Time to end ED-ward divide

EMERGENCY department directors want an overhaul of the way patients are admitted to Australian hospitals, including an end to the us-and-them mentality with the ward.

Removing nurse triage, admitting more patients directly to the wards and increasing the role of generalists in acute care are some of the suggestions made by a team of ED experts writing in the latest MJA. (1)

Associate Professor Harvey Newnham, director of emergency and acute medicine at Alfred Health, Melbourne, led an investigative tour of emergency hospitals in the US and UK to gain an insight into innovative patient flow strategies.

Several of the overseas hospitals had scrapped the use of formal nurse triage in EDs. Instead, patients were assessed “within minutes” by a staff member capable of initiating their care.

There was also more reliance on full-time generalists, and many sites had given senior ED staff authority to directly admit patients to the wards without prior approval from an inpatient receiving team.

Dr Newnham told MJA InSight that that the main barrier in the Australian setting was the need for increased cooperation between the wards and the ED.

“The biggest issue is that it’s the ED against the wards … there’s a need for closer integration”, he said.

As patients increasingly presented with comorbid conditions, EDs also faced the issue of finding the most suitable inpatient unit.

“There’s often a situation where ED doctors are left with patients because they can’t get an inpatient unit to take them … it’s a fight between ED and inpatient doctors. We really need to sort that out”, he said.

Dr Newnham said the Alfred had begun working towards implementing many of the suggestions in the MJA article, although he acknowledged that it would involve some attitudinal change.

Professor Gary Geelhoed, director of the ED at the Princess Margaret Hospital for Children in Perth, agreed with many of the suggestions in Dr Newnham’s paper.

“A lot of what they’re wanting is common sense. It’s about stopping the stupid divide, which makes the ED the dumping ground, as it were. If someone needs to be admitted, send them to the ward”, he told MJA InSight.

Professor Geelhoed coauthored a study in the latest MJA, reporting the first data on how implementing the 4-hour rule — which aims to have 90% of ED patients discharged or admitted within 4 hours — had affected patient mortality in WA. (2)

The researchers found that the mortality rate had decreased significantly, by 13%, equating to 80 fewer deaths, in the three Perth tertiary hospitals in the year after the rule was introduced.

Professor Geelhoed said although hospitals needed to develop individual strategies to achieve the 4-hour rule, the whole hospital had to take responsibility, not just the ED.

“The nub is that for so long we’ve had the absolute paradox, that while the rest of the hospital is allowed to put up the ‘full’ sign, you have patients who are dying in the ED because it’s so overcrowded”, he said.

A related editorial said the WA research was “an encouraging first report” which added to the evidence for a causal relationship between overcrowding and mortality. (3)

However, it singled out some methodological issues with the research, such as the lack of age-specific data or matched controls.

“As National Emergency Access Targets are rolled out in 2012, researchers look forward to large, well controlled examinations of all the patient outcomes”, the editorial said.

- Sophie McNamara

1. MJA 2012; 196: 101- 103
2. MJA 2012; 196: 122-126
3. MJA 2012; 196: 126-127

Posted 6 February 2012

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