Access block can be managed

Peter A Cameron, Anthony P Joseph and Sally M McCarthy
Med J Aust 2009; 190 (7): 364-368. || doi: 10.5694/j.1326-5377.2009.tb02449.x
Published online: 6 April 2009

Access block — the inability to access appropriate beds in a timely manner for emergency patients who require inpatient admission — is the greatest single impediment to safe and efficient emergency care in Australia and New Zealand.1-3 Also called “boarding”, it is associated with significant increases in emergency department (ED) waiting times, adverse events, deaths, and hospital length of stay.3 Hospitals cannot function effectively while there is significant access block.3 ED overcrowding is ubiquitous around Australia and New Zealand and, despite considerable efforts by state and federal governments, has worsened over the past few years.3

In this issue of the Journal, the factors that contribute to access block and the problems that result are explored by Richardson and Mountain.4 The underlying cause is an increase in emergency demand, combined with a decrease in stock of acute hospital beds (Box 1). This has been exacerbated by an ageing community with increased chronic illness, a reduction in residential care options in the community, and increasing expectations of quality of care in community facilities. The significant reduction in after-hours general practitioner services for complex emergencies and house calls5 has also had an effect. Casemix payments, which provide a funding incentive for hospitals to perform simple elective surgery rather than manage complex medical emergencies, have exacerbated access problems in both public and private hospitals.

Yet, there are solutions to the problem of access block, which must be adopted if Australia and New Zealand are to continue to benefit from having health systems that are among the best in the world. Here, we discuss potential solutions, as well as common proposals that are not supported by the evidence.

Reducing demand
Out of hospital

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.

In the emergency department

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

Increasing capacity
In the emergency department

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.

In the hospital
Increasing physical bed capacity

The most obvious and important solution to solving the crisis is to increase physical bed capacity. Clearly, acute public hospital bed numbers have decreased by 15%–30% over the past two decades (now 2.6 per 1000 population).3,19 Some of this decrease is appropriate, because of improved treatments for many acute processes (eg, laparoscopic surgery). However, the spectrum of services provided has increased considerably, and many frail patients with complex illnesses are now kept alive because of improved medical treatment (eg, those with malignancy, chronic obstructive airway disease, chronic cardiac failure and renal failure), all requiring increased bed-days.

There are some arguments against a simple increase in bed numbers. Whenever hospitals and jurisdictions have temporarily increased beds, demand has also increased, suggesting “elasticity” in demand. Any increase in capacity must be associated with demand management.

In some cases when jurisdictions have attempted to fund increased beds, staffing restrictions and rigid staffing models have prevented increases in bed numbers despite the available funding. Also, funding has been made available at short notice for short periods, thus making it impossible to “gear up” quickly. It is not only a question of funding — a different staffing model (moving away from nurse ratios and inflexible categorisation of staff) is required, and funding must be sustained. Many nurses are choosing not to work in acute hospitals and aged care facilities, and alternative ways of staffing these beds are needed (eg, with enrolled nurses, physician extenders and technicians).

Improving exit from the hospital

The Australian and New Zealand health systems face national emergencies that threaten the safety of acutely ill patients across both countries. The solutions are evident and require national leadership to develop a coordinated systematic approach before more lives are lost.

There are effective short-term solutions, such as sending admitted patients to a designated ward area until a ward bed becomes available, planning discharges for earlier in the day, and equalising the spread of elective surgery across the week. Longer-term solutions need to include a sustainable increase in available inpatient beds, as well as better coordination of care for chronic and complex illnesses in the community, better end-of-life planning for older people, and more residential accommodation for the ageing population.

2 Solutions to access block and overcrowding

Reducing demand

In the community

In the emergency department

Balancing demand between elective and emergency programs

Increasing capacity

Emergency department processes

Emergency department beds

Ward processes

Ward beds

Improving exit

Ward processes

Community capacity

Monitoring of acute health sector

Non-solutions (unproven to reduce overcrowding)

  • Peter A Cameron1
  • Anthony P Joseph2,3
  • Sally M McCarthy4,5

  • 1 School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC.
  • 2 Royal North Shore Hospital, Sydney, NSW.
  • 3 Faculty of Medicine, University of Sydney, Sydney, NSW.
  • 4 Prince of Wales Hospital, Sydney, NSW.
  • 5 Australasian College for Emergency Medicine, Melbourne, VIC.

Competing interests:

None identified.

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