Background
ED crowding – Causes and possible solutions
Do time targets reduce ED length of stay?
Methods
Overall approach
Case study design
District population size (2013) | % District population growth 2006–13a
| No. of ED presentations and annual percentage increase 2009–2012 | |||||||
---|---|---|---|---|---|---|---|---|---|
2009 | 2010 | % Increase 2009–10 | 2011 | % Increase 2010–11 | 2012 | % Increase 2011–12 | |||
Hospital 1 | 100–200,000 | 2.32% | 35,608 | 37,503 | 5.32% | 38,221 | 1.91% | 38,556 | 0.88% |
Hospital 2 | >400,000 | 8.36% | 87,706 | 93,804 | 6.95% | 98,103 | 4.58% | 101,457 | 3.42% |
Hospital 3 | 200–400,000 | 5.93% | 54,233 | 58,157 | 7.24% | 62,933 | 8.21% | 66,680 | 5.95% |
Hospital 4 | >400,000 | 9.12% | 52,645 | 56,159 | 6.67% | 59,756 | 6.41% | 62,120 | 3.96% |
Total | N/A | 7.40% | 230,192 | 245,623 | 6.70%2
| 259,013 | 5.45%2
| 268,813 | 3.78%2
|
Data sources
ED length of stay
Case study site interview and ED survey
Integration of sources
Results
The four hospital sites and their official target performance
Did ED LOS reduce, and if so, when?
Trends in reported and Total ED LOS
Case study Hospital | Quartiles of Reported ED length of stay (hours) | |||||
---|---|---|---|---|---|---|
Year | 2007 | 2008 | 2009 | 2010 | 2011 | 2012 |
Hospital 1 | 25th: 2.0
Med: 3.5
75th: 5.4 | 2.0
3.4
5.5 | 2.0
3.6
5.8 | 1.8
3.0
4.6 | 1.8
3.1
4.6 | 1.9
3.0
4.5 |
Hospital 2 | 25th: 2.7
Med: 4.2
75th: 6.4 | 2.6
4.0
6.0 | 2.4
3.7
5.2 | 2.3
3.4
4.7 | 2.3
3.5
4.8 | 2.3
3.4
4.7 |
Hospital 3 | 25th: 3.0
Med: 4.5
75th: 6.7 | 2.9
4.6
6.9 | 2.9
4.5
6.8 | 2.7
4.2
6.1 | 2.4
3.7
5.3 | 2.2
3.6
5.2 |
Hospital 4 | 25th: 3.1
Med: 5.3
75th: 9.6 | 3.4
5.7
9.8 | 3.3
5.4
8.6 | 2.9
4.7
7.3 | 2.3
3.7
5.4 | 2.2
3.6
5.0 |
All case study hospitals | 25th: 2.7
Med: 4.3
75th: 6.8 | 2.7
4.3
6.8 | 2.6
4.1
6.2 | 2.4
3.7
5.4 | 2.1
3.4
4.9 | 2.0
3.3
4.8 |
Case study Hospital | Quartiles of Total ED length of stay (hours) | |||||
---|---|---|---|---|---|---|
Year | 2007 | 2008 | 2009 | 2010 | 2011 | 2012 |
Hospital 1 | 25th: 2.0
Med: 3.5
75th: 5.4 | 2.0
3.4
5.5 | 2.0
3.6
5.8 | 1.8
3.0
4.6 | 1.8
3.1
4.6 | 1.9
3.0
4.5 |
Hospital 2 | 25th: 2.9
Med: 4.7
75th: 8.2 | 2.8
4.6
8.1 | 2.8
4.4
7.7 | 2.7
4.2
6.8 | 2.8
4.5
7.7 | 2.8
4.5
7.5 |
Hospital 3 | 25th: 3.0
Med: 4.5
75th: 6.7 | 2.9
4.6
6.9 | 2.9
4.5
6.8 | 2.7
4.2
6.1 | 2.7
4.1
6.0 | 2.7
4.2
6.0 |
Hospital 4 | 25th: 3.3
Med: 6.2
75th: 13.9 | 3.6
6.4
12.9 | 3.6
6.1
11.1 | 3.2
5.4
9.8 | 2.8
5.0
9.9 | 2.9
5.4
12.9 |
All case study hospitals | 25th: 2.8
Med: 4.6
75th: 8.0 | 2.8
4.6
8.0 | 2.8
4.6
7.7 | 2.6
4.2
6.6 | 2.6
4.2
6.7 | 2.6
4.3
6.9 |
Case study Hospital | Difference between Total ED length of stay and Reported ED length of stay (hours) | |||||
---|---|---|---|---|---|---|
Year | 2007 | 2008 | 2009 | 2010 | 2011 | 2012 |
Hospital 1 | 25th: 0.0
Med: 0.0
75th: 0.0 | 0.0
0.0
0.0 | 0.0
0.0
0.0 | 0.0
0.0
0.0 | 0.0
0.0
0.0 | 0.0
0.0
0.0 |
Hospital 2 | 25th: 0.2
Med: 0.5
75th: 1.8 | 0.3
0.6
2.1 | 0.4
0.8
2.5 | 0.4
0.8
2.1 | 0.5
1.0
2.8 | 0.5
1.0
2.7 |
Hospital 3 | 25th: 0.0
Med: 0.0
75th: 0.0 | 0.0
0.0
0.0 | 0.0
0.0
0.0 | 0.0
0.0
0.0 | 0.3
0.4
0.7 | 0.4
0.6
0.8 |
Hospital 4 | 25th: 0.3
Med: 0.9
75th: 4.3 | 0.2
0.8
3.1 | 0.3
0.7
2.5 | 0.3
0.7
2.5 | 0.6
1.3
4.5 | 0.7
1.9
7.8 |
All case study hospitals | 25th: 0.1
Med: 0.3
75th: 1.1 | 0.1
0.3
1.1 | 0.2
0.5
1.5 | 0.2
0.5
1.2 | 0.5
0.8
1.8 | 0.7
1.0
2.2 |
Trends in the use of short-stay units
Case study site interview and ED survey data: What did hospitals do to reduce ED length of stay?
