The Queen Elizabeth Hospital (QEH) is a 340–361-bed acute tertiary referral hospital in the western suburbs of Adelaide. Since 1999, the hospital has had difficulties coping with emergency admissions demand, especially during winter. Over the previous years, there has been a reduction in acute bed numbers from 476 to 361. Also, within the past two years, there has been the loss of 250 residential care facility (RCF) nursing home beds from the western region of Adelaide. At the same time, the activity of the hospital as measured by casemix activity has remained constant. The inpatient occupancy in winter has resulted in the emergency department (ED) requesting to go on ambulance diversion (bypass) almost daily, usually in late afternoon; however, on most occasions, this has not been either approved or possible.

Waiting times in the ED for patients to be transferred to a ward are sometimes up to several days and QEH's waiting times in the ED are the longest of South Australian hospitals. Cancellation of elective surgical and medical patients has sometimes been necessary.

In a progressive response to reducing access block, the hospital has adopted a range of strategies.

• In 1996, an Interface Unit based within the Division of Medicine was developed to coordinate and facilitate early discharge from the wards and avoid unnecessary admissions from the ED by initiating treatment/management for patients with conditions that may be managed at home but require additional support. The nurses in this unit "broker" or organise external therapy or services (such as subcutaneous heparin for the treatment of deep venous thrombosis, or home supports for someone who is frail and would otherwise have been admitted to hospital) in association with the patient's general practitioner.

• With the loss of nursing home beds from the western Adelaide region, a step-down unit was created in the hospital with a lower registered/enrolled nursing skill mix. An active multidisciplinary team facilitates placing patients in RCFs or at home, with additional resources provided through brokered community services or State-based programs, such as the Adelaide Transition Alliance (which provides respite beds in RCFs) or with the Division of Surgery's "Hospital in the Home" program (which provides post-acute home nursing services from within the division's nursing resources).

• A transit bay of six beds for incoming (ED) and outgoing (discharge) patients has been created. In addition, overcapacity beds (ie, accepting an additional patient into a ward before a patient has been discharged) have been used, and day beds have been used for non-same-day inpatients.

• Emphasis has been placed on promoting appropriate admission and appropriate day stay, with audits conducted by senior nurses from the Interface Unit based on accepted clinical criteria.

• Early discharge remains a priority, and is reinforced at medical handover meetings held each morning to review new admissions, facilitate transfer of care, and provide clinical inservice.

• Home care specialist nurses have also helped prevent admissions (eg, heart failure nurses, home cancer therapy and respiratory care nurses). A "medical flying squad" was established to assess nursing home patients and was clinically effective in reducing transfers from the RCF to the ED, but was too costly to sustain.

• A GP service located within the ED was unsuccessful because of low numbers of triage category level 4 and 5 patients. A further issue was that it sometimes involved a GP referring to another GP.

The impact of these interventions is difficult to measure, as ambulance diversion has sometimes not been allowed in SA. However, without the introduction of the above initiatives, a substantial further reduction in elective activity would have been necessary. One measure of the success of these programs is that in 2001 the hospital had 50 long-stay patients awaiting placement, and this is now down to an average of 25 patients.

There have been strategies undertaken to increase the capacity of the ED, but medical and nursing staffing levels have remained an issue. Changes in chronic disease management are required to minimise acute inpatient demand, especially during winter. Strategically reducing elective surgical activity during winter and subsequently increasing it during summer is difficult. The Division of Surgery has trialled weekend surgery, but this has not been widely accepted by the community.

The management of long-stay patients remains central to improving patient access. The appropriate allocation of nursing home and respite beds is needed on a regional basis. The failure of nursing home beds to become available through licensing is a major issue that must be addressed at a State and Commonwealth level.