Myths versus facts in emergency department overcrowding and hospital access block

Optimal management of mental health patients in Australian emergency departments: barriers and solutions

OBJECTIVES

The study aimed to describe: (i) the perceived barriers faced by emergency clinicians in the assessment and management of patients presenting with a mental health complaint to Australian hospital EDs; and (ii) perceived strategies to optimize care of the mentally unwell in the ED.

METHODS

Semistructured interviews with open and closed question formats were used to explore the barriers perceived by ED doctors and nurses in assessing and managing patients with mental health presentations. Interviews were transcribed verbatim and thematically coded by two researchers using the Framework Approach.

RESULTS

Thirty-six interviews were conducted with 20 members of the Australasian College for Emergency Medicine and 16 members of the College of Emergency Nursing Australasia representing the various Australian jurisdictions. Thematic analyses revealed that a range of resource, environmental, staff and patient factors contribute to difficulties in managing mental health patients. Solutions suggested by interviewees included improved resources, ED redesign and improved links to resources outside the ED. An overwhelming majority of participants perceived the need for more educational opportunities in mental health.

CONCLUSION

Although the provision of timely and quality care is expected for all patients attending EDs, there exist multiple barriers to provision of adequate care for ED patients presenting with mental illness. Many of these are systems-based and thus require systems-based solutions. ED clinician's perceive that improved educational opportunities in mental health, however, might alleviate some barriers they face. Consideration should be given to a comprehensive, quantitative mental health-related learning needs analysis of ED clinicians.

The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995-2015

OBJECTIVE

To measure the growth in emergency ambulance use across metropolitan Melbourne since 1995, to measure the impact of population growth and ageing on these services, and to forecast demand for these services in 2015.

DESIGN AND SETTING

A population-based retrospective analysis of Ambulance Victoria's metropolitan emergency ambulance transportation data for the period from financial year 1994-95 to 2007-08, and modelling of demand in the financial year 2014-15.

MAIN OUTCOME MEASURES

Numbers and rates of emergency ambulance transportations.

RESULTS

The crude annual rate of emergency transportations across all age groups increased from 32 per 1000 people in 1994-95 to 58 per 1000 people in 2007-08. The rate of transportation for all ages increased by 75% (95% CI, 62%-89%) over the 14-year study period, representing an average annual growth rate of 4.8% (95% CI, 4.3%-5.3%) beyond that explained by demographic changes. Patients aged ≥ 85 years were eight times (incident rate ratio, 7.9 [95% CI, 7.6-8.3]) as likely to be transported than those aged 45-69 years over this period. Forecast models suggest that the number of transportations will increase by 46%-69% between 2007-08 and 2014-15, disproportionately driven by increasing usage by patients aged ≥ 85 years.

CONCLUSIONS

These findings confirm a dramatic rise in emergency transportations over the study period, beyond that expected from demographic changes. Rates increased across all age groups, but more so in older patients. In the future, such acceleration is likely to have major effects on ambulance services and acute hospital capacity. This calls for further investigation of underlying causes and alternative models of care.

National Health and Hospital Network for Australia's future: implications for Emergency Medicine

The proposals arising from the agreement reached between the Rudd government and the States and Territories (except Western Australia) in April 2010 represent the most fundamental realignment of health responsibilities since the creation of Medicare in 1984. They will change the health system, and the structures that will craft its future direction and design. These proposals will have a significant impact on Emergency Medicine; an impact from not only the system-wide effects of the proposals but also those that derive from the specific recommendations to create an activity-based funding mechanism for EDs, to implement the four hour rule and to develop a performance indicator framework for EDs. The present paper will examine the potential impact of the proposals on Emergency Medicine to inform those who work within the system and to help guide further developments. More work is required to better evaluate the proposals and to guide the design and development of specific reform instruments. Any such efforts should be based upon a proper analysis of the available evidence, and a structured approach to research and development so as to deliver on improved services to the community, and on improved quality and safety of emergency medical care.

