Access block

Health services administration Emergency medicine
Volume 178 - Issue 3

Responses to access block in Australia: Australian Capital Territory

Author:  Drew B Richardson

Med J Aust 2003; 178 (3): 103-104. || doi: 10.5694/j.1326-5377.2003.tb05093.x
Published online: 3 February 2003
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Access block began to affect hospitals in the Australian Capital Territory during the winter of 2000. Practice was seriously affected first at the Canberra Hospital, a 500-bed mixed adult/paediatric tertiary hospital, in 2000, and then in 2002 at Calvary Hospital (220 beds), the other hospital in the ACT with an emergency department (ED).

Access block in the Canberra Hospital averaged 9.1% (Australasian College for Emergency Medicine/Australian Council for Healthcare Standards [ACEM/ACHS] definition: proportion of admissions with total time in the ED longer than eight hours) during 1999. For 14 days between May and September the rate exceeded 20%. During 2000, it averaged 16.3%, with 56 days in excess of 20% between May and September (Box). This trend continued in 2001, when the figures were 22.9% and 79, respectively. The major underlying cause was a reduction in hospital bed capacity from a monthly average of 533 staffed beds in January–August 1999 to 491 in January–August 2000. As a corollary, a marked reduction in access block occurred when additional beds were made available by cancellation of elective surgery during the Sydney Olympics in September 2000.

Although access block had a measurable effect on ED waiting time performance in 1999,1 it began to affect overall ED function in the second half of 2000,2 when a significantly lower proportion of presentations achieved their desired ACEM/ACHS waiting time performance.

Interventions

The onset of access block prompted review of ED work practice, leading to some improvement in ED performance in the face of access block during 2000, but little change since. The continued severity of the problem has stimulated ongoing review of all hospital work practice, aiming to reduce the demand on overnight beds through improving overall patient flow, and to improve ED function. The changes have proven to be of variable effectiveness.

Interventions to improve patient flow

  • Restructuring and expansion of the Bed Management Unit (May 2001);

  • Revision of admission, discharge and bed management policies (July 2001 to March 2002);

  • Expansion and increased use of hospital in the home and day surgery services (ongoing);

  • Off-site transitional care arrangements for elderly patients (ongoing increase in transitional care beds);

  • Activation of real-time estimated date of departure notification system and daily estimates of occupancy over next 24 hours (May 2001);

  • Containment of elective surgery, particularly during winter (ongoing since 2001); and

  • Opening of a discharge lounge (relatively little effect on time of discharge).

Interventions to reduce ED demand for overnight beds

  • Increased use of overnight discharge from the ED followed by day surgery for orthopaedic, plastic surgical, and gynaecological presentations; and

  • Improved links with community services to facilitate discharge, particularly of geriatric patients.

ED changes to mitigate effects of access block

  • Rearranging medical staff rosters (2001 and 2002);

  • Increasing by one the number of nursing staff on each shift (winter 2001 and ongoing);

  • Drawing additional nursing staff from the hospital pool at times of excessive inpatient care in ED (2002 and ongoing);

  • Establishing formal policies and procedures on prioritisation of ED activity (2001 and 2002);

  • Revising hospital policies on ambulance diversion, although the effect has been limited, as the Canberra Hospital offers the only acute inpatient service in the region for paediatrics, orthopaedics, and most tertiary services; and

  • Providing additional Hospital Assistant and Wardsman staff to assist in the ED (ongoing).

Interventions planned for 2002–2003

  • Renovation of the ED to make better use of the available space;

  • Construction of a Clinical Decision Unit/Observation Unit in the ED to manage short-stay patients; and

  • Opening of a short-stay surgical unit close to the operating theatre to better manage short-stay surgical patients.

Outcome

Access block is the major issue facing EDs in the ACT. Despite the above measures, hospitals in the ACT have experienced a continued increase in access block and significant decline in ED waiting time performance.

Access block at the Canberra Hospital, January 1999 to September 2002

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