to provide maximal clinical benefits to a majority of patients.

Load-sensitive dynamic workflow re-orchestration and optimisation for faster patient healthcare

Hospital waiting times are considerably long, with no signs of reducing any-time soon. A number of factors including population growth, the ageing population and a lack of new infrastructure are expected to further exacerbate waiting times in the near future. In this work, we show how healthcare services can be modelled as queueing nodes, together with healthcare service workflows, such that these workflows can be optimised during execution in order to reduce patient waiting times. Services such as X-ray, computer tomography, and magnetic resonance imaging often form queues, thus, by taking into account the waiting times of each service, the workflow can be re-orchestrated and optimised. Experimental results indicate average waiting time reductions are achievable by optimising workflows using dynamic re-orchestration.

The ebbs and flows of changing acute bed capacity delays

OBJECTIVE

This case study provides a summary of changes in acute hospital bed delays that have occurred over a 4-year period as identified through a Capacity Audit process.

BACKGROUND

Royal Adelaide Hospital (RAH) designed a Capacity Audit process and tool that provides a systematic method to evaluate factors limiting access to inpatient bed capacity. The aim of the audit is to improve understanding of bed capacity by identifying key causes of delay for hospital inpatients and quantify the most frequent causes of blocked bed capacity. This can then be used to underpin targeted improvement work. The Capacity Audit has been undertaken at the RAH over three cycles.

METHOD

The Capacity Audit involves a survey of every open and staffed bed, identifying how the bed is being used: for acute care or treatment, if there was a delay to the patient for discharge, or if the bed was unavailable. The first and second cycle of the audit (2007-2008) involved a twice-daily survey over a 2-week period and the third audit cycle in 2010 occurred once daily for 1 week.

RESULTS

On average, 620 beds were surveyed daily with an audit compliance rate ranging from 85-97%. This process has revealed almost 75% of beds are used positively for care. Of the remaining 25% of hidden capacity identified, non-clinical discharge delays account for 10% of total beds surveyed. Waiting for post-acute beds has consistently remained the main cause of acute bed delay.

CONCLUSION

The Capacity Audit process and tool has been used to track progress, trends and change resulting from service improvement efforts, and to provide the evidence to commence strategies to reduce the hidden capacity issues. This case study has shown that whilst overall bed stock usage for positive care has not changed significantly there are various ebbs and flows over time in relation to the reasons for bed delays.

Emergency admissions and elective surgery waiting times

An average patient waits between 2 and 3 months for an elective procedure in Australian public hospitals. Approximately 60% of all admissions occur through an emergency department, and bed competition from emergency admission provides one path by which waiting times for elective procedures may be lengthened. In this article, we investigated the extent to which public hospital waiting times are affected by the volume of emergency admissions and whether there is a differential impact by elective patient payment status. The latter has equity implications if the potential health cost associated with delayed treatment falls on public patients with lower ability to pay. Using annual data from public hospitals in the state of New South Wales, we found that, for a given available bed capacity, a one standard deviation increase in a hospital's emergency admissions lengthens waiting times by 19 days on average. However, paying (private) patients experience no delay overall. In fact, for some procedures, higher levels of emergency admissions are associated with lower private patient waiting times.

Analysis of three advanced practice roles in emergency nursing

BACKGROUND

There are many Emergency Department (ED) demand management systems that include advanced practice emergency nursing roles. The aim of this study is to examine and compare three advanced emergency nursing practice roles: ED Fast Track, Clinical Initiatives Nurse (CIN) and Rapid Intervention and Treatment Zone (RITZ).

METHOD

A descriptive exploratory approach was used to conduct this study at an urban district hospital in Melbourne, Australia. The study participants were patients managed in each of the three systems with advanced practice emergency nursing roles: Fast Track, CIN and RITZ.

