Time-based Targets Research Articles

Teaching and learning in an era of time-based access targets: Impact of a new model of care on junior medical officers.

Teaching and learning in an era of time-based access targets: Impact of a new model of care on junior medical officers.

International emergency medicine: Past and future

Much has been written about the development of emergency medicine (EM) and its impact on the medical system as a whole. It is still described as ‘new’ and very much seen as a specialty that is evolving, rather than a static domain of knowledge and skills with rigid boundaries. In reality, the fundamentals of emergency treatment in mitigating the effects of acute illness and injury go back to ancient times. This is evidenced by descriptions of the urgent management of acute pain with analgesics, splinting of injured limbs, and more sophisticated procedures, such as the removal of kidney stones and craniotomies. The treatments at that time were limited, but the application of these skills brought relief to many people (and a little pain). The practitioners were generalists and did not limit themselves to emergency treatment alone. Over the past half-century, there has been an acceleration of development in emergency medical treatments and a massive explosion in emergency medical system enhancement. This has resulted in a unique body of knowledge and skills, with the evolution of a new medical specialty specific to the delivery of emergency medical care. It is worth reflecting on the drivers for EM specialisation, where the specialty has come from, and what we can expect as the complexity of medical care increases with technological innovation and social changes associated with increasing connectivity.

Iodine deficiency disorders: Public health measures to mitigate the global burden

Iodine is an essential micronutrient required for the synthesis of the hormones - thyroxine and triiodothyronine. Iodine insufficiency is prevalent throughout the world, and is rated as one of the most significant public health concern in more than 125 countries. An optimal intake of dietary iodine during pregnancy, lactation and early childhood period is crucial for ensuring proper development of the brain of the fetus/newborn. During the course of implementation of the strategy of universal administration of the iodized salt, a wide gamut of challenges has been identified. In order to combat the same and simultaneously enhance the coverage of universal administration of the iodized salt, many measures have been proposed, namely formulating clear plan with time-based targets; encouraging coordination amongst all stakeholders; strengthening of the existing infrastructure; and increasing consumer awareness and demand for adequately iodized salt. To conclude, iodine has a crucial role in ensuring the normal growth and development of the child. However, to expand the coverage of the universal iodized salt to the vulnerable population, sustained political commitment and transparent monitoring and evaluation mechanism is the need of the hour.

The need to maintain quality and build capacity for emergency medicine training

The need to maintain quality and build capacity for emergency medicine training

Is the increase in emergency short‐stay admissions sustainable? Trends across Melbourne, 2000 to 2009

To describe the trends in emergency admissions over 10 years in terms of volume, age-specific rates, hospital length of stay (LOS) and clinical reasons. A retrospective analysis of population-based linked Department of Health ED and hospital admission data for metropolitan Melbourne 1999/2000 to 2008/2009 was conducted. Outcome measures included: hospital admission numbers (total, single day/overnight, ≥2 days LOS); admission rates per 1000 person-years (total, single day/overnight, ≥2 days LOS); hospital LOS. The volume of patients admitted to hospital through EDs rose by 56% over the 10 years to June 2009. The number of same day/overnight admissions rose by 60%, equating to a 6.1% average annual increase beyond that accounted for by demographic change (95% CI 5.7-6.5%). The volume of patients admitted for ≥2 days also increased; however, the admission rate per 1000 persons for these longer-stay patients declined over the decade by 9% (95% CI 5-12%). The most frequent discharge diagnoses were injury or poisoning, and disorders of the circulatory, respiratory or digestive systems. The numbers and mortality rate for ED admissions declined over the decade. Emergency hospital admissions have risen over the last decade even after adjustment for population changes. There was a disproportionate rise in same day/overnight admissions, with overrepresentation of the elderly. This is possibly related to changes in ED models of care, including introduction of short-stay units, improved diagnostic and therapeutic capability, and risk-averse management to optimise safe discharge, within the context of time-based performance targets.

Improving timeliness while improving the quality of emergency department care

Increased ED waiting times, increased ED length of stay and their association with adverse events, including mortality, have refocused government policy on time targets. Time-based performance targets for emergency medicine were highlighted as a potentially useful strategy in the mid 1990s in Victoria with the Emergency Services Enhancement Program, when bonus payments were shown to improve patient access. In the UK, reform of the National Health Service (NHS) included implementation of the 4 h standard or target in 2004, with Western Australia (WA) and New Zealand following suit in 2009. The original intent was that 98% of patients would be seen, admitted, discharged or transferred from ED within 4 h. This was soon revised to 95% in the UK and 85% of presentations in WA. In contrast, the New Zealand Shorter Stays in EDs (SSEDs) target was set at ‘95% in six hours’, following advice from local clinicians and nurses, with the belief that 6 h was ‘long enough for good clinical care but not unjustifiably long’. Evaluation of the NHS targets suggests that they have been successful in reducing long waits in the ED. Significantly, UK emergency physicians describe the major benefit of the target as enforcement of a ‘whole of system’ change without focus on the ED performance in isolation. However, there are conflicting reports on associated clinical outcomes, with concerns about the potential for a fixation on meeting the time standards to the detriment of the quality of patient care. It is notable the new British government responded to these fears by modifying the standard in 2011 to include a suite of eight clinical quality indicators (CQIs) that were designed to focus on timeliness along with the quality of clinical care and the patient experience. In Australia, the impact of time targets on improving the quality of care is unclear, with the Stokes report from WA suggesting need for further study and further monitoring. Initial research has suggested a possible reduction in mortality since the introduction of the 4 h rule in WA; however, methodological issues, including the lack of long-term trends, limit any conclusions at this stage. Introduction of mandatory reporting of CQIs potentially results in a more balanced approach to patient care. As such, the danger of only achieving faster care should be reduced. CQIs need to encompass measures of clinical outcomes, clinical effectiveness, safety and service experience, as well as timeliness. In doing so, they align with the Institute of Medicine’s Quality Care framework of effectiveness, safety, timeliness, patient/ family centredness, access and efficiency. CQIs should also support a culture of continuous improvement in the quality of care; however, this can only be achieved with ongoing monitoring and regular audit, alongside feedback and implementation strategies – which is not explicit in the introduction of these indicators. In this issue of Emergency Medicine Australasia, Jones et al. report on a comprehensive process to develop a set of evidence-based and clinically and locally relevant quality of care indicators for New Zealand. Indicators were initially selected following review of the existing international literature with feedback from the New Zealand emergency healthcare community. This was followed by subsequent validation by a multidisciplinary reference group. The reference group was representative of the wider health system

An inventory sharing and allocation method for a multi-location service parts logistics network with time-based service levels

We consider a model to allocate stock levels at warehouses in a service parts logistics network. The network is a two-echelon distribution system with one central warehouse with infinite capacity and a number of local warehouses, each facing Poisson demands from geographically dispersed customers. Each local warehouse uses a potentially different base stock policy. The warehouses are collectively required to satisfy time-based service targets: Certain percentages of overall demand need to be satisfied from facilities within specified time windows. These service levels not only depend on the distance between customers and the warehouses, but also depend on the part availabilities at the warehouses. Moreover, the warehouses share their inventory as a way to increase achieved service levels, i.e., when a local warehouse is out of stock, demand is satisfied with an emergency shipment from another close-by warehouse. Observing that the problem of finding minimum-cost stock levels is an integer non-linear program, we develop an implicit enumeration-based method which adapts an existing inventory sharing model from the literature, prioritizes the warehouses for emergency shipments, and makes use of a lower bound. The results show that the proposed inventory sharing strategy results in considerable cost reduction when compared to the no-sharing case and the method is quite efficient for the considered test problems.