New Resources (staff and beds) | Improving Patient Flow | Better Information and Communication | Leadership and Social Marketing | |
---|---|---|---|---|
Hospital 1 (H1) | ||||
Early Implementation July 2009-Dec 2010 |
Prior to target QI project (2008): Staffing added ED nursing, flow coordinator trial (2008).
Post target added/implemented:
Staffing: ED, hospital, SSU - Added medical staff SSU and hospital (2010).
Beds: ED, hospital, SSU - Reconfigurations of SSU adding ED observation beds and of medical/surgical wards to add medical (2010). Added bed to acute surgical unit (2010). |
Prior to target QI project implemented 2008:
ED Processes - ED fast track, care pathways for certain conditions.
Post target implemented:
ED processes - 3-2-1 model, changes in triage processes (2010), rapid assessment and direct SSU referral model (2010), ED discharge planning (i.e. discharge model including allied health), orderlies in ED (2010).
Hospital and SSU processes - Discharge planning (i.e. hospital ward discharge, discharge lounge), reconfiguration of bed and clinical specialty models in SSU and hospital wards, daily bed management meetings (2010). |
ED patient flow and reporting - IT screens upgraded for LOS (2010). |
Prior to target:
ED leadership of QI project.
Post target:
CEO leadership - New CEO focused on ED target & “front of house” (2010). |
Later Implementation Jan 2011-Dec 2012 |
Staffing: ED, hospital, SSU
Added ED, SSU nursing and medical staff, implemented aged care/hospital liaison role (2011–12). |
Hospital processes:
Added acute medical clinic for GP referral (2011). Additional acute operating theatre for flow (2012). |
ED patient flow and reporting - Visible real time data in ED, hospital and SSU for clinicians/managers, target breach reports (2011).
Bed information - Hospital/ED bed information improvements (2011). |
Leadership - Separate hospital groups encouraged to include ED target focus (2011). Whole of hospital target leadership group (2012). |
Hospital 2 (H2) | New resources (staff and beds) | Improving Patient Flow | Better Information and Communication | Leadership and Social Marketing |
Early Implementation July 2009-Dec 2010 |
Prior to target QI project (2008): Staffing: added ED nursing and flow manager, added medical staff for new observation unit (2008). Beds: New acute observation unit (2008).
Post target added/implemented:
Staffing: ED, hospital, SSU - Added nursing staff ED, hospital, SSU, afternoon medical coordinator role. Added medical staff added SSU/ED, and orderlies (2009–10).
Beds: ED, hospital, SSU - Increase and reconfiguration hospital medical, surgical ward beds (2009) and specialty SSU beds (2010). |
Prior to target: QI project whole of hospital project including 6 h ED target (2008).
Post target implemented:
ED processes - 3-2-1 model, changes in triage processes, care pathways for certain conditions, rapid assessment and direct SSU referral model, ED discharge planning (i.e. discharge model including allied health), orderlies in ED (2009–10).
Hospital and SSU processes - Ward and specialty SSU reconfiguration to increase beds and SSU hours, discharge planning (i.e. hospital ward nurse facilitated discharge at weekends, surgery discharge lounge), bed management meetings, cohorting patients for improved bed availability, afternoon medical coordinator, staff scheduling, changes (2009–10). |
Prior to target: ED patient flow (2008): IT LOS screens upgraded (2008)
Post target implemented:
ED patient flow and reporting - Visible real time data in ED, hospital, SSU for clinicians/managers, target breach reports (2009–10).
