Emergency Medicine Australasia

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Vol 30 (6 Issues in 2018)
Edited by: Geoff Hughes
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  • Press Release
October 11, 2010

Overcrowded EDs and access blocked patients: will there be progress any time soon?

Attempts to improve overcrowded emergency departments (EDs) and access blocked patients by imposing a four-hour rule may be useful in altering behaviour but such changes have not been applied systematically in every case, with an excessive focus on the ED itself and insufficient focus on the real issues, according to papers by high-profile international specialists in the field.

The papers, published in the latest issue of Emergency Medicine Australasia, the journal of the Australasian College for Emergency Medicine (ACEM), cast doubt on the likelihood of the 4-hour rule being the panacea for ED overcrowding.

A time-based target does nothing to alter the fact that prolonged hospital stays, delayed care, and death are documented results of ED overcrowding.

In an editorial, ACEM President Sally McCarthy says the College welcomes the commitment of governments to substantially improve the prevailing situation of access block and overcrowding faced by Australasian EDs.

“This will only be achieved in a partnership which puts patient clinical outcomes first.”

She describes the implementation of a 4-hour rule in the UK in 2004 and subsequent implementation in Western Australia, the first Australian state to do so.

“Any time-based measure relating to EDs (or any other site of care) should be one of a suite of indicators measuring aspects of the whole patient care process, to identify and quantify all areas for further improvement,” she suggests.

Emergency physician David Mountain, from the Department of Academic Medicine at the University of Western Australia, says in the same issue of Emergency Medicine Australasia, that “it is important to acknowledge that the 4-hour rule is still in its infancy even in the tertiary hospitals, and is clearly a work in progress”.

He says it is also important to acknowledge the positives that have been achieved, but these should be put in perspective.

“All hospitals involved have improved flow to the ED, reduced ED length of stay and made significant gains towards the 4-hour target. …These gains have been made in the face of markedly increased ED activity and hospital admissions (8–10%). At least initially, access block was reduced at all adult sites, and any differences in meeting the 4-hour target at adult sites were not apparent at 8 hours, with hospital access block down to 10–20%.”

Yet, he warns that an analysis is required of problems such as the fact that targets are not being met and that they “are not everything”, and also that there are risks involved in an excessive focus on a 4-hour target.

“All areas of a patient’s journey must have their own target, made publicly available and accountable, and not just focused in the ED then ignored, hidden or forgotten.”

He urged administrators to ensure senior decision makers are available in greater numbers after hours so that every patient is transferred earlier to a ward then receives timely, skilled care.

“The reliance on an ED-based 4 hour rule to solely cope with a lack of capacity in the system will be doomed to fail.

“Flexibility, openness, commonsense and additional resources and capacity must now be brought into the implementation phase of the WA experiment to create the milieu for an improvement in the patient’s overall hospital interaction, whether discharged home or admitted.

“That is the real target, not just timings.”

Another review article in this issue of the journal, by Dr Peter Jones and Dr Karen Schimanski, from Auckland City Hospital, warns that “the impact of the introduction of an ED time target and the associated massive financial investment has not resulted in a consistent improvement in care with markedly varying effects being reported between hospitals. Countries seeking to emulate the UK experience should proceed with caution.”

Dr McCarthy’s editorial outlines ACEM’s response to national access targets, saying time-based targets are a tool to drive change, and not an end in themselves, but emphasis on time alone, rather than quality of patient care, can adversely affect patient safety and staff morale.