Responses to access block in Australia: Royal Melbourne Hospital

Royal Melbourne Hospital (RMH), a 360–390-bed acute tertiary referral hospital in inner Melbourne, began to experience an acute increase in access block from early 2000. Over the previous few years, there had been a gradual reduction in acute bed numbers and a marked reduction in subacute and nursing home beds in the area serviced by the hospital. At the same time, patient throughput, as measured in weighted inlier equivalent separations (WEIS), had not decreased. The access block was manifest by ambulance bypass of up to 150 hours per month in 2001, worsening access of emergency patients to inpatient beds, and increasing and chaotic theatre cancellations for elective patients.

During 2001, in response to a Victorian government initiative, RMH formed a clinician-led taskforce that developed 51 interventions. These aimed to maximise efficient use of inpatient beds and improve access for elective and emergency patients, and were generally adapted from programs tried at other institutions. The interventions were developed over three months from April to June 2001, and were implemented over the following three months. The more important initiatives were:

Following the implementation of the taskforce recommendations, there was a significant improvement in access block indicators, even though hospital bed numbers actually decreased in acute and subacute sectors. The hospital's WEIS remained the same and emergency WEIS increased during the six months from implementation. Ambulance bypass was reduced to fewer than 10 episodes per month, emergency patients waiting more than 12 hours for inpatient beds were reduced by 40%, and same- or prior-day theatre cancellations were reduced to fewer than 10 per month. The elective waiting list remained static during the first six months of implementation.

Although the hospital was funded to increase bed numbers, this was not possible because of nursing shortages and rigid workforce rules.

Significant components of the success of the interventions appeared to be that clinicians were empowered to drive the changes and the focus was on maximising bed use rather than saving money. Individual interventions that had substantial effects on access block were the 48-hour short-stay ward, care coordination in the emergency department, centralised bed management, day-of-surgery admissions, and monitoring of patients staying as inpatients for more than 14 days.

Using a similar strategy, hospitals similar to RMH could function with fewer beds or treat more patients with the same number of beds. It is not possible to determine from our experience whether this would result in cost savings.