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Clinical process redesign for unplanned arrivals in hospitals

Tony J O’Connell, Jane E Bassham, Rod O Bishop, Christopher W Clarke, Carolyn J Hullick, Diane L King, Carmel L Peek, Raj Verma, David I Ben-Tovim and Katherine M McGrath
Med J Aust 2008; 188 (6): S18. || doi: 10.5694/j.1326-5377.2008.tb01669.x
Published online: 17 March 2008

Australian public hospital emergency departments (EDs) have recently been experiencing an overwhelming growth in demand for unplanned care: in New South Wales ED attendances are up 6.5% (Tony Dunn Director, Data Analysis and Performance Evaluation Branch, NSW Health, personal communication). The most obvious sign of this is a queue of patients on ambulance trolleys, waiting for a bed in the ED. The challenges facing Australian EDs have been described previously in this Journal, and include lack of access to inpatient beds, workforce deficiencies,1 safety issues,2 increased mortality,3,4 and inefficiencies that compound each other. The volume of demand for beds for patients being admitted from the ED often also resulted in a destructive impact on elective surgery.5

We have carried out system-wide redesign in over 60 NSW hospitals (through the Clinical Services Redesign Program) and at Flinders Medical Centre in South Australia (through the Redesigning Care Program) to tackle these issues. The diagnostic phase of our redesign work confirms these previously reported observations, and includes other findings, such as:

Clearly, an annual growth in hospital ED demand across Australia of about 5%–8% per year (Tony Dunn, Director, Data Analysis and Performance Evaluation Branch, NSW Health, personal communication) cannot be accommodated by ambulance diversion. Previous explanations for the challenges in EDs have focused on a lack of inpatient beds and workforce deficiencies. While these clearly contribute, our redesign work has identified numerous correctable issues which, when addressed, permit substantial improvements in performance with modest increases in bed capacity and workforce. Examples include such mundane issues as the mismatch of staff rosters to patient attendances and the predictable adverse impact of junior medical staff term rotations.

Time-consuming processes within emergency departments

Increasingly, patients in EDs are older6 and frail, with multiple problems that take many hours to assess. Such patients can be hard to place with medical teams, which have become increasingly specialised around single-organ diseases. Teams may not feel confident outside their subspecialty and may be reluctant to accept the patient. Another large patient group is people with chest pain, who are managed under treatment protocols that require them to wait many hours for tests to exclude a cardiac cause.

Patients of all kinds are often assessed first by junior medical staff, who then present the problem to registrars and then to ED specialists. Thus, decisions about treatment can be delayed for hours. Once assessed by ED staff, patients often need further assessment by specialty teams who may be unable to attend immediately because of other commitments. Patients also wait in the ED for test results while diagnostic departments process samples from all parts of the hospital, and patients from the ED are not necessarily given priority.

Clinical redesign solutions: a whole-of-ED management system

Our experience is that redesigning patient journeys makes it possible to improve flow for all three major patient groups presenting at EDs — those who don’t require admission, those requiring only a short admission, and those requiring a longer admission.

Preventing unnecessary hospitalisation

A large number of patients who have historically stayed in hospital for only 1–2 days have conditions such as cellulitis, deep vein thrombosis and community-acquired pneumonia that are amenable to safe management in the community using “hospital in the home” models.7 Home-based care can also be preferable for older people, who often become confused and debilitated in hospital. Other advantages of community-based care include the reduced risk of hospital-acquired complications, and that such care can replace the final portion of an otherwise longer hospital stay.

Implementing solutions for patients who do not need admission: streaming

In NSW in the 2005–06 financial year, 40% of patients admitted to public hospitals came through EDs (Tony Dunn Director, Data Analysis and Performance Evaluation Branch, NSW Health, personal communication), and these patients are demanding on ED staff time. However, the number of patients attending EDs is over 2 million per annum in NSW, and 77% are not admitted (Box 1). Redesigning pathways for this large group is potentially very beneficial, as moving them quickly through the ED can reduce congestion and frustration and improve the safety of care. A number of care models have been used in NSW to achieve this effect, such as “fast track zones”, advanced practice nurses, and rapid assessment teams.

