The Alfred Hospital, in Melbourne, is a 350–390-bed tertiary referral hospital with acute medical, surgical and psychiatric services. It is one of three hospitals in Bayside Health, a major metropolitan health service, and is one of the two major adult trauma centres in Victoria. The hospital also provides a number of statewide services, including those for heart–lung transplantation, cystic fibrosis and major burns.

In 2000 and early 2001, there was a considerable increase in the occasions that the Alfred's emergency department (ED) had to implement ambulance bypass, and there were difficulties in timely access for high priority elective admissions. Several initiatives had already improved access in the hospital, such as hospital-in-the-home, pre-admission and day-of-surgery admission strategies. In addition, an integrated approach to bed management was in place. This involved daily review of priorities for emergency and elective admission, through a centrally coordinated bed assignment process, overseen by senior medical and nursing managers.

In financial year 2001–02, the Victorian Department of Human Services funded a number of initiatives under the Hospital Demand Management Strategy, which aimed to improve access for emergency and elective patients.

The funded initiatives in the Alfred ED include increased senior medical staff cover after hours and the development of fast-track, an area of the ED where a doctor and a nurse work in partnership to fast-track the patients' care. Other hospital initiatives included a targeted length-of-stay strategy, involving strategies such as additional care coordination for patients admitted to specific clinical units, and the introduction of a weekly ward round by senior medical and nursing staff to facilitate early discharge planning. A third project focused on strategies to avoid patients' presenting to the ED, such as multidisciplinary mobile teams working in concert with nursing homes and general practitioners.

Among the more successful strategies were the Medical Ambulatory Day Unit and the Medihotel. These were designed to meet the needs of patients who required inpatient interventions, but who did not need overnight stay in an inpatient bed. These might be rural patients, patients receiving treatment over a series of days, or patients for clinical review or investigation. Previously, there was no alternative but to admit these patients to multiday inpatient beds.

The Medical Ambulatory Day Unit (MADU) and Medihotel are next to each other within the main part of the hospital's ward area. The MADU was designed to provide a range of medical interventions and consultation facilities, and patients may attend on consecutive days for their treatment or investigation. The Medihotel provides accommodation to patients of the Alfred who are ambulatory and independent who do not require clinical intervention overnight, but who need to be close to professional expertise if required.

A review of the outcomes in late 2001 and early 2002 showed a significant reduction in ambulance bypass, from 291 episodes in 2000–01 to 158 episodes in 2001–02. However, similar improvement was not achieved in the number of ED patients waiting for more than 12 hours for an inpatient bed.

Hospital-in-the-home substitution rates, which estimate the resulting inpatient capacity, were around 11%, which compared well with similar hospitals.

Up to June 2002, there had been more than 3500 occasions of service for patients of the MADU, and more than 1900 patient-nights in the Medihotel. Nearly all clinical units at the Alfred have used the MADU/Medihotel at least once. The ability to plan for elective medical admissions without the risk of cancellation has been well received by staff.

The centralised bed allocation and coordination process is extremely effective in maximising access to multiday beds, although this requires a considerable senior medical, nursing and management commitment. Some of the improvements to bed management flows did not require extra resources, as they related to changes in process. An example was the decision to allocate the first five multiday beds that became available each morning to patients awaiting admission in the ED — this had a considerable impact on the ED, without a flow-on disadvantage elsewhere.

Other initiatives with high impact on access were increasing the number of senior staff in the ED, care coordination and ED disposition nurses, and weekly ward rounds by clinical bed management staff to identify opportunities for redesign of the processes of discharge and bed management.