RESULTS

There were a total of 551 patients: 195 Fast Track patients, 163 CIN managed patients and 193 RITZ patients. CIN managed patients were older (p<0.001), with higher levels of clinical urgency (p<0.001), and higher hospital admission rates (p<0.001). CIN managed patients had shorter waiting time for nursing care (p=0.001) and lower incidence of medical assessment within the time associated with their triage category (p<0.0001). ED LOS for discharged patients was significantly longer for CIN managed patients (p<0.001). CIN managed patients had a significantly higher incidence of electrocardiography (p<0.001), blood glucose measurement (p<0.001), intravenous cannulation (p<0.001), pathology testing (p<0.001), and analgesia administration (p<0.001) when compared to Fast Track and RITZ patients.

CONCLUSIONS

Advanced practice roles in emergency nursing can have different applications in the ED context. Clarity about role intent and scope of practice is important and should inform educational preparation and teams within which these roles operate.

Comparison between emergency department and inpatient nurses' perceptions of boarding of admitted patients

Introduction:

The boarding of admitted patients in the emergency department (ED) is a major cause of crowding and access block. One solution is boarding admitted patients in inpatient ward (W) hallways. This study queried and compared ED and W nurses’ opinions toward ED and W boarding. It also assessed their preferred boarding location if they were patients.

Methods:

A survey administered to a convenience sample of ED and W nurses was performed in a 631-bed academic medical center (30,000 admissions/year) with a 68-bed ED (70,000 visits/ year). We identified nurses as ED or W, and if W, whether they had previously worked in the ED. The nurses were asked if there were any circumstances where admitted patients should be boarded in ED or W hallways. They were also asked their preferred location if they were admitted as a patient. Six clinical scenarios were then presented, and the nurses’ opinions on boarding based on each scenario were queried.

Results:

Ninety nurses completed the survey, with a response rate of 60%; 35 (39%) were current ED nurses (cED), 40 (44%) had previously worked in the ED (pED). For all nurses surveyed 46 (52%) believed admitted patients should board in the ED. Overall, 52 (58%) were opposed to W boarding, with 20% of cED versus 83% of current W (cW) nurses (P < 0.0001), and 28% of pED versus 85% of nurses never having worked in the ED (nED) were opposed (P < 0.001). If admitted as patients themselves, 43 (54%) of all nurses preferred W boarding, with 82% of cED versus 33% of cW nurses (P < 0.0001) and 74% of pED versus 34% nED nurses (P = 0.0007). The most commonly cited reasons for opposition to hallway boarding were lack of monitoring and patient privacy. For the 6 clinical scenarios, significant differences in opinion regarding W boarding existed in all but 2 cases: a patient with stable chronic obstructive pulmonary disease but requiring oxygen, and an intubated, unstable sepsis patient.

Conclusion:

Inpatient nurses and those who have never worked in the ED are more opposed to inpatient boarding than ED nurses and nurses who have worked previously in the ED. Primary nursing concerns about boarding are lack of monitoring and privacy in hallway beds. Nurses admitted as patients seemed to prefer not being boarded where they work. ED and inpatient nurses seemed to agree that unstable or potentially unstable patients should remain in the ED but disagreed on where more stable patients should board.

Does hospital occupancy impact discharge rates?

Objective. To understand what impact hospital inpatient occupancy levels have on patient throughput by analysing one hospital’s occupancy levels and the rate of patient discharge. Methods. A four-stage model was fit to hospital admission and separation data and used to analyse the per-capita separation rate according to the patient load and the impact of hospital over-census actions. Results. Per-capita separation rates are significantly higher on days when the hospital declares an over-census due to emergency department crowding. Per-capita separation rates are also higher or lower on days with 8−10% higher or lower patient loads, respectively, but the response is not nearly as strong as the response to an over-census declaration, and is limited to patients with an elapsed stay of 10 days or more. Within the medical division there is an increase in per-capita separation rates on over-census days, but no significant difference in per-capita release rates for different patient loads. Within the surgical division there is no significant difference in per-capita separation rates on over-census days compared with other days, but the patient load does make a significant difference. Conclusion. Staff do discharge a greater proportion of long-stay patients when the hospital is experiencing high demand and a lower proportion when occupancy is low, but the reasons driving those changes remains unclear. What is known about the topic? The evidence regarding safe and efficient levels of hospital occupancy is limited. There is minimal empirical evidence that confirms the relationship between occupancy and discharge rates. What does the paper add? Per-capita separation rates increase strongly on over-census days. The hospital increases per-capita separation rates on days of high occupancy and reduces it on days of low occupancy, mostly for long-stay patients with over 10 days of elapsed stay. The response to high occupancy is not as strong as the response to over-census. The medical division responds strongly to the over-census and the surgical division does not. The surgical division responds more to occupancy levels within its own division than does the medical division. What are the implications for practitioners? The implementation of over-census-type responses to periods of high occupancy may result in increased per-capita separation rate. Using mathematical analysis to understand patient load on per capita separation is important to create a better understanding of health service delivery, thereby aiding hospital managers, and has the potential to guide system improvement. The clinical drivers for these changes and the service design implications require further investigation.

