Emergency demand access block and patient safety: A call for national leadership

Abstract

There is increasing pressure on ED caused by a relentless increase in ED attendances and rising emergency admissions. This is compounded by the challenge of reduced inpatient bed access. In this issue of Emergency Medicine Australasia, Richardson and colleagues confirm that access block is worsening, having increased nationally by an average of 27% over the 4 years to September 2008. Of interest is the reported improvement in patient flow attributed to the ‘patient journey’ project, despite continuing rising demand throughout this time period in New South Wales. It is not clear whether this has been sustained. Richardson et al. conclude that hospitals have possibly reached saturation point regarding efficiency in managing patient flow. These findings will be no surprise to ED clinical staff, who have consistently stated that the problem extends beyond the walls of individual hospitals. The causes for this access block are known and solutions are evident. It is now time that leadership is shown at both clinical and policy levels to stop the problem. The Australasian College for Emergency Medicine (ACEM) defines an excessive wait for an inpatient bed as greater than 8 h, the UK defines it as 4 h and Western Australia has followed suit. However, in the context of comparison within and between countries, it is pertinent to also consider how access block is defined and measured. For example, ACEM includes the time of arrival to departure from the ED in their calculation, whereas New South Wales Health has excluded ED waiting time, commencing their computation at the time the patient is attended to by a doctor. This latter measure fails to include time delay attributable to hold-up in processes associated with ED overcrowding, and therefore underestimates the overall delay experienced by the patient. The time is also subject to manipulation. There are many ways of measuring access block, including total patient time in ED, time from medical assessment to departure time and collective ‘total access block time’. It is essential for benchmarking to occur that all states collect data in a standardized fashion, which can be verified by outside agencies.