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Solutions to emergency department (ED) overcrowding:
a literature review
July 2009
Introduction
Emergency Departments need to be viewed in the context of the communities they
serve, because ED improvements must
1.
result from tailored solutions to meet each community’s own specific set
of needs for the right treatment to be available at the right time in the most
appropriate place (Alberti G, 2007) and
2.
not be limited to the ED, but made across the whole hospital and social
care community (Richardson DB, 2001, Sprivulus PC, Da Silva J-A, et al,
2006, Wilson MS, Siegel B, Williams M, 2005).
The Working Group for Achieving Quality in Emergency Departments stated that
“solutions to ED problems will need to address the underlying causes, and therefore
span not only the ED, but the whole of the hospital and indeed the whole acute care
system…Implementing such solutions requires engagement and co-ordination from
the highest levels of the health system, including the Ministry and DHB CEOs”
(Working Group, 2008).
Purpose
To support District Health Boards (DHBs) to achieve the Health Target announced in
April 2009, to have 95% of presentations to EDs admitted, transferred or discharged
within six hours, potential solutions need to be identified to problems with ED service
quality, with special reference to factors that contribute to overcrowding. The
following literature review is intended as a resource for the Ministry of Health and
DHBs, to stimulate discussion on ways of reducing ED overcrowding and length of
stay, to meet the ED length of stay target.
Method
The founding documents for the following literature review were the report of the
Working Group for Achieving Quality in Emergency Departments (Working Group,
2008) and the UK systematic review (Cooke M, Fisher J, et al 2005).
A series of literature searches covered journal articles and other published works.
The search method, sources and key words are in the Appendix. Studies were
selected for the likely relevance of their findings for reducing ED length of stay in NZ
and fell, with a few overlaps, into the following eight categories:
1.
Developing and adopting a national acute care strategy
2.
Using master plans within hospitals
3.
Concentrating on ‘primary care’ presentations
4.
Managing acute demand
5.
Hospital capacity planning / managing access block
6.
Developing the ED workforce
7.
Using other wards and units as an alternative to the ED
8.
Improving data quality and monitoring.
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Limitations
Without a body of NZ ED research, it was necessary to look to international studies.
The limitations of those are that
1.
extensive research programmes are still needed to help to inform the
major changes occurring in the delivery and organisation of emergency
health care (Cooke M, Fisher J et al 2005) and
2.
there is a lack of consistent outcome measures and definitions which
makes it difficult to combine study results and to assess whether they can
be generalised.
A key example of the problem with definitions is the lack of an agreed and clear
definition for reporting on access block. Such a definition is important for ED
governance, management, performance and accountability but in August 2008, there
was no agreement across Australia that the ACEM definition applies (Government of
Western Australia, Department of Health, 2008).
Defining access block
That debated definition of access block is “the situation where patients in the ED
requiring inpatient care are unable to gain access to appropriate hospital beds within
a reasonable timeframe. It is expressed as the proportion of patients requiring
admission to a hospital who have a total ED time greater than eight hours” (Forero
R, Mohsin M, et al, 2004). The following diagram and explanatory notes illustrate the
thinking underpinning the definition:
ACHS–ACEM1 definition: Total time in the emergency department (from arrival time to departure
time) exceeding 8 hours.
NSW Health definition 1: Active treatment and delay time (from medical assessment time to
departure time) exceeding 8 hours.
NSW Health definition 2: Delay time (from ready for departure time to departure time) exceeding 4
hours.
Time delay definition: Delay time exceeding 2 hours.
(Forero R, Mohsin M, et al, 2004)
UK evidence for solutions to reducing ED overcrowding, applied to NZ
As a starting point for this literature review, a small group of NZ experts gave their
opinion on the key findings from the UK evidence for solutions to reducing
attendances and waits (ED length of stay) as presented in a seminal UK systematic
review (Cooke M, Fisher J, et al 2005). The summary of those findings and the NZ
experts’ opinions are presented in the following table:
1
ACHS–ACEM = Australian Council on Healthcare Standards and Australasian College for Emergency
Medicine.
2
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UK findings
(Cooke M, Fisher J, et al
2005).
NZ expert opinion – from Ministry of Health Chief
Advisors and senior managers across a range of teams.
It is possible to divert some
999 calls to advice lines but
the safety of such systems
is still being evaluated.
Broadly agree but it is unclear in NZ what proportion of 111
calls could be managed safely elsewhere and Healthline is
not intended as an alternative to 111 calls. Rather than
diverting calls from 111, the approach for primary care is to
have formalised arrangements that provide better
management of acute demand. For this to happen
effectively, the primary sector must be equipped with the
right skills and capacity.
The UK evidence is reasonably compelling (Mason S and
Knowles E, et al, 2007) (Mason S, O’Keeffe C, et al, 2007)
(Gray JT and Walker A, 2008). However, there is a risk of
using paramedics in making appropriate destination
decisions in the NZ context because the competency
requirements and training opportunities may be less well
developed than in the UK.
The role of paramedics in
either discharging patients
from the scene or deciding
on appropriate destinations
had not been adequately
studied to confirm its safety
and effectiveness.
Individuals usually make their own destination decisions,
and so assisting paramedics, including the 100 new ones, to
take on this decision-making role will be important and at
least as safe as individuals making those decisions
themselves.
The perverse incentive to transport patients will need to be
addressed in NZ. At present, ACC only pays for patients
who are transported. There are also perverse incentives
that encourage hospital transfer. To avoid confusing staff
on the phones, St Johns has adopted a policy of giving the
same message for medical calls and ACC calls.
There is no evidence for the
effects on ED length of stay
of general practitioners
working in EDs.
Broadly agree. The Working Group and the Australasian
College of Emergency Medicine concur with this view
(ACEM 2001, 2004a and 2004b).
Nelson Marlborough DHB has used general practitioners in
their ED in the past but due to increasing complexity of
patient presentations and the volume of presentations, it
was mutually agreed to staff a separate after hours primary
care facility and retain the ED using senior medical officers
to provide cover2. Their ED staff may refer patients to the
GP service adjacent to the ED but the ED needs to be
resourced for very acute and emergency needs of the
district (Nelson Marlborough DHB, 2008). There is no NZ
evidence of the effect of having GPs in EDs on ED length of
stay.
Resource utilisation and admission rates may well be
2
The ED is now covered 0800 – 2300 by non-vocationally registered Senior Medical Officers and as a
consequence there is reduced demand on inpatient SMOs to assist in the ED now that the new SMO
model has taken effect. (Conversation with Wairau Hospital staff, July 2009).
3
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UK findings
Primary care gatekeeping
can reduce ED attendance
but its safety is unknown.
equivalent when the GP works in the ED, but maybe the
question should be about the impact of this approach on the
right people getting the right care in the right setting, rather
than just on length of stay.
NZ expert opinion
Not sure if this applies in NZ because the role of primary
care could be broader than just gatekeeping and probably
needs to be. For example, it may be that the impact of
shifting even a small percentage of emergency services to
primary care is greater than previously thought. Modelling
is needed to assess the impact comparatively.
That aside, it is true to say that primary care acts as a
gatekeeper to much of the health system3. For instance,
ambulances sometimes transport patients to primary care
for assessment prior to transport to ED. More of this could
be done, and may result from the Urgent Care Community
Pilot being conducted in Kapiti, which is achieving good
results4.
Walk-in centres and NHS
Direct have not been
demonstrated to reduce ED
attendances.
Countries with strong primary health systems can perform
gatekeeping functions well, so it is difficult to see why the
UK evidence is that its safety is unknown. Perhaps it would
be better to say that there is no evidence that such an
approach is unsafe.
These do not appear to be relevant ways of reducing ED
presentations in NZ. In the NZ context, we have good
access to same day general practice services and one of
the lowest rates of people using ED services for primary
health care services. These are two findings are from the
Commonwealth Fund and appear to be related (Davis K,
Schoen C et al, 2007). See also comments under “phoning
for advice” below.
In NZ, ‘minors’ are more likely to attend an A&M clinic than
an ED and therefore NZ EDs may have a different case-mix
from UK ‘A&Es’, with a smaller proportion of people
presenting for minor emergencies and consequently less
value to gain from walk-in centres and minor injury clinics.
Walk-in centres and telephone advice appear to focus on
convenience rather than severity and so it is understandable
that they have not been demonstrated to reduce ED
attendances.
NHS Direct refers to a health advice and information service
while NZ has HealthLine and Homecare Medical Ltd.
Neither of these services is a triage service used in
emergency situations. To evaluate the Healthline service, a
3
The impact of primary care gatekeeping is likely to be greater in mid-sized and smaller EDs, and less
in tertiaries. It is also likely, although unclear, that ED attendances will be reduced in those mid-sized
cities that have A&M clinics which handle lower acuity presentations.
4
To date, there is only anecdotal evidence of good results. Conversation with Andy Long, Manager,
Kapiti Community Care Pilot
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general public survey was conducted in 2001, with positive
findings such as
 Q7a 93% of those 431 people surveyed agreed or
strongly agreed that Healthline is a good alternative
if you cannot get to a doctor and
 Q7e 63% agreed or strongly agreed that they would
call Healthline if they wanted to check up on advice
or medicine they had been given (BRC, 2002).
UK findings
Triage is a risk management
tool for busy periods but
may cause delays in care
(Asplin BR, 2001 and
George S, Read S, et al,
1992).
Triaging out of the ED can
reduce numbers but more
work is required to assess
the safety of such systems5.
NZ expert opinion
Primary and secondary care need to work to the same
patient pathways and protocols if triage tools, as opposed to
streamlining, are to be effective – otherwise ways to game
the system proliferate. Workforce limitations restrict the use
of triage tools. Triage always causes a delay in care but
sometimes does enough good to provide net benefit.
Not sure is this applies in NZ. The College of Emergency
Nurses is opposed to triaging out (triaging away) because
 health care should not be denied to any patient
requesting care from an ED
 there is no provision by the Ministry of Health or
ACEM for utilising the triage interview and decision
to restrict access to the ED and
 because there is no support in the literature for the
practice of triaging away (CENNZ-NZNO, 2007).
The Working Group that reported on improving quality in
EDs in 2008 and also developed the Sector Disposition Tool
is opposed to it also (Working Group, 2008).