Nonurgent patients in emergency departments: rational or irresponsible consumers? Perceptions of professionals and patients

Background

For several decades, overcrowding in emergency departments (EDs) has been intensifying due to the increased number of patients seeking care in EDs. Demand growth is partly due to misuse of EDs by patients who seek care for nonurgent problems. This study explores the reasons why people with nonurgent complaints choose to come to EDs, and how ED health professionals perceive the phenomenon of “nonurgency”.

Results

Semi-structured interviews were conducted in 10 EDs with 87 nonurgent patients and 34 health professionals. Interviews of patients revealed three themes: (1) fulfilled health care needs, (2) barriers to primary care providers (PCPs), and (3) convenience. Patients chose EDs as discerning health consumers: they preferred EDs because they had difficulties obtaining a rapid appointment. Access to technical facilities in EDs spares the patient from being overwhelmed with appointments with various specialists. Four themes were identified from the interviews of health professionals: (1) the problem of defining a nonurgent visit, (2) explanations for patients’ use of EDs for nonurgent complaints, (3) consequences of nonurgent visits, and (4) solutions to counter this tendency.

Conclusions

Studies on the underlying reasons patients opt for the ED, as well as on their decision-making process, are lacking. The present study highlighted discrepancies between the perceptions of ED patients and those of health professionals, with a special focus on patient behaviour. To explain the use of ED, health professionals based themselves on the acuity and urgency of medical problems, while patients focused on rational reasons to initiate care in the ED (accessibility to health care resources, and the context in which the medical problem occurred). In spite of some limitations due to the slightly outdated nature of our data, as well as the difficulty of categorizing nonurgent situations, our findings show the importance of conducting a detailed analysis of the demand for health care. Understanding it is crucial, as it is the main determining factor in the utilization of health care resources, and provides promising insights into the phenomenon of ED usage increase. For reforms to be successful, the process of decision-making for unscheduled patients will have to be thoroughly investigated.

Inadequate acute hospital beds and the limits of primary care and prevention

Metropolitan Australia is suffering from a serious shortage of acute hospital beds. Simplistic comparisons with the Organisation for Economic Co-operation and Development bed numbers are misleading because of the hybrid Australian public/private hospital system. The unavailability of most private beds for acute emergency cases and urban/rural bed imbalances have not been adequately considered. There is a lack of advocacy for acute bed availability. This attitude permeates government, health professions and the health bureaucracy. Planners, politicians, analysts and the media have adopted false hopes of reducing acute demand by prevention and primary care strategies, vital as these services are to a balanced healthcare system. This paper directly challenges the ideology that says Australia depends too heavily on hospital-based healthcare. Rebuilding the bed base requires recognition of the need for an adequate acute hospital service and strong advocacy for bed-based care in the medical and nursing professionals who should be driving policy. The forces opposing bed-based care are strong and solutions might include legislative definition of bed numbers and availability.

Prolonged length of stay in the emergency department in high-acuity patients at a Chinese tertiary hospital

OBJECTIVE

ED overcrowding is a worldwide issue, with most evidence coming from developed countries. Until now, little was known about this subject in China. The aim of this study was to investigate the situation of prolonged lengths of stay (LOS) in the ED for high-acuity patients in a Chinese tertiary hospital and to identify associated factors.

