To the Editor: I have read with interest your recent series of articles on access block.1-3 While access block is clearly bad for patients, it is a measure that is focused on emergency departments and not patients. Access block only measures the first part of the process of admission to hospital. Surely, the best measure of access into a hospital is not the rapidity with which patients get out of the emergency department but how long before patients get into the ward that is most suited for their care.

At my hospital, patients are shuffled out of the emergency department into a variety of “holding pens”. By this I mean wards (often temporary) whose sole purpose is to act as an overflow area while the patient is waiting to obtain a bed in the home ward of the medical or surgical unit that is looking after the patient. The purpose is to allow the emergency department to function better, but also to allow the hospital to look good from an “access block” point of view. This is hardly optimal patient care. A recent survey at my institution of 136 medical patients at high risk of delirium showed that over 43% had three or more ward moves during their admission, and 60% had three or more bed moves. No wonder they become confused.

Patients who are moved to holding pens have intrinsic disadvantages to their care. They are often seen late in the day by medical teams; the medical and nursing teams are not used to working together; allied health professionals may change from ward to ward, and holding pens often have no allied health staff; patient’s belongings, pathology and radiology requests get lost in the transition to different wards; patient meals can be substandard in holding pens (because they are ordered at short notice); and there are multiple handovers between many different groups of nurses. Medications are missed.

So, hospitals should not be allowed to play games with this metric. The time for patients to get into the home ward (or the most appropriate ward) of the admitting medical or surgical team needs to be part of the equation.