The referral and complete evaluation time study

INTRODUCTION

It has been suggested that inefficiency in the delivery of care in emergency departments (EDs) may contribute to their overcrowding. Specifically the duplication of work by the on take teams of the assessment already performed by the ED doctor has been identified as a possible contributor to prolonged waits for a hospital bed for those requiring admission. Anything that prolongs an individual patient's processing time will contribute to overcrowding.

METHODS

This observational study was performed using a database of all patient attendances to examine the timeliness of the delivery of care to patients requiring admission through the ED and specifically to examine the impact of the referral process on the total time spent in the ED.

RESULTS

Between August 2006 and February 2007, 6973 (25.4%) patients were referred to the on take teams and admitted. The mean total time in the ED for the 4092 (58.7%) medical patients was 21 h 16 min (standard deviation 12 h 24 min) as compared with 14 h 28 min (standard deviation 10 h 46 min) for the 2852 (40.9%) surgical admissions (P<0.001). The referral process accounted for an average of 16.6% of the patient journey through the ED while access block accounted for an average of 59.6%.

CONCLUSION

The overwhelming reason for prolonged waits and overcrowding in Irish EDs is not the duplication of work inherent in the referral process but it is because of a lack of acute hospital capacity.

Measures of crowding in the emergency department: a systematic review

OBJECTIVES

Despite consensus regarding the conceptual foundation of crowding, and increasing research on factors and outcomes associated with crowding, there is no criterion standard measure of crowding. The objective was to conduct a systematic review of crowding measures and compare them in conceptual foundation and validity.

METHODS

This was a systematic, comprehensive review of four medical and health care citation databases to identify studies related to crowding in the emergency department (ED). Publications that "describe the theory, development, implementation, evaluation, or any other aspect of a 'crowding measurement/definition' instrument (qualitative or quantitative)" were included. A "measurement/definition" instrument is anything that assigns a value to the phenomenon of crowding in the ED. Data collected from papers meeting inclusion criteria were: study design, objective, crowding measure, and evidence of validity. All measures were categorized into five measure types (clinician opinion, input factors, throughput factors, output factors, and multidimensional scales). All measures were then indexed to six validation criteria (clinician opinion, ambulance diversion, left without being seen (LWBS), times to care, forecasting or predictions of future crowding, and other).

RESULTS

There were 2,660 papers identified by databases; 46 of these papers met inclusion criteria, were original research studies, and were abstracted by reviewers. A total of 71 unique crowding measures were identified. The least commonly used type of crowding measure was clinician opinion, and the most commonly used were numerical counts (number or percentage) of patients and process times associated with patient care. Many measures had moderate to good correlation with validation criteria.

CONCLUSIONS

Time intervals and patient counts are emerging as the most promising tools for measuring flow and nonflow (i.e., crowding), respectively. Standardized definitions of time intervals (flow) and numerical counts (nonflow) will assist with validation of these metrics across multiple sites and clarify which options emerge as the metrics of choice in this "crowded" field of measures.

State of emergency medicine in Spain

Spain has universal public health care coverage. Emergency care provisions are offered to patients in different modalities and levels according to the characteristics of the medical complaint: at primary care centers (PCC), in an extrahospital setting by emergency medical services (EMS) and at hospital emergency departments (ED). We have more than 3,000 PCCs, which are run by family doctors (general practitioners) and pediatricians. On average, there is 1 PCC for every 15,000 to 20,000 inhabitants, and every family doctor is in charge of 1,500 to 2,000 citizens, although less populated zones tend to have lower ratios. Doctors spend part of their duty time in providing emergency care to their own patients. While not fully devoted to emergency medicine (EM) practice, they do manage minor emergencies. However, Spanish EMSs contribute hugely to guarantee population coverage in all situations. These EMS are run by EM technicians (EMT), nurses and doctors, who usually work exclusively in the emergency arena. EDs dealt with more than 25 million consultations in 2008, which implies, on average, that one out of two Spaniards visited an ED during this time. They are usually equipped with a wide range of diagnostic tools, most including ultrasonography and computerized tomography scans. The academic and training background of doctors working in the ED varies: nearly half lack any structured specialty residence training, but many have done specific master or postgraduate studies within the EM field. The demand for emergency care has grown at an annual rate of over 4% during the last decade. This percentage, which was greater than the 2% population increase during the same period, has outpaced the growth in ED capacity. Therefore, Spanish EDs become overcrowded when the system exerts minimal stress. Despite the high EM caseload and the potential severity of the conditions, training in EM is still unregulated in Spain. However, in April 2009 the Spanish Minister of Health announced the imminent approval of an EM specialty, allowing the first EM resident to officially start in 2011. Spanish emergency physicians look forward to the final approval, which will complete the modernization of emergency health care provision in Spain.