Fast track zones stream patients with conditions of lower urgency or complexity, especially those who are ambulatory, into a separate zone of the ED where they are attended by a separate group of ED staff. Having experienced staff in this zone permits rapid decision making and faster handling. Medical staff can be supplemented in this model by nurse practitioners and experienced physiotherapists (used at Liverpool Hospital for minor musculoskeletal conditions), who are able to efficiently and independently manage a large subset of these patients and achieve high patient satisfaction.8

Protocol-based nurse-initiated ordering soon after patient arrival has reduced time to analgesia and decision making. Rapid assessment teams permit assessment, diagnosis and simple treatments to begin soon after the patient arrives.

At John Hunter Hospital, ED patients are directed into one of three streams: high acuity/high complexity; low acuity/high complexity; or fast track (low acuity/low complexity). The groups are allocated to separate teams. There have been improvements in access block and triage time and a reduction in ED length of stay for both admitted and discharged patients.

At Flinders Medical Centre, patients who present to the ED have been streamed into two broad categories — those most likely to go home and those most likely to need admission. These groups are treated within two separate areas of the ED by distinct staff. Except for patients with time-critical presenting problems, patients are seen in their order of arrival rather than by triage category. This simple approach has resulted in improved access for both groups of patients and has reduced the rate of adverse events.

Implementing solutions for patients requiring short admissions (less than 48 hours)

Many patients require only a relatively short inpatient period of monitoring once their initial assessment and treatment has been completed. Ten per cent of ED attendances in NSW result in a hospital stay of less than 48 hours (Box 1). A number of hospitals have established wards where short-stay patients are managed together, grouped by their likely duration of stay or other characteristics. This can improve the quality of the patient experience and reduce time spent in hospital.

Very short-stay units, such as 12–24-hour wards adjacent to EDs and managed by ED physicians (emergency medical units or short stay observation units) are now common. Wards with stays up to 48 hours managed by inpatient services have also been established. At the Flinders Medical Centre, a short-stay ward for patients whose predicted length of stay is less than 72 hours cares for both medical and surgical patients in the same ward. That one ward now manages around a quarter of all adult overnight, emergency admissions.

Short-stay wards work well when care is straightforward, protocols for common conditions are well developed, and nurses are empowered to advance patients to the next step in their treatment pathways once agreed criteria are met. The most important feature of these wards is the mindset for patients, their carers and staff that the patient will stay only the designated time period. This drives the development of good systems to standardise and coordinate care pathways and avoid delays so that patients can be transferred to the next stage of their journey in a predictable process.

Short-stay wards can be better places than the ED for patients who need a prolonged period of investigation, assessment or monitoring before the decision is made as to whether they need to be transferred to a specialist team.

Implementing solutions for patients requiring longer admissions

The challenge for hospitals in managing patients who stay more than 48 hours is to guarantee processes that support smooth flow through the hospital from presentation to discharge, with minimal waste of time and effort. In NSW, 13% of ED attendances result in hospital stays longer than 48 hours (Box 1).

The following clinical process redesign solutions have been found to enable a faster, safer, more efficient patient journey through the hospital.

Solutions relating to the wards
Results

Overall statewide performance on emergency access key performance indicators (KPIs) has “turned around” since the implementation of the Clinical Services Redesign Program commenced in NSW in August 2004. Performance for the three most challenging KPIs, emergency admission performance (percentage of patients admitted through the ED who egress from the ED within 8 hours), triage 3 performance (percentage of patients in triage category 3 whose treatment is commenced within 30 minutes of arrival), and off-stretcher time (percentage of patients moved off an ambulance stretcher into an ED bed within 30 minutes of arrival) had been progressively deteriorating before the implementation of solutions arising from redesign in August 2004. Since the Clinical Services Redesign Program was implemented, performance has been improving, as shown in Box 2, Box 3, and Box 4.