On the other hand, AMPA, the Association for A&M Clinics
supports triaging out but not to all general practices; their
view is that AMPA trained doctors6 must be part of the
arrangements and proper contractual and funding
arrangements must be made. They wrote: AMPA supports
ACEM's views on Emergency Department matters generally,
including its views on triaging out, and acknowledges the
importance of issues such as of access block (inability to
transfer patients from the ED to a ward) in ED waiting times.
Accident and Medical practitioners and Clinics treat all
patients who attend, including those referred from
5
The ED Working Group Report (2008) summarises Cooke, Fisher, et al on the topic of triaging out as
follows:
“Between 15 and 27 percent of patients can be ‘triaged out’ (i.e. referred from the ED triage desk to
primary care). However:

Only a third may be willing when asked and one percent will be dissatisfied

Up to a third of patients may be triaged our inappropriately, although many studies report no
adverse outcomes

One percent may subsequently be admitted to hospital”.
Cooke, Fisher, et al refer to Society for Academic Emergency Medicine’s position statement on the
ethics of triage which is that “if the principle of ‘triage out’ is to be adopted, then its acceptability to
patients, its safety and it efficacy must all be assessed.” Their reference for this is: Schmidt TA, Iserson
KV, Freas GC, et al (1995). Cooke, Fisher et al list the present policy status of triage out as ‘local
decision’ (Cooke M, Fisher J, et al, 2005).
6
AMPA’s view is that they must first train doctors, get that right and then move on to training nurses
(conversation with AMPA’s Chief Executive in July, 2009).
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Emergency Departments. AMPA does not object to the
concept of "triaging out"7.
Others say that triaging out may be a good thing, given the
absence of adverse outcomes for up to a third of the people
triaged out “inappropriately” (with reference to footnote 5,
bullet point 2 above). They see that a core function of any
health worker is to refer people to other parts of the health
system that may better meet their needs. ED staff do this
already when they are presented with someone needing
hospital specialist expertise.
UK findings
NZ expert opinion
Fast track systems for minor True in NZ and already done in some places, with ACC
injuries reduce ED length of funding of Accident and Medical Clinics’ services. Senior
stay and ideal configurations Staff (doctors and nurses) need to provide mentoring and
include senior staff.
support, not always to see people directly.
Attendance by the elderly,
True in NZ and work being done by the Ministry of Health
those with long term
and DHBs in the areas of Acute Demand Management and
conditions and those with
Long Term Conditions Management are important. The
multiple attendances may be Ministry of Health’s Primary Health Care Implementation
reduced by various
plan covers better integration of social services with primary
interventions. Trials are
care and care of the elderly which will help reduce ED
needed in this area,
attendances. Sustainability of services for older people is a
including the role of social
service risk DHBs have not focused on and in particular
workers.
they have not focused on the risks associated with
increasing obesity, reduced workforce, and the growing
proportion of older people.
The benefit of patient
Yes. Patient education as part of discharge planning and
education is unproven in
increased integration with social services (see under
most areas except long term attendance by the elderly above) is likely to be beneficial for
conditions management.
long term condition management, but it is difficult to know
what kinds of national patient education on ED use would
be relevant in NZ because drivers of acute demand differ
significantly across the country. For instance there is
disproportionate ED demand driven by Māori in Middlemore
Hospital but not in Capital and Coast DHB. Also, we do not
know if there are differences in the benefit of patient
education for Māori and Pacific populations as compared
with the rest of the population. Also, even in long term
conditions management, many education packages are
proven to be ineffective.
Phoning for advice before
Agree. With reference to overnight ED attendance, phoning
going to the ED may reduce for advice is likely to be effective in reducing ED
attendances.
attendances, but only if general practices have 24 hour
cover arrangements in place as required of them in their
contracts with their PHOs. Many GPs now have phones
diverted to HML but do not always have the required faceto-face arrangements formalised as back-up. Another risk
for effective service delivery is that sharing of
primary/secondary clinical information is difficult without
electronic health records.
Specialist nurse care in
Not sure if this applies in NZ. These have not been
7
Email from AMPA’s Chief Executive 17th August 2009
6
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heart failure, chronic
obstructive pulmonary
disease (COPD) and deep
vein thrombosis (DVT) can
reduce hospital admissions.
evaluated in NZ and comparing results of care across the
different disease states is risky. However, the systematic
literature review of the interventions that may reduce
Ambulatory Sensitive Hospitalisations (ASH) found that
 programmes that combined educational
interventions with comprehensive disease
management programmes were likely to be
beneficial and
 comprehensive, multidisciplinary, team-based
medical care programmes were also likely to be
beneficial
(Health Services Assessment Collaboration, 2008).
Current resources seem focused on known patients (i.e. the
group referred to as frequent flyers to hospitals). Also, we
would need to look at high risk patients who have not used
hospital systems. We need an integrated approach to
address social determinants, otherwise we are only
addressing symptoms of an underlying problem.
UK findings
Observation wards may
reduce ED length of stay
and avoid admission.
Home support (medical and
social) can reduce hospital
admissions.
There is a lack of evidence
in innovations in bed
management.
Such specialist nursing care is likely to be part of effective
care pathways and needs to be included in planning for the
shift of some emergency services from secondary to
primary settings.
NZ expert opinion
Yes. In NZ, the systematic literature review referred to
above (Health Services Assessment Collaboration, 2008)
with reference to Specialist Nurse Care showed that
disease specific observation units in EDs were associated
with reducing ASH for specific conditions. Also, many
PHOs already have Primary Options for Acute Care (POAC)
programmes and utilise overnight stay and observation in
the private sector. The results to date from CMDHB POAC
projects are promising, but are not yet proven to be
sustainable, or even generalisable8. The unique
circumstances of CMDHB may well have been responsible
for the impact of the initiatives (Gribben B, 2003).
In NZ, observation wards may not necessarily reduce length
of stay and they may be just another holding pen for
patients who slip through the cracks.
Strong agreement. Good evidence from NHS. In NZ:
 Home support is included in the Primary Health Care
implementation plan and includes case management
by nurses
 Home Based Rehabilitation is funded by ACC.
Not sure if this applies in NZ. There are some innovative
practices, for example in Auckland DHB, and perceptions of
success. However, bed management studies are hard to do
because monitoring data is lacking on admissions from ED,
and consequently it is difficult to find if the patient in ED with
8
The unique circumstances of CMDHB may well have been responsible for the impact of the initiatives
(Gribben B, 2003).
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Allowing ED staff to admit
patients to wards will reduce
delays.
There is a lack of evidence
about innovations to reduce
delayed discharges from
hospital.
UK findings
Most evidence looks at the
causes of delay rather than
the solutions.
Teams of staff available for
unpredicted surges may
reduce delays.
Rotational allocation of
patients may be better than
clinical self-determination10.
Senior staff may reduce
admissions and delays.
Nurse practitioners are safe
the next most serious problem is the one admitted next.
This is likely to be important for NZ but there is a risk that
wards will fill up to the extent that nobody can admit unless
there is surge capacity planning and prediction of demand9.
Yes, but Primary Care may not have sufficient infrastructure
and capacity to take on all devolved work when innovative
models of care begin to be implemented. Further, the
discharge process is not only about delay. Generally the
process needs to be improved and to be part of jointly
constructed care pathways that include social support and
access to prescriptions. Good communication is essential
between Planning and Funding decision makers and
provider arm ED services.
Change is system-wide. Delivery of ED services, delivery of
elective services and devolution of some secondary
services to primary must not be seen in isolation from each
other.
NZ expert opinion
Agree and this also highlights the disincentives for greater
productivity / performance. Configuration of primary care as
competitive providers with capitation based on enrolled
patients, stifles innovation spread. Each DHB should be
doing an analysis. For instance, if there is more capacity in
primary care, how does that impact on ED service delivery
and overcrowding.
Yes, depending on the cause of the delay. It is better than
rostering surplus staff in cases of peak demand which
usually does not happen. A contingency plan responding to
early ED overcrowding is important, particularly in instances
where predictable overcrowding happens at certain times of
the week.
No comment.
Strong anecdotal support but it depends where the problem
is and how the supervision is managed. Also, despite an
increase in FACEMs in some DHBs, it is not clear that there
have been reduced admissions and fewer delays, compared
with hospitals that have not had these staff improvements.
It could be argued that FACEMs at one end of the scale
increase the number of admissions because they are more
likely to identify potential problems than junior staff who may
miss risk factors, but this increase is balanced by FACEMs’
ability to discharge or refer other patients who can be safely
managed in the community.
A clinical leader with an inclusive management style is a
good predictor of a high performing ED (Coombs M, 2009).
The safety and effectiveness of NPs working in EDs is hard
9
There is a demand prediction tool developed by Kaiser Permanente. Once located and when
permission is given for it to be used, this needs to be added to the ED Tools database.
10
This means changing from a system where individual doctors determine their own work
rate, by seeing the next patient when they are ready.
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and effective but their effect
on ED length of stay is
unknown.
to measure and some consider their cost-effectiveness is
the major issue. However, the cost effectiveness of any
part of the ED workforce is difficult to measure. There is a
need to look at the best resource for the task in hand.
The role of other health care Yes, but unless we say EDs are usually going to handle
professionals in emergency
low-medium acuity as well as high acuity patients, it is not
care needs evaluation.
clear what value other health professionals would add here.
Despite the range of practitioners that have been tried in
other countries (physician assistants etc) there is no clarity
about the ideal ED workforce.
The remainder of the literature review presents and comments on the findings from
the literature searches, grouped under the eight headings listed above under
“Method” on page 1.
1.
Developing and adopting a national acute care strategy
One approach is to have a whole of system strategy for addressing problems in
acute care, and particularly those problems which manifest as ED overcrowding are
repeatedly suggested by expert commentators as an important part of the solution.
One suggested model describes three areas of contribution to ED overcrowding –
preload (the number and complexity of patients seeking acute care); contractility (the
ability of the system to accommodate these patients, including the physical and
human resources and the processes for getting things done); and afterload (the ease
of getting the patient to the next phase of care, most notably into a hospital bed)
(Ardagh M, 2006).
“Focusing on a single solution (for example, efforts to reduce low acuity patient
presentations, or opening more hospital beds), independent of other contributing
factors, will frustrate those attempting to fix the problem. So will attempts to fix the
problem of ED overcrowding by focusing on the ED only, when two of the three
contributing areas (preload and afterload) are outside the ED’s influence.
