Emergency demand access block and patient safety: A call for national leadership

See also pp. 472–8 There is increasing pressure on ED caused by a relentless increase in ED attendances and rising emergency admissions. This is compounded by the challenge of reduced inpatient bed access. In this issue of Emergency Medicine Australasia, Richardson and colleagues confirm that access block is worsening, having increased nationally by an average of 27% over the 4 years to September 2008.1 Of interest is the reported improvement in patient flow attributed to the ‘patient journey’ project, despite continuing rising demand throughout this time period in New South Wales. It is not clear whether this has been sustained. Richardson et al. conclude that hospitals have possibly reached saturation point regarding efficiency in managing patient flow. These findings will be no surprise to ED clinical staff, who have consistently stated that the problem extends beyond the walls of individual hospitals.2–4 The causes for this access block are known and solutions are evident. It is now time that leadership is shown at both clinical and policy levels to stop the problem. The Australasian College for Emergency Medicine (ACEM) defines an excessive wait for an inpatient bed as greater than 8 h,5 the UK defines it as 4 h6 and Western Australia has followed suit. However, in the context of comparison within and between countries, it is pertinent to also consider how access block is defined and measured. For example, ACEM includes the time of arrival to departure from the ED in their calculation,7 whereas New South Wales Health has excluded ED waiting time, commencing their computation at the time the patient is attended to by a doctor.8 This latter measure fails to include time delay attributable to hold-up in processes associated with ED overcrowding, and therefore underestimates the overall delay experienced by the patient. The time is also subject to manipulation. There are many ways of measuring access block, including total patient time in ED,7 time from medical assessment to departure time and collective ‘total access block time’.8 It is essential for benchmarking to occur that all states collect data in a standardized fashion, which can be verified by outside agencies. Whichever way it is analysed,9 access block leads to diminished ED performance and restricted access to timely urgent care, thus representing a threat to patient safety. There are multiple consequences of access block that place patients at risk of a poor outcome: overcrowding, whereby ED capacity is exceeded by the number of patients waiting to be seen, undergoing assessment and treatment or awaiting discharge; increased burden in caring for patients whose emergency treatment has ceased but are awaiting an inpatient bed; increased likelihood of adverse events; and ED blockage with ambulance diversion.10 Demonstrable evidence of an association with adverse events10,11 includes an estimated annual 20–30% excess mortality rate corresponding to 1500 additional deaths directly attributable to access bock and ED overcrowding, using data from 2003.12,13 In addition, prolonged length of stay in the ED has been associated subsequently with increased inpatient length of stay,14,15 and disruption to elective surgery.13 As such, access block can be interpreted as a quality indicator for safety in the ED. The underlying causes of access block relate to the increase in emergency demand together with a decreased hospital bed capacity to meet these needs. Since 2003/2004, the number of emergency attendances has risen nationally by 73% from 4.1 million to 7.1 million in 2007/2008. This represents an increase from 202 to 321 ED presentations per 1000 persons.16 Rising demand is not limited to Australia, as the UK, New Zealand, Canada and the USA also report increased ED attendances since the 1990s, with current annual increases ranging from 3% to 6%.17–20 The underlying drivers of this increase in demand are thought to be multifactorial. Population ageing is a likely contributor, with the fastest growth of ED attendances in recent years in the 75+-year-old age group.21–24 Underlying reasons include the growing prevalence of chronic medical conditions and the incidence of age-related acute illnesses and cognitive or physical dysfunction, with 19% of Australians aged >65 years reporting a disability.25 Compounding this are changes in social structure. Wider participation of middle-aged women in the workforce and erosion of the extended family has decreased capacity for family to care for older relatives.26 In addition, government policies encourage older people to remain living in their homes, with the majority of those aged >65 years now living alone.27 Ensuing fragmentation of support can lead to vulnerability, and there is evidence that loneliness and limited social support are associated with a much higher ED attendance rate by the elderly.28–30 Encouragement for mainstreaming of care within the community also includes de-institutionalization of mental health patients.31 This is thought to have contributed to the increased attendance by patients with mental health problems, which rose 10-fold over a 10 year period at one South Australian ED.32 Other studies of repeat ED attendees have noted a high incidence of psychiatric illness and substance abuse.33–35 Changes in health care practice and the medical workforce have resulted in the reduced availability and access to general practitioners.36,37 Studies cite lack of access to a general practitioner as one of the patients' reasons for attending an ED.24,38,39 Furthermore, improvements in accessibility to quality emergency care from specialist paramedic and emergency physicians for low or no cost raises the question of moral hazard as another potential driver of demand. The convenience of a ‘one-stop shop’ with availability of total care from a specialist alongside relevant diagnostics has also been cited by patients as a reason for attendance.39 Health promotion activities and mass media campaigns have raised the general public's awareness about the desirability of seeking early medical attention for a variety of conditions. This might reduce the threshold for seeking care by patients and health professionals. Although alluded to