Improving Admitted National Emergency Access Targets (NEAT) Performance

Summary

A four-bed Emergency Medicine Unit (EMU) is planned for the ED of Orange Health Service, to admit selected patients with conditions that can be dealt with in less than 24 hours but don’t require high-level nursing care or monitoring. This will avoid referrals, formal admission and registrar review, ensuring rapid transfer home after a short stay. Patients with certain conditions will be admitted to the EMU on specific pathways to ensure compliance, avoid bed block and enable nurse-led transfer of care. 

Aim

To improve performance figures for admitted National Emergency Access Targets (NEAT) to more than 50% within six months.

Benefits

• Increased access to quality care and timely treatment.
  
• Improved access to the Emergency Department (ED) to increase availability of nursing staff and space for new patients.
  
• The medical team avoids sending patients through the system unnecessarily and can provide efficient transfer of care with lowest possible length of stay.
  
• The patient can be sent home as soon as possible and only get admitted when necessary.

Project Status

Project dates: May 2014 to November 2015 

Project status: Pre-implementation - planning for the initiative is well underway. Clinician/Consumer consultation has occurred.

Background 

In October 2009, a four-hour NEAT target was introduced in Australia, based on similar initiatives in the English National Health Service (NHS), with the aim of reducing ED overcrowding and bed blocking. 

It is recognised that patients who have been admitted to hospital but remain in the ED because there is no hospital bed available, face higher mortality and morbidity rates. This access block also reduces ED efficiency as well as quality of care for ED patients. A four-hour rule has shown to reduce this access block in both England and Australia, resulting in reduced mortality and morbidity. 

Improvements in the flow of patients who are discharged from the ED at Orange Health Service has resulted in more than 90% of patients leaving the department within four hours. However, data has shown that those who are admitted are still being access blocked due to delays of registrar review, or no access to inpatient beds due to delayed discharges of existing patients.

In June 2013, the overall NEAT performance of Orange Health Service was 76%, with only 36% admitted patients leaving the ED within four hours. There were 442 patients in the preceding 12 months that waited in the ED for more than 24 hours (out of 7693 admissions). This project aims to address the delays experienced by admitted patients, by creating an EMU to reduce the number of patients needing medical review and a formal medical bed.

Implementation

• Planning of the EMU site is underway.
  
• Liaison with relevant stakeholders to implement other solutions including hospital in the home, ambulatory care, avoidable admissions, discharge notices, daily rounding, discharge planning, multidisciplinary team case management, timely discharge and transfer of care summaries, and a handover tool.
  
• Adjustment of nursing staff shifts to ensure there is sufficient nursing staff to manage the unit 24/7.
  
• Planned advertisement of Fellow of Australasian College for Emergency Medicine (FACEM) posts, enabling senior cover of the EMU to ensure initiative is safe and sustainable.
  

Partnerships

• Clinical Excellence Commission
  
• NSW Health Whole of Hospital Program
  
• ACI Centre for Healthcare Redesign
  

Implementation sites

Orange Health Service, Bloomfield Campus 

Results 

At the end of 2014, overall NEAT performance was 81% with most improvement resulting from inpatient NEAT performance. Once the EMU is open we will monitor: 

• numbers admitted and subsequently admitted to ward
  
• Medical Emergency Team (MET) calls to EMU
  
• NEAT data for admitted patients
  
• pathway adherence.
  

Lessons Learnt 

To date, senior engagement and discussions with stakeholders has been vital for improving patient results.

Resources

• Dr Sally McCarthy. 2014. Emergency Department Short Stay Unit (EDSSU) also known as Emergency Medicine Unit (EMU): Policy and operational features [presentation].
  
• NSW Ministry of Health. 2014. Emergency Department Short Stay Units Policy Directive PD2014_040.
  
• Emergency Care Institute. 2014. National Emergency Access Target.

Further reading 

• Geelhoed G, de Klerk N. Emergency Department Overcrowding, mortality and the 4-hour rule in Western Australia. Med J Aust 2012; 196 (2): 122-126.
  
• The College of Emergency Medicine. The Way Ahead 2008-2012: Strategy and guidance for Emergency Medicine in the United Kingdom and the Republic of Ireland. December 2008.
  
• Department of Health [UK]. Clinical Exceptions to the 4-hour Emergency Care Target. December 2003.
  
• Department of Health [UK]. Transforming Emergency Care in England – A Report by Professor Sir George Alberti. 2004.
  
• Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Medical Journal of Australia 2006; 184: 213-216.
  
• Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Medical Journal of Australia 2006; 184: 208-212.
  
• Forero R, Hillman K, McCarthy S, Fatovich D, Joseph A, Richardson DW. Access block and Emergency Department Overcrowding. Emergency Medicine Australasia 2010; 22: 119-135.
  

Contact

Dr Colin Dibble
Director of Emergency Medicine
Orange Health Service
Western NSW Local Health District
Phone: 02 6369 3861
Email: Colin.Dibble@health.nsw.gov.au