These results are not just a one-day snapshot; they reflect millions of ED attendances throughout NSW, rising to over 1.8 million attendances in the final year represented in each graph. Importantly, they highlight how NSW performance in all three parameters was previously progressively deteriorating until redesign commenced.

The performance of a sample of 19 NSW hospitals (including the 10 with the busiest EDs) that underwent redesign of emergency patient flow is detailed in Box 5, showing that even in the face of rising demand (of between 5% and 27%), performance improved or was maintained in 52 of 57 instances for the three KPIs presented.

Conclusion

In the face of rising demand, redesign of clinical processes in hospital wards as well as within EDs is essential for improving patients’ access to emergency care. By setting hospital bed capacity at an appropriate level, raising the awareness of and accountability for performance indicators, and redesigning the processes that underpin clinical care and the patient’s journey, we have found that poor performance can be turned around across an entire state and this improvement can be sustained.

5 Emergency performance indicators in 19 New South Wales hospitals for the financial years 2004–05 to 2006–07

Demand increases (%)


Outcomes (percentage point change*)


Hospital

ED attendances

Admissions through the ED

EAP

Triage 3

Triage 4


St George

18%

16%

16

23

19

St Vincent’s

26%

29%

11

3

4

Prince of Wales

18%

25%

13

17

13

Sutherland

20%

28%

22

10

Wollongong

18%

16%

20

24

16

Royal North Shore

18%

18%

Bankstown

27%

13%

34

8

16 

Concord

19%

6%

24

4

9

Campbelltown

27%

6%

14

12

Liverpool

22%

45%

10

21

16

Royal Prince Alfred

20%

34%

12

14

8

Tweed

5%

43%

12

5

Steady

The Children’s Hospital at Westmead

22%

16%

9

21

23

Blacktown

18%

11%

18

Steady

5

Newcastle Calvary Mater

16%

20%

Steady

4

4

John Hunter

12%

18%

21

30

32

Gosford

9%

6%

Steady

7

Steady

Westmead

24%

23%

11

31

28

Nepean

22%

21%

12

3

4


ED = emergency department. EAP = emergency admission performance (% of admissions through ED who egress from the ED within 8 h). Triage 3 is the percentage of patients in triage category 3 whose treatment is commenced within 30 minutes of arrival. Triage 4 is the percentage of patients in triage category 4 whose treatment is commenced within 60 minutes of arrival.

* Percentage point change (eg, improvement from 63% to 75% is 12).
John Hunter outcomes data cover the period commencing in 2002, as redesign commenced earlier in this hospital.

Source: Tony Dunn, Director, Data Analysis and Performance Evaluation Branch, NSW Health, December 2007.

  • Tony J O’Connell1
  • Jane E Bassham2
  • Rod O Bishop3
  • Christopher W Clarke4,5
  • Carolyn J Hullick6
  • Diane L King2
  • Carmel L Peek6
  • Raj Verma1
  • David I Ben-Tovim2,7
  • Katherine M McGrath1

  • 1 NSW Health, Sydney, NSW.
  • 2 Flinders Medical Centre, Adelaide, SA.
  • 3 Department of Emergency Medicine, Nepean Hospital, Sydney, NSW.
  • 4 Emergency Medicine, Concord Hospital, Sydney, NSW.
  • 5 Faculty of Medicine, University of Sydney, Sydney, NSW.
  • 6 John Hunter Hospital, Newcastle, NSW.
  • 7 Flinders University, Adelaide, SA.


Correspondence: kamcg@doh.health.nsw.gov.au

Acknowledgements: 

We thank the staff of NSW Health who have participated in the Clinical Services Redesign Program, and Professor John Marley for his editorial advice. We also acknowledge the role Dr Deborah Lloyd performed in editing this article and producing this supplement.

Competing interests:

None identified.

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  • 8. NSW Department of Health. Nurse practitioner project. Stage 3 final report. Sydney: NSW Department of Health, Dec 1995.

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