Sally McCarthy

Access Block and Emergency Department Overcrowding

Access block affecting the emergency department (ED), also known as boarding in the United States and Canada, can be described as a phenomenon comprising almost all the challenges in the world of modern EDs. We use the analogy of parallel universes to illustrate both the complexity and the severity of the problem. In the world of physics, many attempts have been made to create a mathematical solution that can answer the more basic questions about physical phenomena in the universe. This has been known as ‘Theory of Everything’. Albert Einstein spent 30 years of his life trying to solve this ‘Theory of Everything’, but failed [1].

Access block and ED overcrowding.

Prospective and retrospective access block hospital intervention studies from 1998 to 2008 were reviewed to assess the evidence for interventions around access block and ED overcrowding, including over 220 documents reported in Medline and data extracted from The State of our Public Hospitals Reports. There is an estimated 20–30% increased mortality rate due to access block and ED overcrowding. The main causes are major increases in hospital admissions and ED presentations, with almost no increase in the capacity of hospitals to meet this demand. The rate of available beds in Australia reduced from 2.6 beds per 1000 (1998–1999) to 2.4 beds per 1000 (2002–2007) in 2002, and has remained steady at between 2.5–2.6 beds per 1000. In the same period, the number of ED visits increased over 77% from 3.8 million to 6.74 million. Similarly, the number of public hospital admissions increased at an average rate of 3.4% per year from 3.7 to 4.7 million. Compared with 1998–1999 rates, the number of available beds in 2006–2007 is thus similar (2.65 vs 2.6 beds per 1000), but the number of ED presentations has almost doubled. All patient groups are affected by access block. Access block interventions may temporarily reduce some of the symptoms of access block, but many measures are not sustainable. The root cause of the problem will remain unless hospital capacity is addressed in an integrated approach at both national and state levels.

Quantifying the proportion of general practice and low-acuity patients in the emergency department

Objective: To accurately estimate the proportion of patients presenting to the emergency department (ED) who may have been suitable to be seen in general practice.

A Literature Review on Care at the End-of-Life in the Emergency Department.

The hospitalisation and management of patients at the end-of-life by emergency medical services is presenting a challenge to our society as the majority of people approaching death explicitly state that they want to die at home and the transition from acute care to palliation is difficult. In addition, the escalating costs of providing care at the end-of-life in acute hospitals are unsustainable. Hospitals in general and emergency departments in particular cannot always provide the best care for patients approaching end-of-life. The main objectives of this paper are to review the existing literature in order to assess the evidence for managing patients dying in the emergency department, and to identify areas of improvement such as supporting different models of care and evaluating those models with health services research. The paper identified six main areas where there is lack of research and/or suboptimal policy implementation. These include uncertainty of treatment in the emergency department; quality of life issues, costs, ethical and social issues, interaction between ED and other health services, and strategies for out of hospital care. The paper concludes with some areas for policy development and future research.

Determining the true burden of general practice patients in the emergency department: Getting closer

Yusuf Nagree, Andrew Gosbell, Sally McCarthy, Katie Moore and David Mountain Emergency, Fremantle Hospital, Fremantle, Western Australia, Australia, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Nedlands, Western Australia, Australia, Australasian College for Emergency Medicine, West Melbourne, Victoria, Australia, Agency for Clinical Innovation, Emergency Care Institute NSW, Sydney, New South Wales, Australia, and Emergency Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia

Determining the true burden of general practice patients in the emergency department: the need for robust methodology.

Yusuf Nagree, David Mountain, Peter Cameron, Daniel Fatovich and Sally McCarthy Emergency Medicine, Fremantle Hospital, Fremantle, University of Western Australia, Academic Emergency Medicine, University of Western Australia and Emergency Medicine Sir Charles Gairdner Hospital, Emergency Medicine, Royal Perth Hospital and University of Western Australia, Centre for Clinical Research in Emergency Medicine, Western Australia Institute for Medical Research, Nedlands Western Australia, NSW Emergency Care Institute, Sydney, New South Wales, The Alfred Emergency and Trauma Centre, Monash University, and Australasian College for Emergency Medicine, Melbourne, Victoria, Australia

Emergency airway management in Australian and New Zealand emergency departments: A multicentre descriptive study of 3710 emergency intubations

The aim of this study was to describe the practice of endotracheal intubation across a range of Australasian EDs.

