The impact of Australian healthcare reforms on emergency department time-based process outcomes: An interrupted time series study

Efficiency measures of emergency departments: an Italian systematic literature review

Life expectancy globally increased in the last decades: the number of people aged 65 or older is consequently projected to grow, and healthcare demand will increase as well. In the recent years, the number of patients visiting the hospital emergency departments (EDs) rocked in almost all countries of the world. These departments are crucial in all healthcare systems and play a critical role in providing an efficient assistance to all patients. A systematic literature review covering PubMed, Scopus and the Cochrane Library was performed from 2009 to 2019. Of the 718 references found in the literature research, more than 25 studies were included in the current review. Different predictors were associated with the quality of EDs care, which may help to define and implement preventive strategies in the near future. There is no harmonisation in efficiency measurements reflecting the performance in the ED setting. The identification of consistent measures of efficiency is crucial to build an evidence base for future initiatives. The aim of this study is to review the literature on the problems encountered in the efficiency of EDs around the world in order to identify an organisational model or guidelines that can be implemented in EDs to fill inefficiencies and ensure access optimal treatment both in terms of resources and timing. This review will support policy makers to improve the quality of health facilities, and, consequently of the entire healthcare systems.

Review article: Has the implementation of time-based targets for emergency department length of stay influenced the quality of care for patients? A systematic review of quantitative literature

Time-based targets (TBTs) for ED stays were introduced to improve quality of care but criticised as having harmful unintended consequences. The aim of the review was to determine whether implementation of TBTs influenced quality of care. Structured searches in medical databases were undertaken (2000-2019). Studies describing a state, regional or national TBTs that reported processes or outcomes of care related to the target were included. Harvest plots were used to summarise the evidence. Thirty-three studies (n = 34 million) were included. In some settings, reductions in mortality were seen in ED, in hospital and at 30 days, while in other settings mortality was unchanged. Mortality reductions were seen in the face of increasing age and acuity of presentations, when short-stay admissions were excluded, and when pre-target temporal trends were accounted for. ED crowding, time to assessment and admission times reduced. Fewer patients left prior to completing their care and fewer patients re-presented to EDs. Short-stay admissions and re-admissions to wards within 30 days increased. There was conflicting evidence regarding hospital occupancy and ward medical emergency calls, while times to treatment for individual conditions did not change. The evidence for associations was mostly low certainty and confidence in the findings is accordingly low. Quality of care generally improved after targets were introduced and when compliance with targets was high. This depended on how targets were implemented at individual sites or within jurisdictions, with important implications for policy makers, health managers and clinicians.

United States' Performance on Emergency Department Throughput, 2006 to 2016

STUDY OBJECTIVE

Studies of early data found that US emergency departments (EDs) were characterized by prolonged patient waiting, long visit times, frequent and prolonged boarding (ie, patients kept waiting in ED hallways or other space outside the ED on admission to the hospital), and patients leaving without receiving or completing treatment. We sought to assess recent trends in ED throughput nationally.

METHODS

This was a retrospective cross-sectional analysis of data from the National Hospital Ambulatory Medical Care Survey from 2006 to 2016. We used survey-weighted generalized linear models to assess changes over time. The primary outcome variables were the number of visits, wait time to consult a physician, length of visit (time from arrival to leaving for home or hospital ward), boarding time, the proportion of patients leaving without being seen, the proportion treated within recommended waiting times, and the proportion dispositioned within 4, 6, and 8 hours.

RESULTS

Between 2006 and 2016, the number of ED visits increased from 119.2 million to 145.6 million. During this period, annual median wait time decreased from 31 minutes (interquartile range 14 to 67) to 17 minutes (interquartile range 6 to 45). The proportion of patients who left without being seen declined from 2.0% (95% confidence interval [CI] 1.7% to 2.4%) to 1.1% (95% CI 0.8% to 1.4%). The proportion treated by a qualified practitioner within recommended waiting times increased from 75.5% (95% CI 72.7% to 78.3%) to 80.8% (95% CI 77.2% to 84.4%). Overall, there was no statistically significant change in median length of visit. However, over time, decreased proportions of the sickest patients were discharged within 4, 6, and 8 hours, whereas increased proportions of low-acuity patients were discharged within 4 hours. The distribution of patient boarding time remained fairly unchanged from 2009 to 2015, with a median of approximately 75 minutes.

