Royal Perth Hospital (RPH) is the largest hospital in Western Australia. The Wellington Street campus has about 600 beds and is located on the edge of the inner city. The emergency department (ED) has an annual census of around 55 000, with an admission rate of 44%. Forty-two per cent of all attendances arrive by ambulance, and data from the ambulance service indicate that RPH receives more priority one ambulances than the other major teaching hospitals combined. From 1996 to 2001, attendances increased by 14% and admissions by 16%. In the same time, inpatient bed numbers have been reduced by about a third. Before 1999, ambulance bypass was extremely rare.

In October 2000, four WorkSafe orders were issued because the ED was contravening regulations of the Occupational Safety and Health Act 1984 (WA):

• employees were not able to move safely within the ED corridors because of obstruction from too many patient trolleys;

• patient trolleys and other equipment were blocking egress through corridors for evacuation in event of fire or other emergency;

• employees were exposed to violence hazards; and

• employees were suffering work-related stress because of excessive work demands.

On 12 December 2000, all three major teaching hospitals in Perth were on simultaneous ambulance bypass. As a result, the then Health Minister appointed an Ambulance Bypass Coordinator to prevent this event recurring.

On 17 November 2001, the cover story of the West Australian detailed the poor conditions for patients and staff in the ED. As a result, the Department of Health formed an Emergency Services Task Force, with broad representation from the emergency medicine and nursing community.

The Box shows the extent of ambulance bypass at RPH from July 1999 to June 2002. Analysis of the first two years indicates that the most common reason for initiating ambulance bypass was entry block (30.4%). Entry block is a result of overwhelming numbers of patients attending the ED in a short period, resulting in a functional block to the entry of the ED and ED overcrowding. This necessitates ambulance bypass, even if there are sufficient inpatient beds available.

A transit lounge was established in July 1999, allowing ward patients who are being discharged to await discharge medications and collection, thus freeing up their beds earlier.

In July 2000, an eight-bed holding bay was opened next to the ED. This is designed for patients who are ready for admission, but for whom the inpatient bed is unavailable, and to relieve the stacking of patients in the ED corridor. Nevertheless, stacking of patients in the corridor still occurs.

Within the ED, a transfer coordinator has been appointed since July 2001. This is a senior nurse who readies patients for inpatient admission and organises transfer to the ward. This frees nurses for clinical duties. The transfer coordinator also identifies and coordinates admission of patients to other sites (eg, private hospitals), and can arrange direct admission to the ward, bypassing ED.

Bed management within the hospital was changed from a divisional system to a centralised bed management mechanism, allowing for effective crisis management.

The hospital now has well-defined criteria for initiating ambulance bypass (involving factors such as excess patient load, environmental, staff or resource issues, excessive number of high-acuity patients, or declared disaster situation). Other options to reduce ED overcrowding include sending trolley patients awaiting admission to wait in the ward corridor. ED medical staffing was increased to address the large patient volume.

The ambulance communications room now has a computerised ED patient tracking system (EDIS) installed. EDIS is present in all EDs in Perth. This allows the ambulance service to distribute its workload between sites.

Other recommendations of the Emergency Services Task Force that have been implemented are to:

• increase bed capacity by permanently opening some closed beds if nursing staff can be found (about 40 beds);

• increase aged care and rehabilitation beds at a regional secondary hospital to allow transfer of inpatients from RPH;

• increase the availability of care awaiting placement beds; and

• increase the bed and investigatory capacity of another secondary hospital in the region to allow for greater retention of patients, thus easing the burden on RPH. ED staffing was significantly increased.

The above measures have had significant clinical input and are designed to increase the capacity of the system, but the most important outcome has been the recognition at all levels of government that the problem exists and needs to be addressed. The situation is under constant review.

Episodes of ambulance bypass at Royal Perth Hospital, July 1999 to June 2002