Bed information - Hospital/ED bed information improvements (2009–10).
Communication devices - Cell phones, voice activated devices for medical, nursing, orderly staff (2010). |
Leadership - Whole of hospital target leadership, clinical/management champions, and governance groups. Culture - Ready for target, strong QI and “can do” culture.
Social marketing - Social marketing strategy group implemented and activity about target within whole hospital. |
Later Implementation Jan 2011-Dec 2012 |
Patient flow and staff management – New hospital operations new unit management (2011). | |||
Hospital 3 (H3) | New Resources (staff and beds) | Improving Patient Flow | Better Information and Communication | Leadership and Social Marketing |
Early Implementation July 2009-Dec 2010 |
Staffing: ED, hospital - Added ED nursing, ED orderlies, and hospital medical staff (2009). ED flow nurse, bed management coordinator and data analyst role for ED target project (2010). |
ED processes - ED flow nurse and orderlies in ED (2009).
ED Patient flow process engineering project with ED 3–2-1 model, flow coordinator, bed management coordination in ED and hospital (2010). |
ED patient flow and reporting - Visible real time LOS data in ED, hospital, SSU for clinicians/managers. Results posted on ED/ hospital noticeboards (2010).
Bed information - Hospital/ED bed information improvements (2010). |
Leadership - Initially ED target implementation led by ED managers & clinicians. |
Later Implementation Jan 2011-Dec 2012 |
Staffing: ED, hospital, SSU - Added nursing, medical staff for ED, hospital SSU (2011).
Beds: ED hospital, SSU - New ED with additional beds (2011). Reconfiguration and additional medical ward beds (2011). Additional beds in children’s and medical SSUs (2012). |
ED patient flow process engineering project (cont.) (2011)
ED processes - Changes in triage processes, flow coordination strategies. ED frequent attenders strategy and low acuity redirect. ED and hospital staff scheduling changes (2011).
Hospital, SSU processes - Ward and specialty SSU reconfiguration to increase beds (2011), extended SSUs hours (2012). Rapid assessment and direct SSU referral model. New Integrated Operations Centre (2011). |
Communication devices - Cell phones, voice activated devices for medical, nursing, orderly staff (2010–11). |
Leadership - Whole of hospital leadership group introduced (2011) but faltered, revised leadership group (2012).
Social marketing - Social marketing activity re target within whole hospital (2011). |
Hospital 4 (H4) | New Resources (staff and beds) | Improving Patient Flow | Better Information and Communication | Leadership and Social Marketing |
Early Implementation July 2009-Dec 2010 |
Staffing: ED, hospital, SSU – QI improvement quality coach (2009) ED target coordinator (2010). Added ED, SSU nursing, medical staff, orderlies (2010). |
ED processes - 3-2-1 model, changes in triage processes, ED nurse triage assessment, discharge planning (i.e. discharge safety checklist, ED lab requests prioritized), ED and hospital staff scheduling changes, orderlies in ED (2010).
Hospital processes – Discharge planning (i.e, hospital laboratory system reorganized, hospital ward discharge lab requests prioritized, discharge planning safety checklist), weekend hospital clinics implemented (2010). |
ED patient flow and reporting - IT LOS screens upgraded (2009). Visible real time LOS data in ED, hospital, SSU for clinicians/managers, daily breach reports (2010). |
Leadership - ED target lead and monthly meetings with ED management (2010). |
Later Implementation Jan 2011-Dec 2012 |
Staffing: ED, hospital, SSU - Added nursing, medical staff for ED, hospital, SSU (2011)
Beds: ED hospital, SSU - New ED with additional beds (2011). SSU ward redeveloped & increased in beds, mixed specialty model (2012) |
ED processes - Patient flow project (2011) Rapid assessment and direct SSU referral model, discharge planning (i.e. discharge planning model including allied health), ED orderlies (2011).
Hospital and SSU processes – Discharge planning (i.e. hospital ward discharge lounge development) (2011). SSU review for patients with uncertain needs (2012). |
Leadership - New hospital operations group (2011).
Social marketing - Social marketing activity about target within whole hospital (2011). |
New resources to help meet the target
Improving patient flow
So there is this group, and that, this group is trying to drive it and the trouble is, it’s attended predominantly by the converted and not the sinners. We’d love the sinners to come along.
Information and ED LOS monitoring strategies
Leadership and social marketing
Discussion
I had to have some fights with people about people about not moving patients who weren’t clinically ready to go to the ward, and with the clinical director of the alpha ward (SSU) so there was some gaming going on…at times the pressure was, just move the patient to the alpha ward.