Therefore, from this model, two principles fall:
1.
The causes and solutions are multi-factorial and should be considered
together.
2.
Two of the three areas of contribution are outside the authority of the ED, so
solutions need to be driven at a DHB level.
Four further principles are:
3.
Unnecessary steps in the patient journey should be identified and eliminated.
4.
The narrowest bottlenecks in the patient journey should be fixed first.
5.
Important tasks in the patient journey (value added tasks) need an
appropriately staffed and resourced place dedicated to undertaking that task
efficiently and effectively.
6.
When the patient has completed that task, he or she moves to the next place,
for the next task”
(Ardagh M, 2006).
There is an opportunity to apply clinically appropriate incentives to manage acute
demand across the patient care continuum. The focus of incentives should be on
driving the right behaviours that target patients (Acute Demand Management
Working Party, 2007). An example of an appropriate incentive to reduce ED
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overcrowding is supporting after hours services11 in line with DHB acute demand
management approaches in the primary health care setting (Ministry of Health,
2008). There is a section on approaches to managing acute demand on pages17–
21 below.
2.
Using master plans within hospitals
To address whole-of-hospital issues that have the potential to impact on ED
overcrowding, it is useful to look at a range of overarching hospital plans.
11
Beginning in the finanical year to 30 June 2009, the Government made $9M available per annum to
those DHBs that submitted acceptable proposals for improved after hours service coverage.
10
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1.
Using a set of basic principles and / or a combination of approaches. One
example of principles for effective emergency care services was developed in
the UK and built on best practice in ED management:
(a)
all services must be designed from the point of view of the patient
(b)
patients should receive a consistent response, regardless of where,
when and how they contact the services
(c)
patients’ needs should be met by the professional who is best able to
deliver the service they need
(d)
information obtained at each stage in the patient’s journey should be
available to other professionals the patient may be referred to (subject
always to the patient giving their agreement and to the introduction of
appropriate safeguards to preserve confidentiality)
(e)
assessment and treatment should not be delayed through the
absence of diagnostic or specialist advice
(f)
emergency care should be delivered in ways which are clear,
consistent, and measurable
(g)
standards which cover each element of the service and the whole of
the patient’s journey (Cooke MW Higgins J and Kidd P, 2003).
Two other studies point to the need for a combination of approaches to ED
overcrowding.
In a Melbourne study of 17 participating public hospital EDs, 15 strategies to
reduce over-crowding were introduced to the EDs including care co-ordination
teams, short stay units, psychiatric services, chest pain units, pharmacy
services, sexual assault service and hospital in the home. Facilitative
initiatives included nurse initiated management, fast track processes,
multidisciplinary triage, disposition nurses/communication clerks and day
treatment clinics. Many traditional inpatient services were incorporated into
the EDs which now provide a different and expanded paradigm of care
(Taylor D McD, Bennett DM, Cameron PA, 2004).
In Memphis, Boston and Atlanta, the three cities with hospitals that form the
Learning Network, a comprehensive list of policies and operational
imperatives was developed when the National Association of Public Hospitals
and Health Systems commissioned a report based on the findings of the
Urgent Matters Learning Network.
That list includes the overarching themes that drove success in each of the
Learning Network hospital’s change efforts:
(a)
Hospitals must recognise that ED crowding is a hospital-wide problem,
not an ED problem
(b)
Multi-disciplinary, hospital-wide teams are essential to overseeing and
implementing change
(c)
A “champion” for change must be identified or cultivated in the
institution
(d)
Senior leadership must send a clear and consistent message that
improving patient flow is a priority
(e)
Hospitals must learn and use formal improvement methods, such as
rapid cycle change12, on a daily basis – and track results Institutions
12 Rapid Cycle Change (RCC) is a quality improvement technique that allows hospital staff to initiate
and test a large number of small changes related to patient flow very quickly by monitoring the
effectiveness of those changes using small data samples.
11
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must commit themselves to using rigorous metrics, because ‘we can’t
fix what we can’t measure’
(f)
Transparency around initiatives and data must become an
organisational value, so that all stakeholders have the information they
need to do their jobs
(Wilson MJ, Siegel B, Williams M, 2005).
2
Optimising the Patient's Journey
In NZ, OPJ is specially aimed at improving the quality of care from the
patient's perspective. It is a national collaborative programme for improving
the quality of care, particularly in hospitals. The programme focuses on
improving a patient's journey within the inpatient setting from before the
patient's entry to hospital to discharge from that episode of care. The
programme also focuses on the management of patients with chronic
conditions who present at the hospital for treatment, and on the flow of
patients from primary care through to the hospital.
OPJ is also aimed at improving the efficiency of service provision. Early
indications are that the programme is reducing the cost per patient episode.
It is anticipated that efficiency should also improve if the number of cancelled
operations can be reduced along with the number of admissions and the
number of emergency department attendances for long term conditions13
(Health Policy Monitor, 2008).
3.
Applying the principles of the Clockwork ED
The US Healthcare Advisory Board undertook a seminal piece of work
published in 1999 as “the Clockwork ED”, which is available only to member
hospitals of the Council of International Hospitals and is subtitled “Best
practices for maximising emergency department throughput and capacity
(Hughes G, 2008). It led to the Advisory Board Company’s Clockwork ED
initiative, to track 20 evidence-based best practices and this initiative was
supported by the ED Log, a database for understanding ED utilisation. The
ED log went live in 2002 and stores patient tracking information from EDs
including a variety of length of stay measures, patients who left without being
seen, admission rates and return rates. The data are used to identify
opportunities and priorities and to track improvements (LSU Health Sciences
Center).
The following two examples illustrate how the Clockwork ED works in
practice.
(a)
St Joseph’s Medical Center, Towson, Maryland
A study of changes in St Joseph’s, a regional medical center, focused
on patient input, throughput and output:
13
Each Collaborative will run for a defined period of time: 18 months for the phase 1 collaborative on
Lean Thinking (June 2008 to March 2009), 24 months for the phase 2 collaborative on the management
of long term conditions (February 2009 to March 2011), after which materials and learning from the
project will be published.
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Input changes
Throughput changes
Output changes
Revamping the triage and
admission processes with a
simple yet effective means of
flagging diagnostic results.
Charts for new patients to be
seen were placed upright,
while charts ready for
disposition were turned on
their sides in the physicians’
rack.
Modifying the physical layout
of the urgent care area to
maximise efficiency in staff
movement and
communications.
Identifying causes
of delays in
discharges and
admissions.
Changing staffing patterns to
match anticipated patient
volume.
Instituting the
practice of flagging
the charts of
patients ready for
discharge.
Revising policies regarding
exchanges with radiology staff.
Implementing
admission orders
to decrease patient
waiting times.
The changes were implemented at first in urgent care and then in the
main ED which was split into three zones, instead of one, each having
nine beds with additional nurses’ stations in the two new zones. This
removed the flow problems which had resulted in physicians having
patients scattered all over the department, nurses constantly walking
back and forth between the order rack and the rooms farthest from the
nurses’ station, and doctors and nurses constantly looking for each
other during the shift.
Key results were that patients began to be placed in treatment beds
minutes after arrival, are seen promptly and the ED is no longer
overcrowded. In August 2004, door-to-provider intervals and length of
stay dropped. The performance levels of part-timers compared with
full time staff was reviewed and part-timers were given the opportunity
to improve their performance. The support of senior management
was found to be essential to the turn-around. The stage was set for
eliminating the “silo mentality” and fostering interdepartmental
cooperation. Significant untapped hospital and staffing capacity was
found by streamlining processes and changing mindsets. The
researchers believe that process improvement can be a valuable tool
in alleviating, if not eliminating, ED overcrowding (Twanmoh JR,
Cunningham GP, 2006)
(b)
Children’s Hospital Medical Center of Akron, in Akron Ohio
With internal process improvement expertise and affiliation with a
healthcare consulting group, the ED leadership at the Children’s
Hospital Medical Center of Akron, in Akron Ohio identified
opportunities to implement best practice initiatives with the
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overarching goal to improve patient throughput. A working group
involved several ancillary departments in the hospital and conducted
weekly meetings over a six month planning phase. Researchers
wrote up the initiatives in a poster for the NACHRI & N.A.C.H14
Creating Connections Conference, to illustrate the impact of the doorto-doctor time interval.
The first initiative which they describe is called “toggelled rapid triage”,
discriminates when ED capacity allows for rapid triage practice at the
patient entry-point. The toggling process featured:
(i)
Traffic stoplights in the ED waiting room and main work station
inform patients and staff of ED capacity.
(ii)
A green light when there is room to take patients immediately
to an exam room, while a red light indicates that the ED is at
capacity and a wait to see a doctor might be expected.
(iii)
Comprehensive triage, which was performed in the patient's
room instead of the ED entry point during "green light."
(iv)
Pre-emptive testing, which was utilised when the ED was at
capacity.
The second initiative, “bedside registration”, decreases door-to-doctor
time by placing the patient registration process in parallel with other
ED visit-related activities instead of in series.
Toggled rapid triage and bedside registration practices had been in
place for one month at the time of this poster submission. When
compared to the same time one year ago, there has been a 25
percent (34 to 22 minutes) decrease in door-to-doctor time interval
and a 12 percent decrease in overall length of stay (112 to 99
minutes). At the time of presenting the results in this poster, the
researchers expected to have more comparison measures such as
more complete throughput data, patient satisfaction measures and
incidence of patients who left before evaluation (Lee T, Johnson N,
2009).
3.
Concentrating on ‘primary care’ presentations to the ED
While EDs will often see patients with primary care problems, particularly after hours,
the evidence for having primary care practitioners in the ED, or for redirecting
patients to a primary care facility, is poor.
Despite perceptions that EDs see a large number of primary care patients, numbers
of primary care presentations at EDs were found to be surprisingly small. Only three
percent of primary care patients attended an ED in preference to visiting their GP
(Eagar K, 2005). It has been proven that general practice (GP) patients do not cause
access block or ED overcrowding and persistence of this belief is detrimental to
finding real solutions (Sprivulus PC, 2004).
