Journal of the New Zealand Medical Association, 14-October-2011, Vol 124 No 1344
Improving acute patient flow and resolving emergency department overcrowding in New Zealand hospitals—the major challenges and the promising initiatives
When hospitals fail to cope with demands for acute care one manifestation is overcrowding of the emergency department (ED). ED overcrowding is associated with a number of adverse consequences, including patient deaths.1–6
In response to concerns about ED overcrowding7 and pressure for more focus on acute care (including the recommendations of the Working Group for Achieving Quality in Emergency Departments8), on 1 July 2009 ‘Shorter Stays in Emergency Departments’ (the Target) became one of six national Health Targets in New Zealand. The Target is defined as ‘95% of patients will be admitted, discharged or transferred from an emergency department within 6 hours’.
At the time of this study New Zealand had 21 District Health Boards (DHBs) which plan, manage, provide and purchase health services for the population of their district.9 Administered by these DHBs are 28 hospitals with EDs of appropriate role delineation (level three and above10) to be subject to the Target.
A small team was formed in the Ministry (the three authors) to facilitate and lead progress towards the Target. As part of this, a priority activity for the team during the first year was to visit each DHB to gain an understanding of their specific challenges and successes in relation to the Target. In addition, the team reviewed documentation from each DHB including a ‘Delivery Plan for achieving Shorter Stays in ED’. The delivery plans were intended to be comprehensive, prioritised, ‘whole of system’ plans detailing the DHB’s challenges and how they intended to overcome them.11
The visits and associated information from DHBs provided a unique national overview of the challenges facing DHBs in their pursuit of better acute care, the resolution of ED overcrowding, and consequent achievement of the Target. The aim of this study was to collate the 10 most common challenges and discuss how DHBs are addressing them.
All DHBs were visited between 1 July 2009 and 1 July 2010. The visits were attended by the National Clinical Director of ED Services (MA) and one or both of the two other members of the Shorter Stays in ED team (GT and/or CP). The visits took a standardised format which included an initial meeting with senior clinicians and managers to discuss the purpose of the visit and general issues related to the Target. This was followed by meetings with ED staff (doctors, nurses and others), staff responsible for hospital bed management and patient flow clinical staff from in-patient specialities and primary care representatives in some instances, to discuss their perspectives of the challenges and the successful initiatives.
Tours of the ED and in-patient facilities enhanced understanding of local issues, and the visit concluded with a final meeting with senior clinicians and managers to discuss the visitors’ impressions and to verify their accuracy. Following the visit a standardised report was constructed with sections describing general conclusions, structure and leadership, specific project components, (for example, ‘pre-load’, ‘contractility’ and ‘after-load’11), specific initiatives at the DHB (for example, Medical Assessment and Planning Unit, acute care pathways, and so on), and finishing with recommendations and agreed actions. These sections recorded both the challenges to achieve the Target and the promising initiatives.
The reports were sent to the DHBs for review and feedback prior to finalising.
The reports of the 21 DHB visits were reviewed by the National Clinical Director of ED Services (MA) and challenges were recorded as present for a DHB whenever they were noted in the report as being significant.
The data was recorded for all DHBs and subcategorised by the seven smallest, seven medium sized, and seven largest DHBs. The size of the DHB was determined by the number of ED presentations in quarter four of 2009/10 (1 April–30 June 2010).
A general list of promising initiatives was constructed based on initiatives already demonstrating success, or initiatives promising to be successful because of experience of similar initiatives elsewhere, and/or initiatives focused on good analysis of the causes and contributors to the challenges (i.e. good ‘diagnostics’, particularly including ‘lean thinking’ methodologies).
The top 10 challenges are presented in Table 1.
Table 1. The top 10 challenges
Of the 15 DHBs which noted access to hospital beds as a barrier, all 15 recorded delays because there was ‘no available bed’ and four DHBs also noted delays getting the patient into a bed even when available. Occasionally ‘no available bed’ meant ‘no suitable bed available’, for example if the patient needed isolation in a single room because of an infectious illness.
Lower in the table is ‘delay to discharge of inpatients’ noted by 11 DHBs, and ‘difficulty accessing aged care beds’ noted by seven DHBs. Both of these might be considered related to ‘access to hospital bed’. If considered together this grouping is alone in first place as the greatest challenge for DHBs.
Access to diagnostic tests were mostly due to delayed access to computed tomography (CT) scanning (nine DHBs) with six DHBs noting delays to other tests, mostly ultrasound scanning. Access to plain radiology and blood and other laboratory tests were not considered significant in causing delays.
Inpatient team delays were noted by 15 DHBs, all of which noted a delay to the registrar coming to the ED and eight also noted a delay to registrar decision-making once there.