CONCLUSION

Overall, there was improvement in ED timeliness from 2006 to 2016. However, we observed a decrease in the proportion of the sickest patients discharged within 8 hours of arrival, although this may be due to increased ancillary testing or specially consultation over time.

Increasing use of CT requested by emergency department physicians in tertiary hospitals in Western Australia 2003-2015: an analysis of linked administrative data

OBJECTIVE

This study aimed to examine trends in number of CT scans requested by tertiary emergency department (ED) physicians in Western Australia (WA) from 2003 to 2015 across broad demographic and presentation characteristics, anatomical areas and presented symptoms.

DESIGN

An observational cross-sectional study over study period from 2003 to 2015.

SETTING

Linked administrative health service data at individual level from WA.

PARTICIPANTS

A total of 1 666 884 tertiary hospital ED presentations of people aged 18 years or older were included in this study MAIN OUTCOME MEASURE: Number of CT scans requested by tertiary ED physicians in an ED presentation.

METHODS

Poisson regression models were used to assess variation and trends in number of CT scans requested by ED physicians across demographic characteristics, clinical presentation characteristics and anatomical areas.

RESULTS

Over the entire study duration, 71 per 1000 ED episodes had a CT requested by tertiary ED physicians. Between 2003 and 2015, the rate of CT scanning almost doubled from 58 to 105 per 1000 ED presentations. After adjusted for all observed characteristics, the rate of CT scans showed a downward trend from 2009 to 2011 and subsequent increase. Males, older individuals, those attending ED as a result of pain, those with neurological symptoms or injury or with higher priority triage code were the most likely to have CT requested by tertiary ED physicians.

CONCLUSIONS

Noticeable changes in the number of CTs requested by tertiary ED physicians corresponded to the time frame of major health reforms happening within WA and nationally.

Where are children seen in Australian emergency departments? Implications for research efforts

OBJECTIVE

With most paediatric emergency research in Australia conducted at tertiary EDs, it is important to understand how presentations differ between those at tertiary paediatric EDs and all other EDs.

METHODS

Retrospective epidemiological study assessing paediatric case-mix and time-based performance metrics (aged 0-14 years) obtained from a national health service minimum dataset for the 2017-2018 financial year, comparing tertiary paediatric EDs and all other EDs. We defined a 'major tertiary paediatric hospital' as one which was accredited for training in both paediatric emergency medicine and paediatric intensive care.

RESULTS

Of the 1 695 854 paediatric ED presentations, 23.8% were seen in nine major metropolitan tertiary paediatric hospitals. Reasons for presentations were more distinctive between cohorts among children aged 10-14 years, where psychiatric illness (5.2% vs 2.5%) and neurological illness (4.5% vs 2.5%) were more commonly seen in major tertiary paediatric EDs. Australian Indigenous children were significantly less likely to present to tertiary paediatric EDs (3.0%), compared with other EDs (9.7%) (odds ratio 0.27, 95% confidence interval 0.26-0.27). While median waiting times were longer in major tertiary paediatric EDs (28 min [interquartile range 11-65]) than in other EDs (20 min [interquartile range 8-48], P < 0.001), patients were also less likely to leave without being seen (5.5% in tertiary paediatric EDs vs 6.9% in other EDs; odds ratio 0.80, 95% confidence interval 0.78-0.81).

CONCLUSIONS

The present study identified key areas of difference in paediatric presentations between tertiary paediatric EDs and other EDs. It is vital to broaden paediatric ED research beyond tertiary paediatric centres, to ensure relevance and generalisability.