This important view is based on studies showing that while a proportion of patients
attending EDs could have been seen in primary care, these patients typically present
with low complexity. Removal of the 20 percent of patients with lowest complexity in
an ED may only reduce the workload on the department by 3.5 percent – removing
such patients would therefore have a marginal impact (Stone K, 2008). The
14
National Associations of Children’s Hospitals and Related Institutions and National Association of
Children’s Hospitals
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perception that GP or primary care appropriate patients are a relatively unimportant
contributor to ED problems is shared by many, though not all, clinical leaders in NZ
EDs (Working Group, 2008).
A study that took place in New South Wales between 1999 and 2006 examined
trends in potential 'primary care' presentations at EDs, comparing these with other
ED presentations and to primary care attendances in the community. Primary care
presentations at EDs increased marginally in the period under consideration, as did
primary care presentations in the community. There was a substantial increase in
other ED presentations. The proportion of ED presentations that were potentially for
primary care decreased over the period, possibly because of new guidelines for the
application of triage categories in 2001. However, trends over time do not show
acute alterations and they continue to hold for the subsequent period after the
introduction of the new guidelines. The researchers concluded that primary care
presentations at EDs are not responsible for recent changes to ED overcrowding in
New South Wales (Siminski P, Bezzina A, et al, 2008).
Diversion of low acuity (i.e. GP) presentations and use of telephone services to
decrease ED presentations were found not to work for reducing access block and ED
overcrowding (Forero R. and Hillman K, 2008). Also, researchers have suggested
increasing co-located after hours GP services to reduce ED presentations, but these
have been unsuccessful in Australia (Forero R. and Hillman K, 2008).
A ‘diversion strategy’ was proposed by a group of researchers at Wollongong
University for situations where there might be a goal to divert primary care
attendances from EDs to GPs. The researchers found that “multi-faceted service at
ED” is a far more important reason for ED attendance by primary care patients than
“GP unavailability”. Accordingly their solution was to promote practices with
convenient multi-faceted services, for patients to view as a one-stop-shop, but the
benefits of such a service seem questionable and the costs high, given the small
percentage of primary care patients found to be attending an ED rather than a GP
(Eager K, 2005).
Some hospitals have used systems where, after initial triage, primary care
appropriate problems are referred to GPs or community primary care rather than
being dealt with at an ED (Murphy AW, Bury G, Plunkett PK, 1996), (Pereira S,
Oliveira E, et al, 2001), (De Silva, 2009). One NZ evaluation of a process that
referred patients back to the community found that of those patients that they could
follow up (only 37 percent), 60 percent did not seek community medical care
although most cases improved (Elley, CR, Randall P-J, et al, 2007).
Similar results were found in a Los Angeles study of 156 patients who used the ED
on weekdays from 7:00am to 3:00pm and who met the criteria for deferred care. The
researchers found that clinically detailed standardised screening criteria can safely
identify patients at public hospital EDs for referral to next-day care. “Patients
assigned to next day care did not demonstrate clinically important disadvantages in
health status or physician visits compared with usual care patients.” The researchers
note that larger studies are needed to assess the possibility of adverse effects
(Washington DL, Stevens CD, et al, 2002).
There is no clear consensus between professionals regarding the concept of
‘appropriateness’ of ED attendances which has implications for any interventions
aimed at addressing ED overcrowding (Richardson S, Ardagh M, Hider P, 2006).
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If expert panels show poor agreement in deciding which cases could be handled in
primary care, when the case is assessed retrospectively with diagnosis and
outcomes known, how are we to expect patients or even triage nurses to do better?
(Elley, CR, Randall P-J, et al, 2007).
Redirecting them is seen as risky, especially if serious cases such as meningitis
could be missed. Redirecting is also time-consuming, and not always in the patients’
best interest (Elley CR. Randall PJ, et al, 2007).
“A common and unfortunate response to a perceived excess of preload has been to
deny or obstruct care to those considered inappropriate for presentation at the ED.
The assessment of ‘appropriateness’ at triage has consistently been shown to be
inaccurate and, in addition to potentially contravening rights of access to care,
triaging patients out of the ED is dangerous and does not reduce costs. Lowering
barriers to more appropriate care is a better solution than raising barriers to
perceived inappropriate care” (Ardagh M and Richardson S, 2004).
A prospective study in Portugal found lower rates of ‘inappropriate’ ED use, although
one criterion for ED appropriateness was that a patient would need to have a
diagnostic test performed, which differs from criteria used in a Portuguese University
Hospital study, where many tests could be performed from primary care (Pereira S,
Oliveira E, Silva A, et al, 2001). This again raises the issue of whether ‘primary care
appropriate’ and ‘ED appropriate’ are mutually exclusive or whether there is
substantial overlap, particularly in the case of minor trauma. Clearly, more
prospective audits are needed (Elley CR, Randall P-J, et al, 2007).
A number of approaches to primary care presentations to ED have been described in
the literature and some of these are summarised below.
1.
There is some research giving limited support to the idea that individual
general practitioners can manage primary care patients and less serious
emergencies effectively and with lower flow-on costs than junior ED staff
(Murphy AW, Bury G, et al, 1996). However, co-locating primary care
facilities within EDs was proposed for Dunedin in 2005 but was found to be
based on a “naïve and simplistic” premise, namely attributing overcrowding in
ED to “excessive numbers of GP type attendees” (Wilson H, 2005). The
proposal does not address how patients are processed within the ED or how
they are transferred to wards later if required (‘access block’). This article
also discusses some other unresolved issues including the GP co-operative
continuing to carry the financial risk for the new (private) service within ED.
“As some patients who currently attend ED because of zero cost will now be
seen by GPs and charged for their consultations (…and may be unable to
pay….), it could be argued that the local DHB is simply shifting the burden of
providing ‘free’ health care to a private facility. The patient, who is at the
centre of these changes, is now caught between two....organisations keen to
reduce their financial risk. Furthermore, commercial viability of the new
facility could be compromised if a new private Accident and Medical clinical
sets up at the old site, as has been mooted” (Wilson H, 2005).
2.
Some argue that although EDs undoubtedly see a proportion of patients who
could have been managed in primary care, it may be better for the patient that
they present to an ED. For instance, it may be to the disadvantage of the
patient with long term condition(s) to be managed without continuity of care,
but for those cases which could be managed in either setting there may be
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little cost benefit to transfer care as the cases are at the lower cost end of the
ED casemix (Elley, CR, Randall P-J, et al, 2007).
3.
There are approaches to reducing ED overcrowding in the context of long
term conditions management, including:
(a)
the Year-Plan Model in which community based bundles of support
are provided for people with long term conditions, or with risk factors
for developing long term conditions. The model is based on three
populations: Level 1: those at risk of developing a long term condition,
Level 2: those who already have a long term condition and Level 3:
those with complex co-morbidities. Services are planned according to
each of the three population groups. These include for Level 1, Expert
Patient Programmes, smoking cessation programmes and yoga; for
Level 2, practice nursing, general practitioner, and outreach services;
and for Level 3, home help, district nursing and social services
(Degeling P, Close H and Degeling D, 2006). Strategies to improve
services provided in primary care settings are being implemented to
reduce emergency bed days by 5 percent in England (DoH, 2005).
The strategies are based on evidence that redesigning existing modes
of service delivery to people with long term conditions, concentrating
efforts in primary care, will improve the prognosis and day to day lives
of people (WHO, 2004) and reduce “the impost of present failures in
primary care service provision on the acute care sector” (Degeling P,
Close H and Degeling D, 2006).
(b)
comprehensive disease management programmes designed to
reduce ASH15. 51 out of 146 NZ studies evaluated the role of such
programmes and out of the 51 studies, 29 (57%) found significant
reductions in ASH. Twenty of the 29 studies (69%) found that well-coordinated, multidisciplinary care programmes were effective in
reducing hospitalisation or re-hospitalisation for elderly patients
recovering from chronic heart failure. The researchers commented
that “Comprehensive, multidisciplinary, team-based medical care
programmes where patients were involved in discharge planning,
were provided education in either a one-on-one setting or using
interactive discussions, and were regularly followed up, were likely to
be beneficial compared to programmes that included only one or none
of these components” (Health Services Assessment Collaboration,
2008).
4.
Providing low cost or free general practice services. Capital and Coast DHB
reports that the Te Aro clinic has done this for more than a decade, using
their strong links into the homeless community and to other people living in
the inner city struggling with poverty, addiction, mental illness, and perhaps
cultural and language barriers. In 2004/05, in response to increasing demand
on unfunded outreach provided by Te Aro clinic staff, specific funding was
provided for a mobile primary care service to homeless people and those in
very transient living situations such as shelters and boarding houses. An
evaluation of the programme documents the effect on ED use and hospital
admissions for a cohort of patients who have utilised this service and continue
to do so.
15
The review only considers one outcome: hospitalisation or not. Studies included in the review
reported multiple outcomes including reductions in unscheduled ED visits and ED Length of Stay
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Key findings were that:
(a)
ASH rates are low compared with other areas of NZ and continue to
decrease
(b)
ED use has decreased for people who enrol with a PHO which
suggests that continuity and care and proactive care are being
provided by general practices, which is the ideal situation. However,
the situation is not ideal, because in parallel with that decrease,
utilisation at the Kenepuru A&M clinic has increased, with the highest
A&M attendance rates being among children and high deprivation
groups. This suggests that the A&M clinic is being used for more than
the backup services for which it is intended. Capital and Coast DHB
comment that this pattern is not surprising given the high levels of
unmet need in the Porirua group most likely to use the A&M. The
unmet need exists because of limited primary care capacity, despite
additional investment.
(Capital and Coast DHB, 2009).
4.
Managing acute demand
Much of the acute demand literature focuses on ED use by older people and on
alcohol in injury-related presentations to EDs.
1.
Older people
Older adult (65+ years) hospital admissions (frequency and rate) and ED
presentations (frequency) increased significantly over the 12-year period
1996 – 2007. Frequency of admissions increased by 83 percent, admission
rate by 46 percent if same day admissions are included in the analysis,
reducing to 50 percent and 27 percent if they are excluded, while frequency of
ED admissions increased by 111 percent (Monash University Accident
Research Centre Victorian Injury Surveillance Unit, 2009). Falls account for
77 percent of hospital admissions and 54 percent of ED presentations in this
age group16.
