Academic journal article Australian Health Review

Aiming to Be NEAT: Safely Improving and Sustaining Access to Emergency Care in a Tertiary Referral Hospital

Academic journal article Australian Health Review

Aiming to Be NEAT: Safely Improving and Sustaining Access to Emergency Care in a Tertiary Referral Hospital

Article excerpt


Delayed access to care in hospital emergency departments (EDs) as a result of impaired patient flow and overcrowding poses risks for patients presenting with acute illness. Access block, defined as the percentage of patients waiting more than a defined period of time (previously set at 8 h) to leave the ED by way of discharge or transfer to inpatient beds, has been associated with increased inhospital length of stay (LOS)1 and mortality,2,3 increased rates of return visits to the ED,4 a higher incidence of prolonged pain, patient and/or carer dissatisfaction, ambulance diversions and ramping, and reduced ED efficiency.5 Factors contributing to ED access block can be intrinsic or extrinsic to the ED. Within the ED, these factors include slow and inappropriate triaging and referrals to inpatient teams, poorly coordinated patient flow through acute cubicles and short-stay wards (SSWs) and mismatch between staffing levels and clinical demand. Factors external to the ED include inefficient processing of admission referrals by inpatient teams who do not accord priority to such tasks, poorly coordinated bed management processes with prolonged transfer times to inpatient wards and suboptimal inpatient unit discharge planning that prevents the early release of inpatient beds for incoming patients from the ED.6-8

In recognition of the hazards of access block, the Federal Health Department in Australia introduced in 2012 the publicly reported National Emergency Access Target (NEAT) for all hospitals. In Queensland, the target was set for 2012 at 70% of all patients leaving the ED within 4 h of presentation, to be raised to 78% for 2013 and 82% for 2014. Achievement of these targets was to be linked to additional hospital funding from the 2014-15 financial year. Data gathered by the National Hospital Performance Authority in 2011 showed that Princess Alexandra Hospital (PAH), a 640-bed tertiary hospital in Brisbane, southeast Queensland, had the lowest NEAT 4-h rule compliance (33%) of all Australian hospitals, compared with an average of 54% for all major metropolitan hospitals. The PAH was averaging 150 ED presentations each day, of which approximately 50 were admitted, 60% comprising medical admissions (of which over one-third were admitted as short stays to a 30-bed medical assessment and planning unit (MAPU)).

The aims of the present study were twofold: ( 1 ) to describe the development and implementation process; and (2) to evaluate the effects on patient flow and safety indicators of various reforms enacted within PAH over a 12-month period, with the goal of increasing the percentage of patients exiting ED within 4 h of presentation.


Design, participants and setting

The present study was a retrospective pre-post intervention study using routinely collected administrative data involving all patients presenting acutely to the ED of the PAH between 1 January 2012 and 31 March 2014. For purposes of comparative analysis and to minimise seasonal effects, the baseline ( prereform) period was 1 January-31 March 2012, the post-reform period was 1 January-31 March 2013 and the maintenance period was 1 January-31 March 2014.

Data collection

Routinely collected data pertaining to patient transit through the ED were extracted from the ED Information System (EDIS) in deriving times of presentation to the ED and exit from the ED (including SSW as an extension of the ED) for all patients discharged from the ED. In addition, for patients admitted to inpatient wards, the following times were ascertained: first seen by ED medical officer; request for inpatient medical team review; attendance by medical team; bed booking made; and actual departure of patient from the ED. These data were used to compute mean transit times for each phase and total mean transit time from ED presentation to discharge, as well as the percentage of patients exiting the ED in under 4 h. Data on ED 'did not wait' rates were also extracted from EDIS. …

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