Close behind the top three challenges was increased demand for ED services, noted by 14 DHBs, with eight of these noting an increase in ‘minor’ patients.
ED facility deficiencies (too small and/or poor layout) and ED staff deficiencies (particularly medical staff deficiencies) were next on the list of barriers, with difficulty engaging hospital clinical staff in changes, and problems at night and weekends completing the top 10.
The nature of recording the challenges and the small numbers in the subgroups precludes an analysis of statistical significance, but some challenges showed a trend of relationship to DHB size. While no challenge was peculiar to DHBs of a particular size, access to hospital beds, inpatient team delays, ED facility deficiencies, delay to discharge of inpatients, difficulty engaging hospital clinical staff in changes, and problems at night and weekends seemed to be more common the larger the DHB.
Table 2 presents generalised descriptions of the more promising initiatives witnessed during the DHB visits. These are discussed further in the discussion section below.
Table 2. Promising initiatives
This study is unique, providing a comprehensive national overview of the challenges facing our hospitals in the pursuit of improved acute care. However, the nature of the methodology can mean the findings are indicative only. They were the insightful opinions of those spoken to during the DHB visits, although these were usually based on significant analysis of patient flow and performance. Most DHBs shared charts, graphs and documents supporting the opinions expressed, although the evidence base for them cannot be assured.
Those spoken to during the visits were broadly representative of the acute care system but indisputably with a bias towards staff associated with the ED. Management staff and those responsible for bed management were well represented, and ward based nursing staff generally had good input. Inpatient medical staff, general practitioners and resident medical officers were usually under-represented.
In addition, the challenges presented were ranked according to how many DHBs saw them as being important and not how relatively large an issue they were. Hence, a challenge ranked lower by this methodology might be more significant because of the number of patients it affects or the extent of the delay it causes.
The results are a stimulus for discussion and in particular, for exploration of appropriate ways to address these challenges. To this end, the remainder of this discussion will briefly recount the authors’ experience of initiatives seen during the visits. More detail and further opportunity for sharing are to be found on the Health Improvement and Innovation Resource Centre (HIIRC) website which has a section on the Target.12
Of particular note is that most of the top 10 challenges, including the top three, relate to issues in the patient journey outside the control of the ED, reinforcing the understanding that improving acute care, resolving ED overcrowding and achieving the Target requires effort across the whole of the patient pathway. This finding reinforces the need for a whole of system structure, with clear leadership and responsibilities, and with a comprehensive (so important things are not missed out), and prioritised (so the most important things are addressed first), plan for progressing improvements in acute care.11
Access to hospital beds, particularly when combined with delay to discharge of inpatients and the related subset barrier of difficulty accessing aged care beds, is the biggest challenge nationally. Discussion in relation to this issue included consideration of an optimal occupancy of hospitals. There is some evidence that hospital occupancy of around 85% allows optimal flow.13 Debate about measuring occupancy, (which beds should be counted, whether beds without a nurse are counted, at what time of the day should occupancy be measured, and so on), and concerns that extra capacity, if acquired, would soon be filled, have distracted from the key understanding—that there needs to be some spare capacity, existing or readily mobilised, so that patients can move to the right bed when ready to go.
DHBs have created capacity by investing in additional capacity or by freeing up existing capacity, or a combination of the two. A number of DHBs have examined their bed stock and have redistributed beds among speciality groups and/or have increased capacity. Many have invested in beds with a specific function, for example inpatient assessment and planning or ED observation, thereby enhancing bed stock but also (ideally) enhancing the efficiency of use of the beds. Guidance on the use of ED observation and inpatient assessment units is available.14
Hospital bed management in New Zealand is variable. Many DHBs are using predictive demand tools and attempting to match capacity to demand as a consequence. A number of DHBs have ‘overcapacity’ or ‘gridlock’ plans intended to mobilise capacity or minimise the risk to patients when the hospital is over occupied. Most DHBs have enhanced daily operational bed management through holding daily meetings, while some are developing sophisticated operations facilities based on precedents in other industries, such as airlines, with promising early anecdotal results.
Many DHBs have introduced programmes such as ‘Releasing Time to Care: The Productive Ward’, which include modules enhancing discharge planning including the use of ‘journey boards’ and multidisciplinary team meetings. Some DHBs are advancing criteria based discharge, some have dedicated a nursing resource to discharging patients, and some are using regular ‘rapid rounds’ with a focus on enhancing decision-making. DHBs reported mixed results from the use of discharge/transit lounges.
Good discharge planning that begins early with multidisciplinary input and as a particular focus of daily activities was considered important to reduce unnecessary patient delays and free hospital capacity.