METHODS

A retrospective study was performed in a Chinese tertiary hospital from 1 January to 31 December 2010. The primary outcomes were ED LOS and associated factors in overall high-acuity patients. Multivariate Cox regression analysis was used.

RESULTS

In this consecutive study period, 7966 high-acuity patients presenting to the ED were triaged to the resuscitation room. The median LOS in the ED for these patients was 10.6 h (IQR, 3.1-23.1 h). In the multivariate analysis, the most significant factor associated with prolonged LOS was boarding for more than 2 h (OR, 4.29; 95% CI, 4.03-4.57). Patients requiring emergency operation or intensive care unit admission experienced a shorter LOS (OR, 0.56 and 0.76; 95% CI, 0.53-0.60 and 0.71-0.81, respectively). Older patients, night shift arrivals, non-spring visitors, general internal medicine patients and patients leaving without receiving advanced therapy had longer LOS.

CONCLUSIONS

We found an excessive LOS in the resuscitation room in this tertiary hospital. The most significant reason for prolonged LOS was boarding block. Shortage of inpatient beds and reluctance of the wards to admit these patients might be the primary reasons for extremely long boarding.

Physiotherapists in emergency departments: responsibilities, accountability and education

Emergency physiotherapy roles have evolved within the UK and are increasingly being adopted in Australia in response to a need for greater workforce flexibility and improved service provision to meet growing patient demand. This paper discusses the need for the physiotherapy profession to develop evidence-based regulatory, ethical and educative frameworks to keep pace with the changing clinical environment and service delivery in emergency departments. Definitions of Emergency Physiotherapy as either advanced practice or extended scope of practice are identified, and the implications for both regulation of practice and education are highlighted. Suggestions for education in areas of clinical skills, ethical understanding and legal and professional knowledge are highlighted as important areas to support physiotherapists moving into this area of practice.

Demand at the emergency department front door: 10-year trends in presentations

OBJECTIVES

To measure the increase in volume and age-specific rates of presentations to public hospital emergency departments (EDs), as well as any changes in ED length of stay (LOS); and to describe trends in ED utilisation.

DESIGN, PATIENTS AND SETTING

Population-based retrospective analysis of Department of Health public hospital ED data for metropolitan Melbourne for 1999-00 to 2008-09.

MAIN OUTCOME MEASURES

Presentation numbers; presentation rates per 1000 person-years; ED LOS.

RESULTS

ED presentations increased from 550,662 in 1999-00 to 853,940 in 2008-09. This corresponded to a 32% rise in rate of presentation (95% CI, 29%-35%), an average annual increase of 3.6% (95% CI, 3.4%-3.8%) after adjustment for population changes. Almost 40% of all patients remained in the ED for ≥4 hours in 2008-09, with LOS increasing over time for patients who were more acutely unwell. The likelihood of presentation rose with increasing age, with people aged≥85 years being 3.9 times as likely to present as those aged 35-59 years (95% CI, 3.8-4.0). The volume of older people presenting more than doubled over the decade. They were more likely to arrive by emergency ambulance and were more acutely unwell than 35-59 year olds, with 75% having an LOS≥4 hours and 61% requiring admission in 2008-09.

CONCLUSION

The rise in presentation numbers and presentation rates per 1000 person-years over 10 years was beyond that expected from demographic changes. Current models of emergency and primary care are failing to meet community needs at times of acute illness. Given these trends, the proposed 4-hour targets in 2012 may be unachievable unless there is significant redesign of the whole system.

Is ED length of stay before ICU admission related to patient mortality?

OBJECTIVE

To describe and identify the relationship between ED length of stay (LOS) and mortality after ICU admission.

METHODS

We undertook a retrospective cohort study of records from the Australian and New Zealand Intensive Care Society Adult Patient Database (from 1 January 2000 to 31 December 2006). Data from 45 hospitals and 48 803 ED patients directly transferred to ICU were included. Patients were divided into ED LOS<8 h and ED LOS>or=8 h. Univariate and multivariate analyses were performed.

