ADMIN/NON MEDICINE

ResponseAn admitted patient who remains in the emergency department for > 8 hours because of a delay in accessing an inpatient bed

ResponseED overcrowding: refers to the situation where ED function is impeded primarily because the number of patients waiting to be seen, undergoing assessment and treatment, or waiting for departure exceeds either the physical bed and/or staffing capacity of the ED.

ResponseED overcrowding refers to the situation where ED function is impeded primarily because the number of patients waiting to be seen, undergoing assessment and treatment or waiting departure exceeds either the physical bed and or staffing capacity of the ED.
Access block is the principal cause of ED overcrowding.

ResponseInability to offload ambulance patients and a resultant loss of capacity in the local emergency response in the community
Inability to place critically unwell patients in an appropriate treatment space when required
Patients undergoing clinical management in a non-treatment area, where privacy and access to basic clinical resources is reduced or delayed
Admitted patients receiving a lower standard of care than they would receive in their destination unit
Obstruction to access and egress routes from the ED in contravention of OH&S requirements

ResponseReduced quality of clinical care
reduced quality of customer service
increased waiting times
reduced symptom control
communication problems
reduced patient perception of quality of clinical care
Increased adverse events
Increased violent behavior
Increased errors
Delayed time to critical care
Increased morbidity
Excess deaths

ResponseInput

• Presentations with more urgent and complex care needs
• Increase in presentation by elderly
• High volume of low acuity presentations
• Access to primary care
• LImited access to diagnostic services in community

Throughput

• ED nursing staff shortages
• Presence of junior medical staff in ED
• Increased patient evaluation/complexity
• Delays in receiving test results and delayed disposition decisions

Output

• Access block
• ICU and cardiac telemetry census
• ICU

ResponseExpedite admissions
Expedite / sit out discharges or low acuity patients
Plan to move patient direct to OT for management
Move patients to short stay (if available)

ResponseOver census
Open decommissioned / non-staffed / unfunded bed spaces
Utilise other treatment areas – day procedure, recovery, transit lounge, radiology holding area
Immediate audit of bed stock – identify empty beds not previously identified

ResponseMaximise weekend discharges

• Friday multi disciplinary meets to plan discharges;
• Post take consultant WR for all teams

Extended hours hospital avoidance strategies

• Hospital in the home programs; RAFC outreach programs; Acute community based psychiatric teams;
• Day hospital; Step down facilities

Optimise week:weekend bed utilisation

• Long stay admissions planned for early in the week;
• Bed utilisation predictive tools

Early escalation strategies

• Anticipate excess load with triggers at ambulance, ED and hospital levels;

Load sharing with adjacent towns

ResponseInput

• GP lead walk in centres/co-located GP
• Choice of ED
• Social interventions interventions including education campaigns, financial disincentives, redirection

Throughput

• Earlier physician assessment /physician lead or supported triage
• Fast track/flexible care area
• Fastre labs/radiology
• ED flow coordinator
• Bedside registration
• Nurse initiated protocols
• Earlier inpatient consultations
• Increased ED bed/staff numbers

Output

• Active bed management
• Nationally mandated time targets
• ED staff direct admission rights
• Admitting teams prioritise ED admissions
• Alternative admission policies
• Increased patients beds/staff

ResponseDelayed access to definitive assessment and care in the acute hospital setting, with these delays likely to be associated with the same poor outcomes already known to be associated with delayed emergency department care.

ResponseDemand (Surg/major event/pandemic)
Lack of primary healthcare availability(Shit GP’s, weekends)
Other health services bypass
Lack of senior staff
Delayed decision making
Delay to inpatient review
Abdsolute staff deviciency/sick leave/rostering
Delay to imaging/path results
Lack of alternate treatment spaces
ED areas full of admitted patients
Hospital occupancy over census
Delays to discharge planning
Lack of alternate services ie: HITH
Lack of alternative services (eg; Outpt clinics)

ResponseNotify ambulance services – consider load sharing
ED/hospital exec – clear beds, hospital disaster plan
Assign staff to ramped patients – ID + managed critical pateintes
Clear space, admit directly to ward
Alternate space for well pts awaiting results (Eg EMU)
Staffing – Call in
Early rounding + early decision making

ResponseEffects on the timelines of ambulance responses, as there are fewer crews available to cover the same geographic areas. This is reflected in deteriorating response times for critical and emergent patients
Lost ambulance and personnel time for ambulance services, which either reduces ability and flexibility or increases ambulance service and community cost due to additional overtime or the need for additional crews and ambulances
Potential impacts on funding and resultant financial penalties for ambulances and hospitals, as ramping affects key performance measures for ambulance services and ED’s
Prolonged poor publicity for health systems, ambulance services, hospitals, and ED’s, leading to poor staff morale and poor public perceptions of key areas of the health system and personnel within that system
Increased stress and interpersonal conflict between patients, paramedics and ED staff

ResponseDebrief staff involved
Notify next of kin, open disclosure
Apologise to NOK for events
Pledge to investigate
Notify Hospital Med Super/Exec of situation
Review case specifics and documentation
Ensure case reported through local QA processes ie Riskman, Morbidity and Mortality, Patient Safety
committee
Document all events
Others ok