Complex patients are twice as likely to have unplanned hospital admissions
via the ED. In a New South Wales study, 526 (239 men and 287 women)
people aged 55 years and over were interviewed. Musculoskeletal disorders,
hypertension, gastrointestinal disorders and ischaemic heart disease were the
most frequently reported of the chronic illnesses surveyed. A total number of
70 people from the survey group with a total of 115 admissions through
emergency departments were recorded. The researchers concluded that
there was significant association between multiple chronic diseases and
emergency admissions for older people. Of these, hypertension and
ischaemic heart disease were found to be significant predictors. Age per se
was found to be of borderline significance (Chan DKY, Chong R, et al, 2002).
Older patients more frequently present to the ED than younger patients and
are more frequently admitted to hospital. At presentation, there is often a
history of short-term decline in health. This raises the theoretical possibility
16
Elderly patients with hip fractures were the subject of a New York study where the
researchers found that this group was at risk for underassessment of pain, considerable delays
in analgesic administration after pain is identified, and treatment with inappropriate analgesics
in the ED. The more overcrowded an ED, the poorer the pain management (Hwang U,
Richardson LD, et al, 2006).
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that, if there could be some intervention after older patients start to decline
but before they reach the stage at which they require admission, it might be
possible to improve their health enough to avoid admission to hospital.
A New South Wales prospective, randomised, controlled trial with 18 months
of follow-up study designed to assess the effects of comprehensive geriatric
assessment (CGA) and multidisciplinary intervention on elderly patients sent
home from the ED found that multidisciplinary intervention improved health
outcomes of older people at risk of deteriorating health and reduce unplanned
admissions to hospital. The researchers studied the discharge of the elderly
from the ED (DEED) because patients aged 75 and older who are discharged
from the ED have a greater risk of being admitted to the hospital over the
following two weeks or month and are at increased risk of death. The
researchers suggest that patients aged 75 and older should be referred for
CGA after an ED visit (Caplan GA, Williams AJ, et al, 2004).
A nursing discharge planning risk assessment tool applied to 2139 elderly
patients in Queensland, men and women over 70 years of age, reduced the
risk of re-presentation with the same condition by 16 percent and decreased
the re-admission rate by 6 percent. Overall length of stay in hospital was
reduced from 6.1 to 5.4 days. An unexpected finding was the decrease in representations in frequent flyers, those who re-presented to the emergency
department three or more times per month. The study aimed to ascertain
whether a model of risk screening carried out by an experienced community
nurse was effective in decreasing re-presentations and re-admissions and the
length of stay of older people presenting to the ED. It was apparent to the
researchers that older people presenting to the emergency department have
complex care needs. The researchers found that undertaking risk screening
using an experienced community nurse to ascertain the correct level of
community assistance required and ensuring speedy referral to appropriate
community services has positive outcomes for both the hospital and the
patient. They suggest that the decrease in re-presentations was the result of
increased referral and use of community services. It appeared that the use of
a specialist community nurse to undertake risk screening rather than the
triage nurse may impact positively on service utilisation (Hegney D, Buikistra
E, et al, 2006).
In the UK, paramedics with extended skills were found to provide a clinically
effective alternative to standard ambulance transfer and treatment in an
emergency department for elderly patients with acute minor conditions such
as those resulting from falls (Mason S and Knowles E, et al, 2007, Mason S,
O’Keeffe C, et al, 2007, Gray JT and Walker A, 2008). These findings
underpin the Urgent Community Care pilot being conducted with funding from
ACC and Capital and Coast DHB17.
17
For this to be effective in NZ, ambulance paramedics will in future need to be registered health care
professionals, so that they can see and treat or treat and refer to PHC professionals and leave in the
community – and not worry about not being paid. At present, ambulance paramedics are funded to
see and transport. They can only see and treat if they are recognised as being health care
professionals (conversation with Andy Long, Manager, Kapiti Urgent Community Care Pilot, July
2009).
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2.
Alcohol in injury-related presentations to ED
An international study, the first international attempt to quantify the role of
alcohol in injured persons from several different countries using the same
methodology based on ED data, suggests that 10-18 percent of injured
patients attending EDs are alcohol-related cases (WHO, 2007). NZ, based
on an Auckland site, reported the second highest proportion of alcohol-related
injury presenting to an ED, which was 36 percent (Richards G, 2008).
More data gathering and analysis has been called for in international studies
of alcohol-related injury. For example, alcohol-related ED visits studied at a
national level using data from the USA’s National Hospital Ambulatory
Medical Care Survey for 1992 through 2000 were found to be approximately
three times higher than previous estimates. The study found that alcoholrelated diseases and injuries pose a significant burden on hospital EDs.
Because patients often fail to disclose their drinking habits to physicians, and
ED physicians sometimes fail to identify signs of alcohol abuse, the number of
alcohol-related ED visits may have been underestimated (McDonald AJ III;
Wang N, Camargo CA Jr, 2004).
In the absence of more conclusive evidence, the researchers used 37
diagnoses that could be alcohol-related to estimate the total number of
alcohol-related ED visits from 1992 through 2000. Patients aged 30 to 49
had twice the rate of ED visits with diagnoses that were considered to be
completely attributable to alcohol than patients aged 15 through 29, or 50
and older. The visit rate for males with diagnoses 100 percent attributable
to alcohol was three times higher than for females, and the visit rate for
blacks with such diagnoses was approximately two times that for whites.
"Although U.S. public health officials recognize that EDs throughout the
United States face an enormous burden from alcohol-related diseases and
injuries, this study shows that the current literature significantly
underestimates the magnitude of this burden," write the authors. "Our nineyear study also reveals a rising trend in the number and rate of alcoholrelated ED visits and a widening gap between sexes and a shrinking gap
between races among those seen in the ED with certain alcohol-related
diagnoses." The researchers conclude that "… improving the frequency of
ED screening may lead to more appropriate referrals and interventions during
alcohol-related ED visits, with a reduction in subsequent illness and additional
visits to the ED" (McDonald AJ III; Wang N, Camargo CA Jr, 2004).
Literature relating to the burden of alcohol-related injury in NZ is described in
a brief guide (Richards G, 2008) but the impact of alcohol-related injury on ED
presentations is only covered in only two of the studies to which Richards
refers (Humphrey G, Casswell S, Han DY, 2003) and Connor J, Broad J,
Jackson R, 2005).
One of the studies took place during December 2000 using a random sample
of patients who were interviewed and breath tested in the ED continuously for
a three-week period (Humphrey G, Casswell S, Han DY, 2003).
This study reports that:
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(a)
there is comparatively little research in NZ that examines the role of
alcohol in injury occurrence, and none that clearly documents the level
of alcohol’s involvement. They refer to a study of NZ rugby injury,
which found 14 percent of males and 8 percent of females
participating reported that injuries they sustained in the previous 12
months were the result of their drinking (Quarrie K, Feehan M, et al,
1996). That 1996 study also found that heavier drinking was the
norm, with 61 percent of males and 38 percent of females consuming
six drinks or more in one session at least weekly.
(b)
there had been an earlier study that used the New Zealand Health
Information Service database to examine the incidence of death and
hospitalisation from assault occurring in and around licensed premises
(Langley J, Chalmers D, Fanslow J, 1996).
In this 1996 study, in spite of some recording inconsistencies, the researchers
found that when place of assault was recorded, 10 percent of these assaults
took place in or around licensed premises, 17 percent involved people under
20 years of age, and males were over-represented in all assault figures.
Alcohol-related injury patients were more likely to report heavy typical
consumption patterns, to have experienced prior alcohol-related injury, and
were unlikely to use health care services other than the ED.
The other comprehensive NZ research into this topic was conducted in 2005
(Connor J, Broad J, et al, 2005 and 2005a). The key findings from this
research were that “Injury was a major contributor to alcohol-related mortality,
being responsible for 51 percent of deaths (532) and 72 percent of years of
life lost (12,434 YLLs) Most alcohol-related deaths before middle age were
due to injury.” Cancers and other chronic diseases contributed to the
remaining alcohol-related mortality.
Not enough is known about the numbers of ED presentations due to alcohol
in NZ. If data were gathered consistently across time and place, the likely
impact of alcohol-related presentations on ED overcrowding at certain times
of the year18 and in certain parts of the country could be described and
analysed – and solutions developed. Most potential sources of data on
alcohol-related harm are subject to extraneous influences, which vary over
time and space.
A NZ study used the five solutions19 for deriving indicators which were
developed by the World Health Organisation in their International Guide for
Monitoring Alcohol Consumption and Related Harm (MACRH).
The
researchers found that MACRH needs to be revised to include criteria for a
valid outcome indicator (Langley J, Kypri K et al, 2008).
18
An anecdotal report from Waikato Hospital describes such surges. In early 2009, Waikato Hospital
reported its busiest day ever with almost 191 patients assessed and treated in a 24-hour period
illustrated by a surge of alcohol-related injuries. There were no major trauma cases so ED clinical nurse
manager Jenni Yeates put the busy day down to an increased number of people in the city. “It was a
huge day for us. We had an increased number of young people and alcohol related injuries which is
probably all the events happening in the city with Waikato University’s O-week” (Waikato DHB, 2009).
19
(i) use only alcohol-specific cases (ii) identify subsets of events known to be highly alcohol-related,
(iii) utilise control indicators that are rarely alcohol-related, (iv) estimate alcohol attributable fractions and
(v) develop composite indicators.
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The Alcohol Advisory Council would like to see emergency departments
routinely recording the number of patients presenting with alcohol-related
injuries to help show the size of the problem. Chief Executive Gerard
Vaughan was quoted in the Otago Daily Times as saying that such figures
could then be used to see how effective any changes to the availability of
alcohol were. He was commenting on a report in the Otago Daily Times (on
27 April 2009) in which Dunedin Hospital ED consultant Dr John Chambers
linked extended opening hours to an increase in the number of people
attending the department with injuries following alcohol consumption. Mr
Vaughan said if figures were kept, they could be made available to general
practitioners, who could then be advised when one of their patients was
involved with an alcohol-related injury or accident. "There would then be the
opportunity for the GP to administer a brief intervention by questioning their
patient about their alcohol consumption." There were ways of recording the
information in such a way that the level of intoxication was indicated. Mr
Vaughan said the Council was one of many bodies wanting better information
and data collection relating to alcohol use (Otago Daily Times, 28 April 2009).
5.