Difficult access to aged care beds prevents the discharge of some patients. Capacity shortages in aged care facilities, and a lack of cohesion between the hospital and aged care facilities, were two common contributors noted. Some DHBs also described behaviours, such as a reluctance to receive patients in aged care facilities at any time other than early on a weekday, as also being contributory. Good access to aged care facilities was considered to be an important component of a ‘whole of system’ response.
Access to diagnostic tests, and particularly CT scanning, is next on the list. Some DHBs are constructing mutually agreed guidelines which describe when CT scans and other tests are warranted for particular patient groups. The Australasian College for Emergency Medicine and the Royal Australian and New Zealand College of Radiologists are soon to publish agreed guidelines for imaging in acute care. These guidelines should be very influential for practice in New Zealand. In addition, some DHBs have embarked on significant process improvement initiatives within their Radiology Departments to enhance access to acute imaging and the rapid provision of expert reports on images.
Guidelines and pathways for accessing imaging, and a responsive service for the provision of both images and expert interpretation, were considered to be important initiatives for removing unnecessary delays in this part of the patient journey.
‘Inpatient team delays’ was one of the top three barriers and mostly referred to a delay in the inpatient registrar attending the ED. In the majority of DHBs, with most patient groups, a patient could not be transferred to a bed, or have a bed organised in anticipation, until the inpatient registrar had given approval to do so. This practice persisted even if a senior ED doctor had determined that admission was required and the registrar giving approval to admit was considerably more junior. Frequently an additional step of ‘clerking’ the patient by the inpatient house officer was interposed between the ED referral to the inpatient team and the registrar approval to admit.
Some commentators thought these steps were unnecessary and caused long and uncomfortable waits for patients, ED overcrowding, and conflict when busy inpatient registrars were ‘hassled’ by ED staff to see their patients. Many thought the additional assessment in the ED seldom added value to patient care. However, others were of the view that the practice needs to continue for reasons of safety (an incompletely ‘packaged’ patient might deteriorate on the wards where there are neither the doctors nor the facilities required to rescue them), convenience (it is usually harder to assess a patient and get diagnostic tests performed on a general ward), and appropriateness (the patient might end up under the wrong team).
While the traditional practice of inpatient registrar assessment in the ED is causing delays, some were concerned the Target could encourage a swing to the other extreme —all patients will be transferred to the ward without inpatient registrar assessment in the ED when the clock ticks past a certain time.
A ‘middle ground’ was generally thought to be best for patients. For a large proportion of patients, although not all, if the right things are done in the ED by the right people they can be safely, conveniently and appropriately transferred to the ward without an assessment in the ED by the inpatient team. There they can wait in relative comfort and quiet, with dedicated nursing oversight, and without contributing to ED overcrowding and all the harms that ensue. However, other patients who will benefit from staying in the ED for reasons of clinical safety, or because that is the best place for them to have further diagnostic workup, should stay in the ED until these needs are met, regardless of their length of stay.
For General Medical patients, the use of Medical Assessment and Planning Units (MAPUs) allows a space for the registrar assessment of the patient which is well suited to this purpose (much more so than an ED corridor, or a general ward in the middle of the night), and which is equipped to address issues of safety and convenience.
It was noted that delays for inpatient registrar attendance in the ED were common among the surgical specialities, mostly because the registrars were busy elsewhere. Registrars were sometimes engaged in elective theatre lists or outpatient clinics while also being rostered to attend ED if required. Many DHBs are responding to this by separating acute and elective commitments, either with dedicated elective surgery centres or by separating acute and elective rosters, thereby enhancing the provision of a responsive service for acute surgery and its subspecialties.
Pathways for patients with fractured neck of femur are almost ubiquitous in our DHBs, allowing movement of the patient to the ward without orthopaedic registrar review in the ED once an agreed set of interventions has occurred. Some DHBs have produced pathways with similar objectives for other patient groups. It was considered that there is great potential for pathways of this type to apply to a large number of patient groups, from finger flexor tendon lacerations to pneumonia with a particular severity score.
The production of pathways has the additional benefits of standardising diagnostic test ordering (as discussed above), enhancing decision-making particularly among junior medical staff, providing clinical information based on evidence and accepted practice, and reducing conflict over patient referrals by stating an institutional agreement. While such pathways will need to be locally relevant, there is great opportunity to share efforts and learnings through existing relationships and the HIIRC website.
