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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
I dont think I missed the point. Admitting appropriately quickly is correct, ie sick patients need treatment not faffing around in ED with a third person taking the history, admitting inappropriately (ie, not actually getting the patients accepted to the correct unit) is potentially fatal and mostly incredibly time consuming.
The model does need to change but just bunging everyone on a ward at 4 hours won’t change anything.
I suggest that the WA study improvements were related to the fact they were participating in the study, and ED consultants would have tried hard. In addition mortality is a pretty feeble metric ie, it’s very coarse.
Be interesting to look at costs per admission, time spent by inpatient teams etc.
Apparently the divide between them and us (wards and ED) continues.
I’m all for having patients properly worked up, assessed, treatments implemented in a timely manner, patients receiving the undivided attention of the treating staff, and then being safely either discharged with all referrals in-place or transferred to the ward into the welcoming arms of the ward team who have been liaising with the ED staff to achieve the best outcomes for our patient. Sadly this doesn’t happen. The pressure of increased presentations, increased acuities pressures staff to move continually between different patients to try to facilitate that longitudinal flow so that we can create another empty bed for the next patient who is just as sick but is still waiting to be seen due to lack of space. As mentioned previously we have multiple referrals from GPs accompanied by “a letter” thanking us for taking over care and suggesting all the things that should be done (in fact could have been done in the outpatient setting) and having given the patient the clear impression that when they arrive there will be a bed and a waiting medical team to commence all their treatment. Then of course we have the patient whose GP has liaised with the accepting specialist, who then suggests sending the patient for admission through the ED as they are too busy to organise a bed and to do the admission work up for that patient directly on the ward.
I get embarrassed when we send patients to the ward who have not been adequately worked up and then expect the ward RMO to finish the admission due to pressure for beds in the ED.
I empathise with the JMOs who are under the gun to assess, diagnose and come up with a management plan so that we maintain the throughput. I feel for the SMOs who are continually interrupted as junior staff seek out them for advice. I take my hat off to the triage nurses who deal with multiple patients who don’t understand that “first in first seen” doesn’t apply in the ED. Is this post a rant. Yes it is and thank you for listening 🙂
The 4hr rule implies that EDs are somehow spending too long working up patients to decide either to admit or discharge. It needs to be reiterated that it is a shared problem with the wards/units and cannot be solved merely by targeting the ED to increase efficiency. If there isn’t a bed to send them to they will stay in ED no matter how quickly and efficiently we do our part. I agree that patients who are ready for admission are at greater risk. The ED mindset is that they are no longer acute – lets move on to the next patient and care (both medical and nursing) then suffers. Sue you are right but so is JD. It is time that wards were also put under the same microscope currently being used to examine practices in ED.
JD’s response illustrates the title of this post well – “Time to End the ED-Ward Divide”. Perhaps JD is not aware that ED people have been saying for years that ACCESS BLOCK IS A WHOLE-OF-HOSPITAL PROBLEM. Despite this, it appears that JD and colleagues have done very little (if anything) to try to improve their work practices in the wards. On the contrary, EDs have had to turn themselves inside out and back-to-front to gain efficiencies. The models of care developed in EDs, such as standardised triage systems, fast-track streaming, front-loaded allied health consults, short-stay wards – were not imposed on EDs by edict. They were developed by ED staff as a way of coping with increasing load. What have JD and colleagues done in the meantime to improve work practices on inpatient wards? Do any inpatient consultants work shift work, as ED consultants do (this was generated from within the specialty, in response to need – not imposed “from above”). Finally, in terms of how the WA data has been interpreted: I agree that there is no direct evidence that the better flow alone saved lives. What is important to note, however, is that it clearly did not cost lives. To all those people who want patients to stay more than 4 hours on a trolley in ED, and who dramatically threaten that sending them to the ward means that “patients will die” – there is no evidence in WA that they did. In fact, to the contrary. If JD and colleagues want to wait for the detailed analysis before re-thinking the way your work is done, the world will pass you by.
With due respect to Dr Ieraci, the point I make is about the causal conclusion being drawn from the data and the 4h-rule; an association is not proof of a causal relationship (see http://www.aoec.org/CEEM/methods/emory2.html. Also, I don’t pretend to be across all the “evidence”, but if it is uncontrolled, as it is in the WA study in question, then the data may be subject to observer bias. So, it is not the volume of “evidence” but the quality that is important.
Hence, what I am saying is that it is not the 4h-rule that may be improving mortality (if this is indeed real), but better bed access and staff:patient ratios that might be a consequence of the 4h-rule. In effect, Dr Ieraci is saying the same thing, that the latter 2 issues are what is important. So then, what is going to be done as more patients present to ED? Introduce a 2h-rule in order to clear the place for more patients? There may be some efficiencies to be gained such as abolishing triage nurses, but in the end it is a question of adequate resourcing, not only of ED but of the entire hospital.