Hospital capacity planning / managing access block
Evidence that more hospital beds, or better hospital bed management, improves ED
overcrowding is not strong in the literature. However, intuitively and based on
perceptions in relation to efforts in this regard, it is reasonable to conclude that
hospital capacity planning is an important part of the solution.
Will hospital capacity planning reduce ED length of stay? There is no conclusive
answer to this because relatively little research has examined the correlation
between hospital bed occupancy and length of stay in the ED. One study found that
“modest decreases in hospital occupancy resulted in highly significant reductions in
ED waiting times…..and….emergency department overcrowding due to large
numbers of admitted patients awaiting hospital admission is a major cause of ED
dysfunction.” (Dunn R, 2003, quoted in Ali W, 2006).
In a descriptive review of acute hospital bed occupancy and length of stay for
patients in the ED, the total time spent in the ED was found to relate to the immediate
availability of an inpatient bed (Ali W, 2006). It is important to note that in that
review, no studies were included that evaluated the effectiveness of interventions to
manage hospital bed occupancy and the impact on the associated time spent in the
ED.
ED overcrowding is associated with inability to access hospital inpatient beds
(access block). As noted on page 2 above, access block is a term used to describe
the delay experienced by ED patients who need hospital admission when their
inpatient bed is unavailable (Forero R, Hillman K, 2008). There is strong evidence
for access block as a cause of overcrowding (Ardagh M, Richardson S, 2004),
(Bradley VM, 2005), (Estey A, Ness K, Saunders D, 2003), (Proudlove NC, Gordon
K, and Boaden R, 2003).
Further, the significance of access block as a cause of overcrowding has been
illustrated in a number of studies that found that the time interval between the order
of admission for a patient and the time when the patient is actually transferred to the
assigned bed appears to be most affected by the immediate availability of the bed
rather than by other causes (Bagust A, Place M, Posnett JW, 1999), (Kyriacou DN,
Ricketts V, et al, 1999), (Cooke MW, 2003), (Dunn R, 2003), (Forster AL, Stiell I, et
al, 2003), (Gorelick MH, Yen K, Yun HJ, 2005).
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Prolonged ED length of stay, exceeding 8 hours, has been studied and attributed to
an increase in the frequency of access block at many hospitals (Cooke MW, Wilson
S, et al, 2004), (Ali, 2006). Access block has been correlated with total hospital
inpatient bed occupancy of 90 percent or greater and a target occupancy of 85
percent has been suggested as an ideal level in order to balance between the
possibilities of either unused bed capacity or inefficient inpatient flow (Sprivulis PC,
Da Silva J-A, et al, 2006). According to a number of commentators, high inpatient
occupancy levels lead to an inefficient patient flow in the hospital, which with other
factors can then lead to overcrowding in the ED (Emergency Nurses Association,
2006).
In Australia “there is clear evidence that the main cause of access block and ED
overcrowding is a combination of major increases in emergency admissions and ED
presentations with almost no increase in the capacity of hospitals to cope with the
demand. Between 2002 and 2007 the rate of available beds in Australia was
reduced from 2.65 beds (1998 – 99 level) per 1000 population to 2.4 in 2002, and
has since remained steady between 2.5-2.6 per 1000 population. In the same period
the number of ED presentations has increased over 38 percent from 4.1m to 6.7m,
(from 3.5m in 2006-07)” (Forero R. and Hillman K, 2008).
Only a small part of the solution to access block resides within EDs (Forero R. and
Hillman K, 2008), (Richardson DB and Mountain D, 2009). There is no similar NZ
study of the rate per 1000 of available acute beds but it would be useful to establish
that rate, for comparison with other countries.
Access block is likely to be best addressed by increasing the capacity of the system,
most directly by increasing the number of beds available at all levels of care within
hospitals. Hospitals must recognise that ED crowding is a hospital-wide problem, not
an ED problem (Wilson MJ, Siegel B, Williams, 2005). This means
1.
having more inpatient beds by optimising patient flow to increase bed
availability and
2.
using different approaches to increasing the effectiveness of ED staffing.
The prevalence of ED overcrowding may rise in developed economies as age-related
demand for hospital services grows over the coming 10 to 15 years. Additionally,
economic incentives tend to favour higher, rather than lower, occupancy. It may be
necessary to realign the incentives that favor high occupancy at the expense of
emergency access (Sprivulis P, Da Silva J-A, et al, 2006).
One approach to optimising patient flow is streaming. Researchers at the Flinders
Medical Centre, a 500-bed teaching general hospital in Adelaide, designed a study to
illustrate in some detail the methods used in, and outcome of, applying Lean Thinking
in establishing streams for patient flows20 (King DL, Ben-Tovim DI, Bassham J,
2006). They gained an understanding of the impact of Lean Thinking through
process mapping with staff, followed by the identification of value streams (those
patients likely to be discharged from the ED, those who were likely to be admitted)
20
Pioneered in the automotive manufacturing industry by Toyota, the Lean process is a management
philosophy aimed at eliminating waste and improving overall customer value (Womack JP, Jones DT,
Roos D, 1991). “Being “Lean” is about understanding value from the customer's perspective and
delivering exactly what is required at the right time with minimum effort and no waste in a safe
environment” (Kulkarni RG, 2007).
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and the implementation of a process of seeing those patients that minimised complex
queuing in the ED.
The researchers found that streaming had a significant impact on waiting times and
total durations of stay in the ED. There was a general flattening of the waiting time
across all groups. A slight increase in wait for Triage categories 2 and 3 patients was
offset by reductions in wait for Triage category 4 patients. All groups of patients
spent significantly less overall time in the department and the average number of
patients in the ED at any time decreased. There was a significant reduction in
number of patients who did not wait and a slight decrease in access block. The
streaming of patients into groups of patients cared for by a specific team of doctors
and nurses, and the minimising of complex queues in this ED by altering the
practices in relation to the function of the Australasian Triage Scale improved patient
flow, thereby decreasing potential for overcrowding (King DL, Ben-Tovim DI,
Bassham J, 2006).
In Central London, competition between patients with emergency needs and those
with routine (elective) needs led to disruption of both services. This issue was
addressed by increasingly separating elective and emergency workload into different
‘paths’ of work, each with dedicated resources in hospital and primary care settings.
This required additional investment and an additional £40 million was allocated to
support the implementation of nurse-led minor injuries and conditions services. The
reforms encouraged a whole systems approach, involving NHS Direct, primary and
social care, Ambulance Trusts, and secondary care in improving access and
reducing waiting times in line with the targets outlined in the NHS plan. The
streaming of services for patients with minor injuries and conditions was central to
the reforms. (DoH, 2002)
A key streaming study found that the introduction of a separate stream for minor
injuries can produce an improvement in the number of trauma patients waiting over
an hour by about 30%. If this is associated with an increase in consultant presence
on the shop floor it may be possible to achieve a 50% improvement. Accordingly, it
was recommended that departments use a separate stream for minor injuries to
decrease the number of patients enduring long waits in A&E departments (Cooke
MW, Wilson S and Pearson S, 2002).
Another approach which is likely to be useful for increasing the effectiveness of ED
staffing is to use queuing theory21, to estimate the number of providers needed
during each staffing interval. Analytic models such as queuing models can never
capture all characteristics of an actual operational setting. However, models can be
invaluable in providing decision support greatly improving performance, particularly in
complex environments. Queuing models are useful in EDs because they apply
where resources are tight relative to demand and small changes in staffing can have
a dramatic impact upon delays. One study examined the response of one ED
measure of performance, left without being seen (LWBS), to a provider staffing
reallocation based on queuing theory. A software package was used to document a
single queue of arrivals assuming an unlimited waiting room and a constant rate.
The daily pattern of peaks and valleys was quite consistent but the overall average
volume across a week had greater variation, indicating that the policy of identical
staffing levels for all days of the week needed to be revisited (Green LV, Soares J, et
al, 2006).
21
Queuing theory is a widely studied topic within operations research and follow the work of A.K. Erlang
and the NHS used lessons from Erlang theory in their training material (NHS Modernisation Agency,
2002).
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6.
1.
Developing the ED health workforce
Focusing on the healthcare professional (HCP) / teamwork
In Singapore, placing a senior emergency physician with the triage nurse
reduced waiting times for walk-in cases. One third of attendances were
treated and discharged quickly, allowing the ED and Patients Activity Score 1
/ PACS 2 doctors to act more efficiently (Travers JP, Lee FCY, 2006). In this
study, the HCP performed the same jobs: assessing, recording treating and
discharging over one third of cases as soon as they came through the
casualty department doors, did not require further intervention and did not
need to wait to be seen in a consultation room. Limitations of the study are
that not all hospitals would be able to use the team triage described here as
they may have separate problems because of a different case-mix. Not all
hospitals would be prepared to merge the roles of the triage doctor and nurse,
to produce a ‘healthcare professional’ as a team. However, on a more
positive note, the study found that “potential exists for a large number to be
discharged within a few minutes of arrival if appropriate senior assessment
skills are available at first contact, and this may require more senior
assessment than is currently used” (Travers JP, Lee FCY, 2006). This
observation could be applied in NZ where it was found that the rapid
management of patients with problems that do not require prolonged
assessment or decision making is beneficial not only to those patients but
also to other patients sharing the same limited resources (Ardagh MW, Wells
JE, et al, 2002).
A transition team was created in Rochester New York, where ED
overcrowding proved to be a complex problem deeply rooted in “issues of
inpatient capacity, inadequacy of alternatives for hospitalisation, and hospital
resource shortages” (Schneider S, Zvemer F, et al, 2001). Overcrowding was
only alleviated after hospital administration and the local administration
realised that system reform was necessary. Hospital administration created a
short-stay observation unit and a transition team to expedite the care of
patients being boarded in the ED. The local department of health developed
effective early warning systems and contingency plans. These interventions
had a great impact on ED overcrowding and ambulance diversion (Schneider
S, Zvemer F, et al, 2001). To alleviate overcrowding and better ensure the
safety of ED patients, communities struggling with ED overcrowding must
tackle the crisis with a similar multi-disciplinary system wide approach
(Trzeciak S and Rivers EP, 2003).
St. Joseph Hospital of Orange implemented a new ED programme, the Rapid
Assessment and Discharge in Triage (RADIT) programme, designed to
reduce patient waiting time and, importantly for the study and for the patient
group, to improve overall patient satisfaction. ED visitors presenting nonurgent problems were served by a roving RADIT team. The hospital
established a goal of 90 minute average time in RADIT and sought to reduce
overall time in ED.
