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| Journal of the New Zealand Medical Association,
14-October-2011, Vol 124 No 1344
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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.
MethodsAll 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).
ResultsThe 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
DiscussionThis 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.ardagh@cdhb.govt.nz
References:
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