Dr Ieraci refers to my “lack of doubt” but I am also certain that she is not suggesting that poor workup, management plans, and intial and ongoing treatment have a neutral or beneficial effect on mortality in acutely ill patients – some things in medicine are basic and don’t need to be subjected to trials. The question is whether you can do these things as effectively on a sick, complex patient on a “low-dependency” ward as you can in ED. I know that I can accomplish a lot more in “half a working-day” in ED than on these wards.
Unlike the “minute”, detailed analysis given to politically-sensitive EDs, the wards have been relatively neglected in recent years. With the imminent introduction of the 4h-rule, I see no sign of extra resources being given to wards, no increase in after-hours staffing (junior or senior), no generalists, nothing. Just the magic 4h bullet.
Every intervention in medicine has side-effects and the MJA editorial on WA study states, “We must interpret this research cautiously, and encourage appraisal and debate.” The potential side-effects of the 4h-rule unsupported by a global hospital approach are unknown and a real concern.
“JD” – you say “I have no doubt” – can you explain the basis of your conclusions? You may not realise that, in contrast to ward environments, ED activity is analysed minutely. There is a lot of data, research and review evidence so that people don’t have to make individual judgments – we can look to the evidence. As someone who works within the ED system and knows the data and issues intimately, it is less likely that I am misinterpeting the data than it is that casual commentators are misinterpreting it. And, the evidence DOES show that access block costs lives. Acess block is not just about how long a patient spends in ED, it is the time from the end of ED care to ward transfer. Of course patients should be stabilised as far as practicable before leaving ED, but sometimes this is just not possible. Four hours is not a short “shoot through” ED – for many people, it is half a working day. Finally, it is true that patients will benefit from a whole of hospital approach – ED people have been calling for that for many years. IF JD is seeing “no sign of this” – then this is a symptom of a relatively fixed inpatient system that is resistent to change. Why not start the change, JD?
What kills patients in ED, I have no doubt, is being poorly worked-up, not having a correct initial diagnosis, not having a good management plan and vital initial treatment started and continued, not how long they spent in ED. In fact, time spent doing these things is time well spent, no matter how long it takes; to set an arbitrary limit is to deny the complexity of some patients, and the intrinsic chaos of hospital life to which we are constantly trying to bring some degree of order. Dr Ieraci (not intentionally, I think) is not interpreting the data correctly – what it shows (flawed as the study may be) is that overcrowding/under-staffing in ED is detrimental to the patients, making it harder to bring order to a particularly chaotic hospital department.
The problem is that hastily moving patients to understaffed wards, where investigations may be less accessible, and the staff more junior, can have serious consequences. These hasty moves might also be a consequence of overcrowded/under-staffed EDs.
This article points out that the *entire* hospital needs to be involved as part of a global approach with better staffing and the ability to manage and investigate acutely ill patients, if a 4 hour rule is to be introduced. I see no sign of this; it’s as though clearing ED will be the magic bullet to cure all that ails the health system – bizarre.
In Sydney, general medicine has essentially disappeared from teaching hospitals where subspeciality empires have taken over. Where are the generalists going to train? Rotating through a few subspecialities where a single-organ approach predominates with consults to other subspecialities with similar approaches to patients is not how to train general physicians.
As John Stokes says, “Mostly we need more common sense”. Presentation and admission to hospital should be based on what the patient needs – not what inpatient teams choose to accept, or which funding source is stretched the most. “Gas Reg”, as a Reg, has a very limited view, and clearly doesn’t recall how hospitals worked before emergency medicine developed. The combination of emergency medicine, increasing demand and a decreasing bed base meant that people having been dying due to ED overcrowding. Time-based measures represent one area of strategies to improve this, and must be implemented with clinical appropriateness. Having said that, 4 hours is a relatively long time – it is not optimal for critically ill patients to remain in ED for this length of time, while others are entering through the front door. People who work in ICU have a closed system with a front door, which is tightly controlled. EDs have open front doors, and increasing demand. Perhaps Gas Reg should spend some time training in an ED to learn how to work with an uncontrolled workload.
I find the comments posted so far sum up the inherent problems: Pressure from admin/government to push patients out of ED on a time basis from arrival (not time seen or more appropriately patients rapidly going to ward once properly sorted – yes, this includes notifying teams); ongoing friction and lack of clarity between ward and ED staff over “ownership” of patients who have been accepted (and often seen) by a team but still awaiting a ward bed; increasing subspecialisation in the setting of an ageing population with an increasing burden of chronic multisystem disease; increasing ED presentations with decreasing beds per capita; wards that are not set up/equipped for procedures requiring patients to stay in ED (try telling that to admin as a reason for a patient breaching the 4 hour rule). Understaffed teams trying to cover clinics, wards and ED admissions… As a person who works in both ED and ICU I have seen both sides of poor patient outcomes and have a ward staff story to match every bad one about ED practices. The point of the article is that the system is flawed and is looking at ways of improving it, something that is desperately needed as illustrated by the comments
You are only describing one half of the problem. In my observation (a decade in ‘corporate’ GP practice) the typical GP referral to a public hospital (emergency or outpatient clinic) is a slough. And general practice has become so de-skilled that GPs do not even know it. A single vague sentence of ‘indication’, surrounded by a template generated, commonly inchoate mass of ‘clinical information’, generated by the medical practice program, takes 15 seconds to generate, indeed more time to print out. Either no past pathology – or buckets full. Give it to the patient, tell them to take it to ER, and you can move to your next patient. The ability to summarize a case in a paragraph is a lost art form. (Although in Australia it was never taught.)