Supervision and feedback for junior medical staff in Australian emergency departments: findings from the emergency medicine capacity assessment study

BACKGROUND

Clinical supervision and feedback are important for the development of competency in junior doctors. This study aimed to determine the adequacy of supervision of junior medical staff in Australian emergency departments (EDs) and perceived feedback provided.

METHODS

Semi-structured telephone surveys sought quantitative and qualitative data from ED Directors, Directors of Emergency Medicine Training, registrars and interns in 37 representative Australian hospitals; quantitative data were analysed with SPSS 15.0 and qualitative data subjected to content analysis identifying themes.

RESULTS

Thirty six of 37 hospitals took part. Of 233 potential interviewees, 95 (40.1%) granted interviews including 100% (36/36) of ED Directors, and 96.2% (25/26) of eligible DEMTs, 24% (19/81) of advanced trainee/registrars, and 17% (15/90) of interns. Most participants (61%) felt the ED was adequately supervised in general and (64.2%) that medical staff were adequately supervised. Consultants and registrars were felt to provide most intern supervision, but this varied depending on shift times, with registrars more likely to provide supervision on night shift and at weekends. Senior ED medical staff (64%) and junior staff (79%) agreed that interns received adequate clinical supervision. Qualitative analysis revealed that good processes were in place to ensure adequate supervision, but that service demands, particularly related to access block and overcrowding, had detrimental effects on both supervision and feedback.

CONCLUSIONS

Consultants appear to provide the majority of supervision of junior medical staff in Australian EDs. Supervision and feedback are generally felt to be adequate, but are threatened by service demands, particularly related to access block and ED overcrowding.

Perceptions of nurse practitioners by emergency department doctors in Australia

BACKGROUND

The Australian Medical Association is strongly opposed to the nurse practitioner (NP) role with concerns that NPs may become doctor substitutes without the requisite training and education that the medical role demands. Despite this, NPs have been heralded by some as a potential solution to the access block, workforce shortage and increased demand affecting emergency departments (EDs).

AIMS

The purpose of this study was to determine the perception of NPs by medical staff working in Australian EDs.

METHODS

Semi-structured telephone interviews were conducted with closed and open-ended questions. Participants were drawn from a representative stratified sample of two city, two metropolitan and two provincial hospitals of each State/Territory.

RESULTS

A total of 95 doctors from 35 EDs participated in this study including 36 Departmental Directors; 36% of participating Directors indicated having an NP on staff. Doctors were strongly opposed to the statement that NPs could replace either nurses or other prevocational doctors; 71 interviewees commented on the role of NPs in the ED. Thematic analyses revealed polarised views held by doctors. Eight major themes were identified, the most common being that there is a lack of clarity of the NP role definition, their scope of practice and differentiation from the medical role.

CONCLUSION

Although ED NPs represent a highly skilled professional group their role is poorly understood by ED doctors. Opposition to the NP role is a significant barrier to the introduction of great numbers of ED NPs as a strategy to overcome the medical workforce shortage.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (doi:10.1007/s12245-010-0214-8) contains supplementary material, which is available to authorized users.

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 of ideal hospital occupancy

Significant problems in health care, such as access block and long waiting lists for elective surgery, have led to calls for keeping hospital occupancy at no more than 85%. It is elementary queueing theory that a finite-capacity system with variable demand cannot sustain both full utilisation and full availability. However, the statement that there is a single level of ideal or safe occupancy suitable for all situations is a simplistic interpretation and application of the underlying science. We argue that specific study and action are necessary to understand and deal with the problems of long waiting lists and access block in any given health care facility.