Impact of the Four-Hour Rule in Western Australian hospitals: Trend analysis of a large record linkage study 2002-2013

Background In 2009, the Western Australian (WA) Government introduced the Four-Hour Rule (FHR) program. The policy stated that most patients presenting to Emergency Departments (EDs) were to be seen and either admitted, transferred, or discharged within 4 hours. This study utilised de-identified data from five participating hospitals, before and after FHR implementation, to assess the impact of the FHR on several areas of ED functioning. Methods A state (WA) population-based intervention study design, using longitudinal data obtained from administrative health databases via record linkage methodology, and interrupted time series analysis technique. Findings There were 3,214,802 ED presentations, corresponding to 1,203,513 ED patients. After the FHR implementation, access block for patients admitted through ED for all five sites showed a significant reduction of up to 13.2% (Rate Ratio 0.868, 95%CI 0.814, 0.925) per quarter. Rate of ED attendances for most hospitals continued to rise throughout the entire study period and were unaffected by the FHR, except for one hospital. Pattern of change in ED re-attendance rate post-FHR was similar to pre-FHR, but the trend reduced for two hospitals. ED occupancy was reduced by 6.2% per quarter post-FHR for the most ‘crowded’ ED. ED length of stay and ED efficiency improved in four hospitals and deteriorated in one hospital. Time to being seen by ED clinician and Did-Not-Wait rate improved for some hospitals. Admission rates in post-FHR increased, by up to 1% per quarter, for two hospitals where the pre-FHR trend was decreasing. Conclusions The FHR had a consistent effect on ‘flow’ measures: significantly reducing ED overcrowding and access block and enhancing ED efficiency. Time-based outcome measures mostly improved with the FHR. There is some evidence of increased ED attendance, but no evidence of increased ED re-attendance. Effects on patient disposition status were mixed. Overall, this reflects the value of investing resources into the ED/hospital system to improve efficiency and patient experience. Further research is required to illuminate the exact mechanisms of the effects of FHR on the ED and hospital functioning across Australia.

ACEM position on a time‐based access target in Australian and New Zealand EDs

Access block and subsequent overcrowding have been affecting Australasian EDs since the late 1980s, and have been increasingly and extensively reported as problems in the USA, Canadian and UK health systems over the same period. In April 2004, the ACEM published a paper titled ‘Access Block and Overcrowding in Emergency Departments’ which summarized the then already comprehensive evidence of the causes and consequences of ED overcrowding. The present paper reported ‘There is still no national focus or leadership to deal with this crisis that is affecting hospitals and individuals around the country. It is essential that the issue of emergency department overcrowding and access block becomes the focus of national attention and a priority within the health system’. The paper proposed that ‘A new approach to hospital funding that rewards achievement rather than failure i.e. a carrot and stick approach is needed’.

Application of four-dimension criteria to assess rigour of qualitative research in emergency medicine

BackgroundThe main objective of this methodological manuscript was to illustrate the role of using qualitative research in emergency settings. We outline rigorous criteria applied to a qualitative study assessing perceptions and experiences of staff working in Australian emergency departments.MethodsWe used an integrated mixed-methodology framework to identify different perspectives and experiences of emergency department staff during the implementation of a time target government policy. The qualitative study comprised interviews from 119 participants across 16 hospitals. The interviews were conducted in 2015–2016 and the data were managed using NVivo version 11. We conducted the analysis in three stages, namely: conceptual framework, comparison and contrast and hypothesis development. We concluded with the implementation of the four-dimension criteria (credibility, dependability, confirmability and transferability) to assess the robustness of the study,ResultsWe adapted four-dimension criteria to assess the rigour of a large-scale qualitative research in the emergency department context. The criteria comprised strategies such as building the research team; preparing data collection guidelines; defining and obtaining adequate participation; reaching data saturation and ensuring high levels of consistency and inter-coder agreement.ConclusionBased on the findings, the proposed framework satisfied the four-dimension criteria and generated potential qualitative research applications to emergency medicine research. We have added a methodological contribution to the ongoing debate about rigour in qualitative research which we hope will guide future studies in this topic in emergency care research. It also provided recommendations for conducting future mixed-methods studies. Future papers on this series will use the results from qualitative data and the empirical findings from longitudinal data linkage to further identify factors associated with ED performance; they will be reported separately.