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ED average length of stay with RADIT (N=35,065) versus
(N=31,936)
Group
Prior to RADIT
July – Oct
2005
Total outpatient or discharged home 2 hr 48 mins
patients
RADIT patients
–
Total ER patients
oputpatient)
(all
inpatient
and 3 hrs 07 mins
period prior to RADIT
With RADIT
Dec 2005 – Mar 2006
2 hr 57 mins
1 hour 37 mins (97
mins)
3 hrs 18 mins
After six months, results indicated that RADIT patients were discharged on
average in 97 minutes. Also, a patient satisfaction survey indicated that
about 96% of RADIT patients rated the quality of service received as either
good or excellent. For this success, the researchers credit the CQI process,
which had a goal of improving existing processes and outcomes, and
sustaining the improved performance (Vega V and McGuire SJJ, 2007).
2.
Innovative roles
An Australian study (Victorian Department of Human Services, 2005) found
that the main developments identified from the literature that were relevant to
their project, which was in the area of work analysis in EDs, intensive care
units and radiology departments, were
(a)
The emergence of a new health worker that could be classified as a
paramedical officer
(b)
The importance of the use of supplementary health workers who
provide health care services and perform procedures on
predominantly low acuity patients
(c)
Developing the role of the nurse practitioner (see below) and
(d)
Creation of specialist units and/or use of staff trained in other than
emergency care.
New and developing roles were found to be taking over some of the medical
staff tasks such as triage, ordering and reading x-rays, minor trauma,
prescribing over-the-counter and prescription drugs – as a response to the
realisation that many people present to the ED with associated or underlying
non-medical conditions.
A useful example of how one new role is changing EDs is that, in response to
increasing numbers of people presenting to the ED with a mental illness,
some hospitals in Australia have established ‘psychiatric sub-units’ in the ED
and /or use ‘mental health nurse consultants’ in the ED (Joyce PR,2005).
Other examples of innovative roles that impact on ED use are:
(a)
Expanded Scope Paramedics (ESPs) in rural locations where
interactions between ambulance services and rural communities had
an overall benefit for health care including emergency response
capability (Stirling CM, O’Meara P, et al, 2007).
(b)
Emergency Care Practitioners (ECPs), considered by Sir George
Alberti to be “one of the great innovations of the new NHS” (Skills for
Health). Within the overarching framework provided by competency
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requirements, ECP roles can be deployed in a variety of ways to
support local services. Examples included working in GP surgeries,
conducting home and community visits, providing care in minor injury
units and delivering after hours services. ECPs are also able to
facilitate referral to other services, which improves the overall patient
experience. Working in this way, an elderly patient suffering minor
injuries from a fall can be assessed and treated in their own home with
a follow-up referral made to the community nursing service (Skills for
Health). Care provided by ECPs appears to reduce the need for
subsequent referral to other emergency and unscheduled care
services in a large proportion of cases (Mason S, O’Keeffe C, et al,
2007). ECPs help to prevent attendances and admissions by delivery
of clinical care and assessment at point of access to health care
beyond that traditionally provided by UK ambulance services (Gray JT
and Walker A, 2008). The ECP role is considered to be likely to be
incorporated into any urgent community care services that develop as
a result of the Kapiti Urgent Community Care pilot22.
3.
Exploring the more extensive use of ED nurses and ED nurse practitioners
(NPs)
In Australasia, triage is carried out by emergency nurses. It is recognised that
because triage is so important to both the smooth running of an ED and the
outcome of the patients, it should be carried out by staff who are both
specifically trained and experienced (ACEM, 2000).
The literature supports the practice of nurse-initiated x-rays at triage and
nurses have been doing this in the UK, Canada and Australia for many years,
with varying degrees of reduction in waiting times. Conventional triage
processes often extend waiting times for lower acuity patients unless
secondary triage takes place. Secondary triage includes nurse-initiation of xrays, investigations and administration of intravenous fluids. Conventional
triage with its ‘one portal’ system is disadvantaging many patients, particularly
those with minor conditions. Improved patient flow after triage may alleviate
this problem (Rudd J, 2005).
In a systematic review of the literature from Australia, the US, the UK,
Scotland and Canada the impact of NPs on cost, quality of care, satisfaction
and wait times in the ED it was found that although some questions remain,
NPs can reduce wait times for the ED, lead to high patient satisfaction and
provide a quality of care equal to that of a mid-grade resident23. Cost, when
compared with resident physicians is higher; however data that compares
NPs with hiring additional medical professionals (e.g. more residents, another
attending physician or a physician/s assistant) is lacking (Carter AJE and
Chochinov AH, 2007).
In a UK “see and treat” model using NPs, the average wait time to see a
practitioner dropped from 56 to 30 minutes, the average time in the
department decreased from I hour and 39 Minutes to 1 hour and17 minutes,
22
Conversation with Andy Long, Manager, Kapiti Urgent Community Care Pilot, July 2009
It needs to be noted that the role of Nurse Practitioner varies from country to country so the different
NP studies will sometimes be relevant in NZ and sometimes not. The NZ NP is modelled on the USA
NP, rather than on the UK one. There is wide variation in the role across the UK and sometimes within
different UK departments as well.
23
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and the wait time for all patients in the department was lower after the
introduction of this model (Rogers T, Ross N, Spooner D, 2004). Most
studies examined NPs in minor treatment areas; however two studies
suggested that NPs could also reduce wait times by seeing higher acuity
patients (Blunt E, 1998), (Tachakra S and Stinson A, 2000).
In a study in Victoria, Australia, researchers found that NPs appeared from
the overseas examples to offer the opportunity for provision of ED services
with limited supervision required from medical staff. The range of tasks
performed by NPs included minor procedures, ordering investigations,
prescribing, admitting and discharging – all within established clinical practice
guidelines. They supported the establishment of ED Nurse Practitioners in
Victoria, a model in its infancy in Victoria in 2005, because, providing they
could discharge patients, they would reduce:

the workload of doctors

waiting time in EDs (Victorian Department of Human Services, 2005).
7.
Using other wards and units as an alternative to the ED
A variety of models of care, with different referral processes and hospital
configurations, result in different parts of hospitals being used in emergencies. The
area of GP referrals direct to inpatient teams, which is widespread across NZ 24, is an
area in which NZ is set apart from Australia where the vast majority of referrals from
GPs are to ED staff.
The models of care include:
(a)
Auckland Hospital’s Emergency Care Centre with its Acute
Assessment Unit co-located within its ED
(b)
Hawkes Bay DHB’s model in which all comers are seen, including GP
referrals for admission
(c)
Use of very senior inpatient staff to field admission request calls from
the GP/ED. For example, Nelson Marlborough DHB has a referral
pathway for medical admissions from the ED which goes direct to the
medical specialist, which anecdotally appears to be an important
determinant of reducing the length of stay in the ED for that referred
group of patients.
While there is uncertainty about the most efficient model of emergency care
(Australian Health Workforce Advisory Committee, 2006), several different models
are reported in the literature.
1.
Integrated model
An attempt was made to improve the process of emergency care in a hospital
in Cambridge UK by developing an integrated model in which a clinical
decision unit replaced the more traditional observation unit. In this model, the
medical admissions unit was relocated onto the existing ED and came under
the four-hour target. Medical case records were redesigned to provide a
common assessment document for all patients presenting as an emergency.
Medical, surgical and paediatric short-stay wards were opened next to the
ED. (Boyle AA, Robinson SM, et al, 2007).
With this model it was found that integrated emergency care has the ability to
use spare capacity within emergency care. If offers significant advantages
24
Correspondence with ED Advisory Group member, July 2009. Anecdotally, patients who are referred
by their GP to an inpatient ward wait longer for review in comparison with direct presentation to the ED.
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beyond the ED. However, improved efficiency in processing emergency
patients placed the hospital at a financial disadvantage.
2.
Observation units
Over the past two decades, the use of observation units to treat such
common conditions as chest pain and asthma has greatly increased. These
units allow patients to be directed out of ED acute care beds while potentially
avoiding inpatient admission. Many studies have demonstrated the clinical
effectiveness of care delivered in such a setting compared to the ED or
inpatient ward and it has been shown that increased admission to an
Observation Ward reduced admission to inpatient wards for selected
diagnoses (Williams AG, Jelinek GA, et al, 2000). However, although
observation units have emerged as a cost saving alternative to traditional
ward admission for many paediatric illnesses (Mallory MD, Kadish H, et al,
2006) there are limited data published about observation unit finance (Baugh
CW and Bohan JS, 2008).
Subtraction of costs from payments may significantly underestimate the
financial value of an observation unit admission. However, the positive value
generated by an observation unit bed must be considered in the context of
other projects available to hospital administrators (Baugh CW and Bohan JS,
2008).
In NZ, the establishment of disease specific observation units in EDs is
associated with ambulatory sensitive hospitalisations for specific conditions
(Health Services Assessment Collaboration, 2008).
A management protocol introduced into an existing ED observation unit for
heart failure safely decreased ED visits by 56%. The protocol included
diagnostic and therapeutic algorithms, cardiology consultation, close
monitoring, patient education and discharge planning (Health Services
Assessment Collaboration, 2008).
3.
A range of different kinds of wards and units
It is important to distinguish among the different kinds of wards and units that
are associated with EDs. There are holding wards, clinical decision units,
short stay units, all with slightly different functions.
For instance, some hospitals have instituted holding areas for patients waiting
for transfer to wards (Gantt LT, 2004). In a Melbourne study of 17 EDs where
a range of traditional inpatient services were incorporated into EDs, short stay
units were found to decrease patient admissions and average length of stay
(ACEM, 2006) without compromising re-presentation rates upon discharge
(Taylor D McD, Bennett DM, Cameron PA, 2004). Physically separating
boarding patients from those still requiring emergency care gives clarity about
the numbers of patients waiting and also enables staff to focus on the most
appropriate care delivery for each group of patients. However such separation
could also be viewed as adding another queue to the system rather than
removing barriers to transfer (Bichan I, 2005).
8.
Improving data quality and monitoring
The ED Working Group recommended that enhancements could be made to the
National Non-Admitted Patient Collection (NNPAC) in order to collect more detailed
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patient-level data from EDs. By 2010/2011 this could enable more nuanced
monitoring of ED length of stay data, and exploration of the relationship between
length of stay and patient outcomes (Working Group, 2008).
