A safe approach to emergency treatment performance

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Overcrowding and prolonged length of stay in the emergency department (ED) for admitted patients is associated with poorer outcomes. Access block has also resulted in non-admitted patients remaining in the ED for longer than necessary, reducing access for new patients presenting at the ED and delaying ambulance offloads.

Principles

  • Use ED attendance and performance data and redesign methodology to support performance improvement where necessary. Work to understand patterns of arrival, discharge, when and why waits occur and to reduce system variability. This may include analysing ED, hospital occupancy, elective waiting lists and outcome data.
  • Improving performance is a shared whole of hospital responsibility.
  • Executive engagement and leadership are essential at both hospital and local health district level.
  • A large amount of the change required may need to occur in the health system rather than in the ED.
  • EDs can benefit from reviewing existing processes and models of care for efficiency.

Top tips

Consider these points to support the delivery of timely access to ED care.

  • Quality of care should be the driver of change with time as one component. Don’t work to achieve the target, work to improve the patient’s whole experience.
  • At all times patient safety is paramount.
  • Involve consumers in system redesign and improvement.
  • Patient flow is crucial. For example, it was found in the United Kingdom that the greatest variability in the system is with elective admissions not emergency admissions.
  • Form committees and working parties that reflect whole of hospital ownership of the target, i.e. executive, surgery, patient flow, medicine, radiology, pathology and ED.
  • First meetings should:
    • Review current performance of the hospital with respect to ETP.
    • Identify challenging areas in the hospital, the ED and other units. These could include access to surgical consult, diagnostics in ED, access to intensive care units or high dependency beds, access to imaging within the hospital, quantity and location of unit outlier patients, in-hospital and discharge planning and options for out of hospital care, such as outpatient departments, hospital in the home, enhanced outreach to residential care facilities and models of care.
    • Determine what information is required to support identification and monitoring of challenges.
  • Admitted patients from ED may be smaller numbers than those discharged, but creating available beds within the hospital within a timely manner is where the greatest challenge lies. This improves access for new ED patients.
  • Patient transfers need to be reviewed and streamlined with both the referring and receiving hospitals agreeing process and communication.
  • The role that a medical assessment unit, surgical assessment unit, clinical decision unit or community assessment unit can play should be explored to determine if appropriate for the facility.

What the ED can do

ETP is a whole system target and the focus should not be on the ED alone to achieve and implement this. EDs have a crucial role to play and there will always be scope for improvements within the ED environment.

These are some of areas that facilities can focus on.

Staff

  • Match staffing levels to arrival times and peak activity.
  • Consider the use of a navigator role. A navigator role aims to help facilitate the patient journey through the ED to ensure that it is as efficient and timely as possible, taking action when this is not the case. The role also aims to support staff delivering care.
  • Involve staff in the process from the outset. Staff input is crucial in identifying how and what can be improved. Consider asking staff the top three barriers for patients moving through the ED. Listen to their suggestions.
  • Maximise the use of all clinicians in the ED. Look at skill mix and task allocation so that all providers are working according to the top of their scope of practice.
  • Introduce support roles in the ED to transfer non-clinical tasks from clinicians as appropriate.

Tests

  • Carefully consider the ordering of diagnostic tests to ensure they are always appropriate. If a result is not vital to a decision being made, do not wait for it.
  • Have agreed turnaround times for investigations, tests and pathology to reflect clinical urgency.
  • Consider exploring enhanced access to radiology and pathology, including point of care testing, with agreement on who can request according to protocols.

Patient flow

  • Investigate admitting rights for designated medical staff in the ED.
  • Use models of care that are appropriate for case mix, complexity and activity in your department, such as fast track, early treatment zone or senior assessment.
  • Focus on the identified delays in the patient journey in the ED and use a patient journey template to assist this:
    • Waiting to be seen
    • Waiting for diagnostics and procedures
    • Waiting for specialist review
    • Waiting for senior clinical decision making and a plan of care
    • Other delays relating to clerical and domestic roles may also impact on time
    • Existing models of care should be reviewed for efficiency
    • Ways to avoid admission and attendance at the ED
    • Issues around workforce skills mix and capacity need also be noted.
  • Have a balanced scorecard to help monitor progress that includes key performance indicators for whole hospital, e.g. discharges before 11am, length of stay, etc.
  • Have staged targets within the four hours to help with the whole system to respond in a timely manner, such as referring the patient to the inpatient team at X hours.
  • Determine how referrals to the admitting team work and the process after acceptance to ensure timely departure from the ED. Audit and feedback on this.

We recognise that this is not a comprehensive list and would love to hear about particular initiatives or ways you have found to improve efficiencies within your ED. Please email us at aci-ecis@health.nsw.gov.au with your thoughts and suggestions.

Performance measurement timeline

In NSW the focus of performance measurement followed the international and national experience, evidence and mandates.

  • 2000

    National Health Service (NHS) in the United Kingdom inplements four-hour rule target

  • 2009

    Western Australia introduces four-hour rule target

  • 2012

    Australian government creates National Emergency Access Target (NEAT)

    NSW Health starts Whole of Hospital program

  • 2015

    Whole of Hospital becomes Whole of Health program in NSW

Resources

Whole of health program
Overview and resources to support the Ministry of Health program.
NSW Ministry of Health

Patient flow program
This NSW Health program provides staff with the knowledge and tools to minimise delays in patients moving through care.
NSW Ministry of Health

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