Close behind the top three challenges is increased demand for ED services, which many DHBs claimed was hiding progress made in other areas. Despite 14 DHBs raising this concern many had done little or no analysis of ED attenders to attempt to ascertain the drivers of increased demand, and only a few had instituted initiatives to mitigate demand. Initiatives included enhanced allied health intervention to prevent admissions, greater access to diagnostics in the community and management of conditions such as cellulitis and deep venous thrombosis in the home.
ED facility deficiencies (too small and/or poor layout) and ED staff deficiencies (particularly medical staff deficiencies) are among the top 10 challenges.
The experience of EDs around New Zealand suggests that increased size alone is not the solution to ED overcrowding. Although greater capacity is often justified, it needs to be designed to match an appropriate model of care. In particular, it was considered beneficial to have a layout which allows ‘streaming’ of patients (triaging them to an area that suits their needs), and ‘command and control’ including good oversight and responsibility for all patients so that they are kept safe, but also to understand and advocate for their needs including facilitating progress through the stages of care.
Often good command and control was achieved by giving staff responsibility for an area of the ED, ensuring clear lines of communication when concerned about patients, and having nursing and medical leadership on a shift with explicit responsibility for oversight of patient flow and distribution of the human resource in response to fluctuating demand in different areas of the ED. With clarity of the functional layout of the department, and the ‘command and control’ relationships and responsibilities of staff on a shift defined, the required number and type of staff becomes dictated by the needs of a roster to achieve this.
Many DHBs have increased senior staffing of the ED to enhance the quality and safety of clinical care in the ED and to enhance ED decision-making.
Difficulty engaging hospital clinical staff in changes was a common concern and was largely seen to be a consequence of the perceived ED-centric nature of the Target. Smaller DHBs seemed to engage staff more easily, but a few of the larger DHBs (one very successfully) have ‘marketed’ the work in a way which promotes the whole of system brief, the intention to enhance the quality of patient care, and the responsibility of all staff to contribute.
Finally, problems at night and weekends completes the top 10. This category included a number of the problems already discussed, which are more pronounced at night and weekends, for example, fewer and more junior staff, delayed decision-making, fewer inpatient registrars on site further delaying inpatient assessment, and poorer access to diagnostics.
Weekend shifts are typically busy in EDs, but hospitals usually have skeletal staffing and reduced access to services. Continuing acute admissions over the weekend, combined with significantly fewer discharges, meant that many of our hospitals started the week with little or no bed capacity. Mondays are typically one of the ED’s busiest days with a high admission rate due to the case mix mobilised after the weekend. It was considered that hospital flow could be greatly improved if activities over the weekend were increased to a level similar to that provided during weekdays.
Although bed availability was not a specific night time concern, transfer to the ward at night was delayed by all the other challenges, and by concern that patients were less safe in the wards at night. At the start of the day shift a number of EDs often have a large accumulation of patients remaining from the night shift. All EDs have an influx of patients starting between 10am and midday and continuing into late afternoon or evening. If this influx is superimposed on a full ED, and particularly if discharges on the wards are not occurring until late in the day to free up beds for new patients, the ED will suffer severe overcrowding.
At least one DHB had addressed this by rostering senior doctors over the night shift, while others were using observation beds to accommodate patients who might go home in the morning (particularly the elderly after falls).
While it was considered inappropriate to have the same access to all services at nights, (demand is less, a daytime service needs to be maintained and many non-urgent interventions are less safely performed at night), it was apparent that our hospitals need to augment acute services at night. An elderly patient spending the night on a hard stretcher, in a bright and noisy ED, scantily clad in public view, simply because the ward does not take admissions at night, or there is no orthopaedic registrar on site, or a CT scan cannot be accessed, or there is insufficient medical seniority to make a decision, is poor care.
Consequent to their limitations, the top 10 challenges presented should not be considered the definitive top 10 in terms of content or ranking. However, the list is based on a significant consensus of many people involved in acute care, informed by experience and local analysis, and representing small, medium and large hospitals from the length and breadth of New Zealand. Hence, they should not be ignored.
Progress towards addressing some of them is excellent in places, but piecemeal nationally, but with a general consensus that significant momentum had been gained since the institution of the Target. It is hoped that this paper will encourage consideration and discussion of the challenges to improving acute care, and the sharing of thoughts and solutions in various forums.
Competing interests: None.
Author information: Mike Ardagh, National Clinical Director of Emergency Department Services, Ministry of Health, New Zealand, and Professor of Emergency Medicine, University of Otago, Christchurch; Gary Tonkin, Senior Project Manager, Ministry of Health, New Zealand; Clare Possenniskie, Senior Advisor, Ministry of Health, New Zealand
Correspondence: Mike Ardagh, Emergency Department Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand. Fax: +64 (0)3 3640286; email: Michael.email@example.com
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