EM Notes – Overcrowding & Access Block

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Factors

Pre hospital

  1. Inc patient number / seasonal
  2. Inc patient complexity
  3. Inc patient expectation
  4. Lack of available GP is not a major factor

ED

  1. Triage
  2. Medical – Dr/Nurse, No./Skill mix
  3. Inv – XR, Path times
  4. Allied health
  5. ED design and size
  6. Delays in decision-making
  7. In-patient team – time to team review/necessary in ED intervention
  8. Clerical/transport/bed allocation

Post ED/Access Block (pt for admission who remains in ED>8h because of delay in accessing inpatient bed)

  1. Length of stay
    1. Availability of outpatient/clinic
    2. DC planning/lounge
    3. Critical care/transfer
  2. Admin
  3. Resources – insufficient open beds, high hospital occupancy (> optimal 85%), availability of appropriate admission bed, specialisation of whole wards
  4. Financial incentives – elective vs emergent

Impact of overcrowding (Consultoid issues)

  1. Bio
    1. Adverse events
    2. Morbid/mortality – 20-30% extra, 1500+ more deaths/yr
    3. Pt care
    4. Infectious disease
  2. Ψ/soc
    1. Pt dissatisfaction/complaints
    2. Staff stress
    3. Financial strain on hosp/ED
  3. Legal/ethical
    1. Record mixing
    2. Privacy
    3. OH+S risk
  4. Departmental
    1. Increase wait time and hospital stay (+20-25%)
    2. Communication load
    3. Error risk

Solutions

Pre hospital

  1. Pt – education, awareness
  2. Appropriate non-ed services/clinics – GP, Clinics, Community groups
  3. Ambulance service communication/coordination/distribution
  4. Community health – prevention of illness
  5. Direct interhospital/specialist rooms ward transfer/admission

In ED

  1. Triage – Fast tracking
    1. Team allocation to areas of ED
    2. Supervisor vigilance of waiting times
  2. Medical – Dr, Nurse, Allied, Inv
    1. Skill mix and availability
    2. Medications, Equipment, Education, Protocols, Staff
  3. Design/layout/EMU
  4. Systems – computerization, documentation, clinical pathways (PTCA, trauma calls), communication systems
  5. Team – policies re admission
    1. Time to review
    2. Incentives
  6. Clerical – bed officer, clerical, staff

Post ED

  1. Surge beds
  2. Shortened inpatient stay
    1. Outpt mx
    2. Clinics
    3. Hospital in the home
  3. DC planning (incl earlier DC ward rounds) / DC lounge
  4. Info systems / bed tracking / bed availability
  5. Incentives – Elective vs Emergent bed prioritisation (cancel elective surgery)