Dump that information on a triage nurse and the patient WILL sit in the ER waiting room for 6 hours.
The concept of a ‘triage nurse’ is – in the historical use of the word – a contradiction in terms. In Napoleon’s field hospitals, a senior surgeon made a quick assessment of incoming casualties. Those who were going to die were sent in one direction, those for whom a surgical procedure would benefit went in a second direction. The ‘walking wounded’ were sent in a third direction. The medical officer who made these decisions was expected to be experienced and skilled.
It is that kind of expertise you need as the first hospital contact with the sick and injured. But the ‘hospital generalist’ will need to be re-invented.
We have come full circle and have finally realised that some patients are better off in the ward and should never have gone via ED, and when we have a saner system patients who truly need ED will get their care started there and the others will more quickly get to the wards. In the end the sub-specialisation of medicine has helped a few patients but lead to poorer care for many others. Sub-specialisation should be accepted, as should the need for the appointment of, and the remuneration for good generalists. Mostly we need more common sense.
EDs are becoming increasingly more interested in getting patients out of their unit (and responsibility) than in assessing and treating them. In the last few weeks, I have taken multiple calls (in ICU) to patients in resus ED cubicles where the ED doctors have refused to provide basic resuscitation measures because “the patient has already been admitted to a unit”. They have left hypotensive, unconscious and hypoxic patients all untreated.
At the 4 hospitals where I have worked where ED doctors have forced admitting rights, patients have continuously been sent to the wards without basic investigation and treatment, and often haemodynamically unstable. I had a patient die an hour after being sent to the ward without even a courtesy call to the home team or covering intern.
EDs need more oversight, not more unilateral power to abuse!
Until EDs are staffed with competent, senior and experienced people, there will always be an issue with the optimal patient management.
I don’t believe that either MAU’s or generalists are the answer. Someone with an AMI or type 2 respiratory failure does not need a generalist. They need a competent, urgent assessment and then be triaged to the appropriate team.
The main problem is with patients with complex problems, multiple co-morbidities and then finding the most suitable team to manage them.
Most of these patients are elderly and there already exists a generalist to care for them, namely the geriatrician.
I agree with the comment that investigations are best performed in the ED. Once results are in, the correct team can be notified.
Daman Langguth appears to have missed one of the key findings in this paper – in WA, implementation of the 4-hour target was associated with a LOWER mortality. The allegation that “Admitting patients by ED registrars will lead to deaths on the ward.” is just not supported by the real evidence – we already know that leaving patients for prolonged periods in ED increases mortality (multiple studies have shown this) and now we have evidence that moving stabilised patients out of ED improves mortality. EDs have developed enormously over past decades, while inpatient units have become, if anything, more insular. The return to generalist inpatient medicine would be welcome by both ED staff and patients.
Unwell patients require supervision and management in acute care areas which are well staffed by medical and nursing staff, with the facilities to investigate and care for them. The framework presented by ED staff is generally to remove patients from their dept, but as they lack responsibility for longitudinal care for people who pass through ED they remain unaware of the poor outcomes that can therefore occur.
Unless an entirely new paradigm creating acute care wards inside hospitals (that are properly staffed and resourced) the ED will remain the best place for acute patients who lack management plans. Medical assessment units are popping up in larger hospitals but they are usually ‘prefab’ structures that are really housing areas rather than purpose built acute care facilities.
I see no end to this impasse given resource problems. Acute patients require complex care, and at the moment the only environment we have that is suitable is the ED.
This divide exists in public hospitals, and is related to the demands on junior staff but also their attitude to work. Admitting patients by ED registrars will lead to deaths on the ward. Pts are often misdiagnosed or sent to the easiest team as some teams are harder to contact than others. This happens frequently (or the “I have referred it to you so you need to see them” syndrome).
EDs have attempted to control and takeover all acute medicine,
so some of this is reaping what you sew.
Routine admissions should be seen by inpt teams, but we all know that access to investigations is much easier in ED than from the ward. Really consideration needs to be given to having a medical team on for routine admissions. This used to be done in NZ when I was a student, and worked well with seprate areas of the hospital for booked admissions and for ED.
Perhaps the key to this is increasing the staffing and capability of wards with senior cover and adequate staffing day and night, and including generalists running admission ward areas then designating to subspecialties, rather than the process of early subspecialty referral that leads to much of the angst about destination units for patients- so that ED may take on (regain?) a role of resuscitation of the seriously ill and initial sorting and management of the majority.
Investment in wards and capable generalist acute care hospital staff, rather than expanding EDs, will clear the EDs, make the wards safer and more efficient, and best serve the community.