In response to this recommendation, there are planned enhancements to the
NNPAC. The Ministry of Health is planning to introduce additional fields to the
NNPAC collection in order to supply the following information for emergency
department patients:
1.
Triage category
2.
Time of presentation to the department
3.
Time of first contact with doctor or other clinician offering definitive
4.
assessment and treatment
5.
Time of departure from the department (discharge, transfer to inpatient ward,
or transfer to another facility).
Introduction of these additional fields is expected to take place beginning with the
2010/2011 year.
Conclusion
In the literature, there is a wide range of innovative approaches and solutions to ED
overcrowding and many of these are supported by good evidence. However,
evidence from NZ is very sparse.
As the table on pages 3 – 8 above shows, NZ experts concurred to a large extent
with many of the findings of the UK systematic review (Cooke M, FisherJ, et al, 2005)
but both the UK researchers and the NZ experts noted that many of those
innovations have not been researched. Some suggestions follow, based on the
expert opinion summarised on those pages, for work that might be done by DHBs to
describe what happens at present and where they might make improvements for the
purpose of reducing ED overcrowding:
1.
Diversion of 111 calls, supported by after hours arrangements
2.
Fast track systems for minor injuries
3.
Interventions to reduce attendance by the elderly and those with long term
conditions
4.
Patient education in long term conditions management
5.
Phoning for advice before going to the ED
6.
Use of observation wards
7.
Home support
8.
Allowing ED staff to admit patients
9.
Discharge from hospital that includes jointly constructed care pathways,
social support and access to prescriptions
10.
Teams of staff available for unpredicted surges
11.
Use of senior staff, particularly clinical leaders with an inclusive
management style
12.
Use of Nurse Practitioners and other health care professionals.
Some of these overlap with the following suggestions for further research which are
based on research findings under the eight headings of the literature review.
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Approach or strategy
Draft suggestions for NZ research
1. Using a national acute
care strategy
Contractility (throughput) studies (p.9) and perhaps a
study based on or replicating the throughput changes
in the St Joseph’s study (p.11)
Pages 9 – 13 – a range of research possibilities
2. Using master plans
within hospitals
3. Concentrating on
‘primary care’ presentations
4. Managing acute demand
5. Hospital capacity
planning
6. Developing the ED
workforce
7. Using other wards and
units as an alternative to
the ED
8. Improving data quality
and monitoring
Prospective audits of appropriateness of ED
presentations (p.13 )
Replicate NSW DEED study (p.16)
EDs screen for alcohol-related injury (p.18)
Rate per 1000 of available acute beds (p.19)
Studies of streaming using Lean (p.20)
A range of new roles, use of NPs, expanded scope
paramedics and other expanded scope professionals
(pp. 24–27)
Models of care: studies based on EDs in Auckland,
Hawkes Bay and Nelson Marlborough DHBs (page 27)
Run a health information research programme parallel
to NNPAC improvements (p.24)
___________________________________________________________________
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Appendix
Search methods
A review of the literature was undertaken by searching various electronic databases
including Medline, Cochrane, EMBASE, CINAHL, PUBMED, Trip, as well as
bibliographic references and snowballing to locate relevant papers.
The electronic database searches were restricted to literature published in English
language between 1996 and 2009 and editorial or opinion articles were excluded.
Grey literature searches were conducted, for government reports, academic reports
and conference proceedings. Bibliographies of retrieved articles were searched for
relevant citations. The Working Group’s Report references were followed up.
Key words for electronic database searches
Database: Ovid MEDLINE(R) <1996 to February Week 4 2009>
Search Strategy:
-------------------------------------------------------------------------------1 Emergency Service, Hospital/ (18106)
2 (emergency adj2 department$).mp. (19880)
3 1 or 2 (28869)
4 3 and (solution$ or "best practice" or "best practices").ab,ti. (427)
5 Crowding/ (710)
6 (overload$ or overcrowd$).mp. [mp=title, original title, abstract, name of substance word,
subject heading word] (13463)
7 4 and (5 or 6) (32)
8 (capacity adj2 asses$).mp. (1188)
9 (full adj3 capacity planning).mp. [mp=title, original title, abstract, name of substance
word, subject heading word] (0)
10 (surge adj2 (capacity or demand)).mp. (185)
11 (optim$ adj3 size).mp. [mp=title, original title, abstract, name of substance word, subject
heading word] (933)
12 (trolley adj2 (stay$ or wait$)).mp. (4)
13 (corridor$ adj2 (stay$ or wait$)).mp. (1)
14 Waiting Lists/ (4561)
15 4 and 14 (11)
16 14 and 3 and reduc$.mp. (57)
17 3 and reduc$.mp. (3722)
18 *Emergency Service, Hospital/og (2446)
19 18 and coordinat$.mp. (58)
20 3 and access block$.mp. and (solution$ or best practice$ or reduc$).mp. [mp=title,
original title, abstract, name of substance word, subject heading word] (11)
21 3 and demand manag$.ab,ti. (7)
22 3 and (8 or 9 or 10 or 11 or 12 or 13) (63)
23 3 and reduc$.mp. and (5 or 6) [mp=title, original title, abstract, name of substance word,
subject heading word] (88)
24 7 or 15 or 16 or 19 or 20 or 21 or 22 or 23 (287)
25 (England or Ireland or Wales or Scotland or Sweden or Denmark or Holland or France
or Spain or Germany or Italy or Canada or Australia).mp. (309408)
26 24 and 25 (48)
27 24 and (systematic review$ or meta-anal$).ab,ti. (5)
28 24 and review$.ti. (9)
29 26 or 27 or 28 (56)
30 queu$ theory.mp. [mp=title, original title, abstract, name of substance word, subject
heading word] (45)
31 ambulance diversion$.mp. (77)
32 3 and (30 or 31) and (25 or systematic review$.mp. or meta-anal$.mp.) [mp=title,
original title, abstract, name of substance word, subject heading word] (9)
33 29 or 32 (60)
34 limit 33 to (english language and yr="2003 - 2009") (45)
43
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35
from 34 keep 1-45 (45)
1 Hospital Bed Capacity/ (1159)
2 Emergency Service, Hospital/ (18106)
3 (emergency adj2 department$).mp. [mp=title, original title, abstract, name of substance
word, subject heading word] (19880)
4 1 and (2 or 3) (143)
5 (ward$ adj2 space$).mp. or hospital units/ [mp=title, original title, abstract, name of
substance word, subject heading word] (2907)
6 (2 or 3) and 5 (165)
7 (surge adj2 (capacity or demand)).mp. (185)
8 7 and (2 or 3) and plan$.mp. [mp=title, original title, abstract, name of substance word,
subject heading word] (40)
9 unscheduled care collaborative.mp. (0)
10 triage/ (3850)
11 patient admission/ (8573)
12 admitting department/ (253)
13 10 and (11 or 12) and (2 or 3) (134)
14 (patient adj2 flow).mp. [mp=title, original title, abstract, name of substance word, subject
heading word] (506)
15 patient transfer/ (2740)
16 (14 or 15) and (2 or 3) (712)
17 (England or Ireland or Wales or Scotland or Sweden or Denmark or Holland or France
or Spain or Germany or Italy or Canada or Australia).mp. (309408)
18 4 or 6 or 8 or 9 or 13 or 16 (1129)
19 17 and 18 (170)
20 limit 19 to (english language and humans and yr="2003 - 2009") (92)
21 from 20 keep 1-92 (92)
22 ((when or time) adj2 admit).mp. [mp=title, original title, abstract, name of substance
word, subject heading word] (14)
23 22 and (2 or 3) (2)
24 23 and 17 (0)
25 18 and (systematic review$ or meta-analysis).mp. [mp=title, original title, abstract, name
of substance word, subject heading word] (4)
26 21 or 24 or 25 (96)
27 from 25 keep 1-4 (4)
28 from 26 keep 1-96 (96)
Emergency Services Solutions - Cochrane
#1 MeSH descriptor Emergency Service, Hospital explode all trees 1264 edit delete
#2 (emergency department*):ti,ab,kw 2222 edit delete
#3 (#1 OR #2) 2751 edit delete
#4 (solution*):ti,ab,kw or (best practice*):ti,ab,kw or (reduc*):au 16731 edit delete
#5 (#3 AND #4) 112 edit delete
#6 MeSH descriptor Triage explode all trees 156 edit delete
#7 MeSH descriptor Patient Transfer explode all trees 104 edit delete
#8 "patient flow":ti,ab,kw 19 edit delete
#9 MeSH descriptor Patient Admission explode all trees 601 edit delete
#10 MeSH descriptor Admitting Department, Hospital explode all trees 4 edit delete
#11 MeSH descriptor Hospital Bed Capacity explode all trees 183 edit delete
#12 MeSH descriptor Hospital Units explode all trees 2396 edit delete
#13 "ward space":ti,ab,kw 0 edit delete
#14 MeSH descriptor Crowding explode all trees 15 edit delete
#15 (overcrowd* ):ti,ab,kw or (overload*):ti,ab,kw 546 edit delete
#16 (capacity):ti,ab,kw 11004 edit delete
#17 (corridor stay*):ti,ab,kw or (trolley stay*):ti,ab,kw 1 edit delete
#18 (optimum size):ti,ab,kw 59 edit delete
#19 MeSH descriptor Waiting Lists explode all trees 219 edit delete
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#20 (access block):ti,ab,kw or (ambulance diversion):ti,ab,kw or (queue theory):ti,ab,kw or
(demand manage*):ab 341 edit delete
#21 (#3 AND ( #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR
#16 OR #17 OR #18 OR #19 OR #20 )), from 2000 to 2009 172 edit delete
#22 (#21 AND ( solution* OR ( best AND practic* ) OR strateg* OR reduc* )) 71 edit delete
#23 (#1 AND ( #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR
#16 OR #17 OR #18 OR #19 OR #20 )), from 2000 to 2009 128 edit delete
#24 (#1 AND ( #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR
#16 OR #17 OR #18 OR #19 OR #20 )), from 2000 to 2009 128 edit delete
#25 (emergency):ti 1745 edit delete
#26 (#24 AND #25) 65 edit delete
#27 (#26), from 2003 to 2009 43 edit delete
45