in one study,40 this does not appear to have been quantified in relation to emergency service use in Australia. However, presentations by 75+-year-olds increased following a health screening program in the UK,41 and stroke presentations increased to Canadian ED following a media campaign.42 The extent to which each of the above factors contributes to increasing demand is yet to be established. Despite this, strategies should be implemented to reduce ED presentations. The impact of demand on ED access is exacerbated by an increasing number of patients requiring admission from the ED. In 2007/2008, 28% of ED presentations were admitted.16 However, there has been no increase in hospital capacity with the number of available public beds remaining at 1998/1999 levels at 2.6 beds per 1000 persons,16 plus an additional 1.2 private beds per 1000 persons.43 In combination, this means that our national acute bed availability lies below that of the Organisation for Economic Co-operation and Development (OECD) average of 3.9 acute care beds per 1000.44 However, almost 60% of the population are unable to access these additional private beds, leaving the public hospital bed capacity well below the OECD average. Inhospital bed capacity is also directly affected by access to community residential facilities. In many circumstances, acute hospital beds are used as inappropriate substitutes for more long-term residential care. Access block and overcrowding became a critical issue in Australia, the UK, Canada and the USA in the 1990s.2,10,45–47 By the late 1990s, emergency physicians through their professional associations and peer-reviewed journals began to initiate organizational changes primarily at the level of the individual hospital.3,10,45,48–50 Variable but generally positive improvement occurred in access block in a number of ED around Australia following implementation of changes throughout 2001/2002.48 Of particular interest was the reported striking improvement at Royal North Shore Hospital following a hospital-wide focus on discharge planning and centralization of bed management.48 However, the study commissioned by ACEM in 2008 suggested that this progress has not been sustained, as 40% of ED workload was devoted to caring for patients awaiting admission following completion of their emergency treatment.51 Solutions lie with effective short-term operational changes at a hospital level in conjunction with long-term systemic policy change. Operational change requires strong clinical leadership within and across hospitals. Although bed capacity is important, an increase in capacity without changes across the system will not resolve access block. The most effective solution will be to also reconfigure the wider system. With the relentless rise in the number of patients seeking care at ED, it is essential to take an upstream approach to reduce the demand on emergency services through system reform. In addition to the current focus on prevention and early intervention, reform would include expansion of hospital outreach programs and primary health services to include multidisciplinary health teams providing coordinated care for the elderly and patients with chronic disease in the community. Furthermore, targeted media campaigns could potentially educate the community and health professionals52 on the appropriate and timely use of community and emergency health services. In addition, clinical and policy leadership is required to prioritize access to care. At present, priority access is decided by the length of the queue, either on the elective waiting list, or the ramp in an ED. Many patients are denied access to appropriate care, with its good evidence to support improved outcomes, whereas costly treatments with minimal evidence of effectiveness are provided. System redesign is a key recommendation of the National Health and Hospitals Reform Commission.53 One of the priorities recognized was ‘timely access to quality care in public hospitals, particularly care in emergency departments . . .’ Although increased funding to guarantee bed availability for emergency admissions features as a key recommendation of the commission, it is unlikely that this will occur in the immediate future, given the current state of the economy, nor will it resolve access block. The National Health Service in the UK have determined that bed occupancy rates above 82% lead to a high risk of access block and cancellation of elective surgery.54 In this context, consideration should be given by the Federal Government to assist hospitals to maintain such levels of occupancy that enable a degree of flexibility to manage the fluctuations in demand, without compromising patient safety. The key to this will be to ensure appropriate bed use, to fund public hospital bed numbers to at least an OECD average level, and to balance elective and emergency demand with seasonal fluctuations. Simplistically stating that hospitals should maintain 15% of beds free for ED demand is not workable in a capped federally funded public health system. The capacity to flex beds in individual wards across hospitals (including varying staff: bed ratios), providing that there is tight bed management, could enable hospitals to manage variable demand. Access block is a problem that extends beyond the walls of hospitals, with solutions in the hands of hospital administrators, policy-makers and politicians. Clinicians must provide leadership to ensure that workable solutions are developed. We have to move beyond the simplistic approach of constant redesign projects that attempt to improve hospital and ED efficiency, and instead look at more fundamental issues. A uniform national measurement would provide a consistent benchmark across the country. We must increase the capacity of hospitals to manage variable emergency demand to approximately 15% of base-level bed stock. We need to identify and mitigate drivers for increased emergency demand. Most importantly, we must discuss a rational approach to prioritization of effective medical care that is not determined by the length of an ED ramp, or days on an elective waiting list. JL is the recipient of a National Health and Medical Research Council Postgraduate Research Scholarship. Nil.

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