RESULTS

Median ED LOS was 3.9 h (interquartile range 2.0-6.8). Patients transferred within 8 h (80.9%) were younger (P<0.001) and more seriously ill (higher mortality and mechanical ventilation rate) than those transferred>or=8 h. There was no clear relationship between ED LOS and hospital survival for patients admitted directly to ICU (odds ratio=1.01 per hour, 95% confidence intervals 0.99-1.02).

CONCLUSION

Although 20% of critically ill patients spend more than 8 h in ED before transfer to ICU, we were unable to demonstrate an adverse relationship between time in ED and hospital mortality.

Pandemic (H1N1 influenza 2009 and Australian emergency departments: implications for policy, practice and pandemic preparedness

OBJECTIVE

To describe the reported impact of Pandemic (H(1)N(1) ) 2009 on EDs, so as to inform future pandemic policy, planning and response management.

METHODS

This study comprised an issue and theme analysis of publicly accessible literature, data from jurisdictional health departments, and data obtained from two electronic surveys of ED directors and ED staff. The issues identified formed the basis of policy analysis and evaluation.

RESULTS

Pandemic (H(1)N(1) ) 2009 had a significant impact on EDs with presentation for patients with 'influenza-like illness' up to three times that of the same time in previous years. Staff reported a range of issues, including poor awareness of pandemic plans, patient and family aggression, chaotic information flow to themselves and the public, heightened stress related to increased workloads and lower levels of staffing due to illness, family care duties and redeployment of staff to flu clinics. Staff identified considerable discomfort associated with prolonged times wearing personal protective equipment. Staff believed that the care of non-flu patients was compromised during the pandemic as a result of overwork, distraction from core business and the difficulties associated with accommodating infectious patients in an environment that was not conducive.

CONCLUSIONS

This paper describes the breadth of the impact of pandemics on ED operations. It identifies a need to address a range of industrial, management and procedural issues. In particular, there is a need for a single authoritative source of information, the re-engineering of EDs to accommodate infectious patients and organizational changes to enable rapid deployment of alternative sources of care.

Queensland Emergency Medicine Research Foundation: special report

Development of any new profession is dependent on the development of a special body of knowledge that is the domain of the profession. Key to this is research. Following sustained lobbying, the Queensland Government agreed to establish an emergency medicine research fund as part of an Enterprise Bargaining Agreement in 2006. That fund is managed by the Queensland Emergency Medicine Research Foundation. The present article describes the strategic approaches of the Foundation in its first 3 years, the application of research funds, and foreshadows an evaluative framework for determining the strategic value of this investment. The Foundation has developed a range of personnel and project support funding programmes, and competition for funding has increased. Ongoing evaluation will seek to determine the effectiveness of the current funding strategy on improving the effectiveness of research performance. It will also evaluate the clinical and organizational outcomes.

Unplanned return visits to emergency in a regional hospital

Objective. The aim of this study was to determine the patient characteristics associated with unplanned return visits, using routinely collected hospital data, to assist in developing strategies to reduce their occurrence. Methods. Emergency department data from a regional hospital were analysed using univariate and multivariate methods to determine the influence of clinical, service usage and demographic patient characteristics on unplanned return visits. Results. Around 80% of the 16 000 patients attending emergency presented on only one occasion in a year. Five per cent of patients presented with an unplanned return visit. Older patients, those with minor and low urgency conditions and with non-psychotic mental health conditions, those presenting during winter and after hours were significantly more likely to present as unplanned return visits. Conclusion. Although patient characteristics associated with unplanned return visits have been identified, the reasons underpinning the unplanned return visit rate, such as patient service preference and attitudes, need to be more fully investigated. What is known about the topic? Patients who present as unplanned return visits are older and have a range of chronic and acute conditions. Some unplanned return visits occur because of limited access to other non-hospital service. What does this paper add? This paper adds to the field by providing information from a regional hospital in NSW Australia on the patient characteristics associated with unplanned return visits. It provides a basis for differentiating between other groups of frequent emergency department patients. However, the reasons behind the unplanned return visit rate need to be more fully investigated. What are the implications for practitioners? The implications of the findings of this study for policy makers, administrators and clinicians are that access to alternative services for the conditions associated with unplanned return visits need to be further investigated in the context of the role for emergency department services.

