Access block can be managed

The persistent 5%–10% annual increase in emergency demand is unsustainable in the long term. The reason for the inexorable increase is not clear; it is only partly explained by the increasing and ageing population (which would account for 1.5%–2% of demand).8 Patient expectations are increasing, and medical professionals are continually expanding the treatment options available. Clearly, in a system that is unconstrained by the financial considerations of consumers (ie, it is free), there must be limits to what can be provided.

Managing emergency demand is complicated and highly political. Solutions such as copayments for ED services are appealing, and there is some evidence that payment for services reduces demand slightly. However, there are potential dangers, as patients with serious conditions may be reluctant to attend — resulting in delayed attendances for heart attacks, strokes and other time-critical conditions.9

A major component of the increase in demand comprises services provided to older patients.10 Inappropriately aggressive treatment of patients who are clearly dying, management of palliative-care patients in acute hospitals because of poor end-of-life planning, and lack of planning for treatment failure (especially after hours) in frail medical patients with complex conditions all contribute to this demand. As well as contributing to hospital overcrowding, the failure to address these issues is clearly not in the interests of the patients or their relatives. Attempts to improve the management of this vulnerable group of patients have had mixed success.3,9

In Victoria, the Hospital Demand Management Strategy was initiated in 2001 and involved a comprehensive suite of measures aimed primarily at reducing ED attendances across the state, including the provision of alternative services for individuals at risk of emergency admission. This program was initially associated with a plateau in demand, but recently there has been a renewed increase in demand.8,11 Various states have had success with “frequent attender programs”, which identify patients with conditions associated with recurrent admission, such as chronic obstructive airways disease and heart failure, and “case manage” them to reduce admissions. Although successful at a local level, the overall impact has been limited because of the small number of patients and uncoordinated approach. Ideally, a coordinated primary care program could identify high-risk individuals and institute case management with care plans that do not involve acute hospital admission as the first option.

ED presentations for mental health problems have increased significantly as a result of the mainstreaming of mental health care from the early 1990s, associated drug use, and increasing community awareness of mental health issues.8 Community psychiatric teams, fast-tracking of patients with mental health problems, and improved access to mental health facilities could improve management for this important group of patients.

There have been a number of attempts to limit ambulance transports to hospital, by referring apparently non-urgent calls to phone triage, and also by using paramedic practitioners to treat simple problems at the scene. The latter programs have had limited success, but need further exploration to realise the potential benefits. In addition, GPs could be better utilised to help plan community treatment (as opposed to default ED management) of complex medical conditions in frail and older people.

Many hospitals have introduced varying outreach models of care, including hospital-in-the-home, hospital-in-the-nursing-home, medical assessment teams, and chronic disease management programs. Most have had some success, but their lack of efficiency and funding, and duplication of other community services require review.

Advance care planning for older people is also essential, but most patients in nursing homes and other residential care facilities do not have an explicit care plan.12 Even when there is a care plan, it is often not followed because of the lack of coordination between treatment agencies, especially after hours.

A fundamental feature shared by all these programs is a lack of sustained funding and of coordination with existing infrastructure.

The ED has a critical role to play in reducing demand for hospital beds. Availability of senior decision-making capacity 24 hours per day reduces demand for beds and improves patient safety.13 The provision of short-stay beds for observation over a few hours and more comprehensive testing and consultation further reduces the need for hospital admission.14 Research to develop safe, accelerated protocols for chest pain, minor head injury, abdominal pain and other common conditions has shown major improvements in safety and speed of decision making.14,15 Despite this, few standardised approaches to these common clinical conditions have been adopted in Australia. Standardisation of processes has been shown to improve patient safety,16 and in other industries has improved efficiency and reduced error through techniques such as “lean thinking”.17

It is essential for EDs to have sufficient capacity to manage patients according to standard protocols. The Australasian College for Emergency Medicine has promulgated standard guidelines for EDs.18 Expanding ED capacity beyond this will not decrease overcrowding, as it is philosophically similar to building a car park to manage the queue at a fast-food facility.

The ward discharge process is an important element in utilising hospital beds efficiently. Discharging patients a few hours earlier can free ED space for the expected peak of admissions in the early afternoon. Modifying the conduct of inpatient ward rounds, delegating decision making to ward nurses (event-based discharge), plus innovative use of the transit lounge, and use of unit coordinators to facilitate pharmacy, outpatient allied health and community services, could all help. Specific programs, such as the Post Acute Care Program in Victoria, have played a major role in attempting to coordinate community services after discharge, although coordination between acute and community services has been problematic.21

Discharging patients before midday and balancing demand with availability of allied health and other services (eg, physiotherapy) across the whole week are important.22

Changes to family structure and the obligation of families to support family members when they are incapacitated have had a major impact on public hospitals. GPs have also significantly changed their role, with a funding model that supports office consultations of less than 20 minutes, and not coordination of care for patients who require complex interventions outside the office environment. A focus on work–life balance for health professionals has also seen the withdrawal of after-hours support.

Community-based care is provided by multiple agencies involving different tiers of government. This care is frequently uncoordinated and often breaks down because of this. When community-based care breaks down, or is insufficient, patients have no alternative other than to present to the acute hospital sector via the ED. This is inefficient, often results in prolonged hospital stays, and is bad for the wellbeing of patients and their families.

There are continued attempts to improve access to GPs by developing after-hours, collocated and “super” clinics for general practice patients. Although access to ambulatory GP services is an important component of the health system, it does not greatly influence access to inpatient beds.28,29 A more important role for GPs in helping prevent hospital overcrowding is to provide care for complex patients in the home or residential care settings, thus avoiding their transport to hospital and possible inpatient admission. Present funding arrangements make the provision of these services unprofitable for GPs.

The national roll-out of nurse-on-call services has improved access to telephone advice. However, there is no evidence that these reduce demand for emergency services, and in fact there is significant evidence to the contrary.30,31

In the present crisis, ambulance diversion is used in most capital cities as a means of controlling demand. This should be seen as a tool for managing disasters, not for routine demand management.