ED overcrowding: the Ontario approach

Ontario is Canada's most populous province, with approximately 12 million people and 130 emergency departments (EDs). Canada has a national single-payer universal health care system, but provinces are responsible for administration. After years of problems and failed attempts to address chronic ED overcrowding, in April 2008 Ontario embarked on an ambitious program to improve system performance through targeted investments (initially CAN$500 million over 3 years) and realigned incentives. Supporting the program were requirements for hospitals to submit timely data and targets for length of stay (LOS) and annual improvements; results are publicly reported. The program has been continued this year. While not all our provincial level targets have been met as yet, major improvements have been made, especially in access to care and LOS in the ED for patients eventually discharged home. The greatest improvements were made among the cohort of mainly urban, high-volume EDs that had the worst performance at baseline. This presentation will highlight some of the controversies and challenges and key lessons learned. Overall, the Ontario experience suggests ED overcrowding is a soluble problem, but requires a system-level intervention.

Review article: Crisis resource management in emergency medicine

Effective team management is a core element of expert practice in emergency medicine. Thus far, training in emergency medicine has focussed predominantly on proficiency in medical and technical skills, with emergency physicians acquiring these 'non-technical' skills in an ad hoc manner or by trial and error with varying levels of success. This paper describes a set of behaviours that, when practised in conjunction with medical and technical expertise, can reduce the incidence of clinical error and contribute to effective teamwork and the smooth running of an ED. Teaching and practice of these behaviours is now a core element of training and skills maintenance in other high-risk areas, such as aviation, and is becoming part of the routine training for anaesthetists. They address areas, such as communication, leadership, knowledge of environment, anticipation and planning, obtaining timely assistance, attention allocation and workload distribution. We outline the application of these behaviours in the speciality of emergency medicine, and suggest that the teaching and practice of crisis resource management principles should become part of the curriculum for training and credentialing of emergency medicine specialists.

Work pressure and patient flow management in the emergency department: findings from an ethnographic study

OBJECTIVES

In this hypothesis-generating study, we observe, identify, and analyze how emergency clinicians seek to manage work pressure to maximize patient flow in an environment characterized by delayed patient admissions (access block) and emergency department (ED) crowding.

METHODS

An ethnographic approach was used, which involved direct observation of on-the-ground behaviors, when and where they happened. More than 1,600 hours over a 12-month period were spent observing approximately 4,500 interactions across approximately 260 emergency physicians and nurses, emergency clinicians, and clinicians from other hospital departments. The authors content analyzed and thematically analyzed more than 800 pages of field notes to identify indicators of and responses to pressure in the day-to-day ED work environment.

RESULTS

In response to the inability to control inflow, and the reactions of inpatient departments to whom patients might be transferred, emergency clinicians: reconciled urgency and acuity of conditions; negotiated and determined patients' admission-discharge status early in their trajectories; pursued predetermined but coevolving pathways in response to micro- and macroflow problems; and exercised flexibility to reduce work pressure by managing scarce time and space in the ED.

CONCLUSIONS

To redress the linearity of most literature on patient flow, this study adopts a systems perspective and ethnographic methods to bring to light the dynamic role that individuals play, interacting with their work contexts, to maintain patient flow. The study provides an empirical foundation, uniquely discernible through qualitative research, about aspects of ED work that previously have been the subject only of discussion or commentary articles. This study provides empirical documentation of the moment-to-moment responses of emergency clinicians to work pressure brought about by factors outside much of their control, establishing the relationship between patient flow and work pressure. We conceptualize the ED as a dynamic system, combining socioprofessional influences to reduce and control work pressure in the ED. Interventions in education, practice, policy, and organizational performance evaluations will be supported by this systematic documentation of the complexity of emergency clinical work. Future research involves testing the five findings using systems dynamic modeling techniques.