ED stays decreased but with strings attached

ED stays decreased but with strings attached

Research into hospital emergency department waiting times has shown that waiting times are lower than ten years ago but significant challenges remain for treating patients in a timely manner.

The study, published in BioMed Central Health Services Research studied ED waiting times at four New Zealand Hospitals between 2006 and 2012.

In 2009, the government introduced a hospital emergency department (ED) target – 95 per cent of patients seen, treated or discharged within 6 hours - to reduce crowding in public hospital EDs.

While official figures reported that most DHBs met this target by 2012, the University of Auckland researchers wanted to test whether waiting times were actually shorter.

Over the past decade, hospitals have increasingly introduced and used ‘short-stay-units’ (sometimes known as acute observation wards) that are attached to EDs. However, when patients are transferred to these units, they are no longer counted in the ED figures.

The research team compared changes in the reported ED LOS, to changes in their measure of total ED LOS. The difference between them is that the total LOS figure includes the time ED patients spent in short-stay units, whereas the reported LOS figure does not.

The study analysed ED LOS in four New Zealand hospitals, two in large urban areas, one in a regional centre, and a fourth in a provincial city. The researchers analysed changes in ED waiting time data over the 2006 to 2012 period for these hospitals, and conducted extensive interviews and surveys with hospital clinicians and managers in order to understand why changes occurred.

The article’s lead author, Associate Professor Tim Tenbensel of the University of Auckland’s School of Population Health says that the ED target was initially successful in reducing ED length of stay, but its effectiveness was limited over the long term.

“Firstly, it appears that the effectiveness of the target in reducing patient time in EDs was confined to the period from mid-2009 to late 2010. From 2011 onwards, improved target performance was achieved by increasing use of short-stay units as a tool for managing acute hospital demand”, Dr Tenbensel says. This means that the continued improvement of DHBs in official ED target performance after 2010 does not give the full picture.

Both the reported and total ED LOS figures showed reductions in the first 18 months of the target. However, while reported ED LOS continued to improve after 2010, total ED LOS figures remained static. That means that the main way in which hospitals improved their target performance was by transferring patients into short-stay units that were ‘off the target stream’.

The authors emphasise that in most cases, shifting patients to short-stay units is entirely appropriate and clinically justified. According to Dr Tenbensel, “having patients in these short-stay units is certainly preferable to having them wait in hospital corridors as was common before 2009. However, we know from our interviews that there were some instances where the only reason patients were transferred to short-stay was to avoid breaching the target.”

The study was also able to show what really worked in reducing ED waiting times. The most effective initiatives were those that sought to streamline patient flow through the hospital. This activity was based on a range of quality improvement programmes including clinical and operational process improvements implemented in 2009 and 2010.

These included adopting the 3–2-1 model, where the patient journey for admitted patients is split into a 3-hour ED assessment phase, a 2-hour inpatient assessment phase and a 1-hour transfer to ward phase.

Rapid assessment practice and triaging of patients to ED and inpatient short stay units enabled early movement of patients into other parts of the hospital. Process improvements were also enhanced by introducing new or changed clinical roles in EDs and hospitals.

Each of the hospitals studied reconfigured medical rosters to better match and respond to the demand for acute patient care. The lack of available beds in inpatient wards is known to create ED bottlenecks, so all hospitals improved their processes of managing the discharge of patients from hospital wards to free up ward beds.

The study also found that other strategies to meet the target were introduced after 2010. All hospitals dedicated new staff resources, particularly medical and nursing staff for the ED or short stay unit. Other steps taken by the hospitals included the introduction of real time information on the target that enabled clinicians and managers across the hospital to closely monitor delays to patient flow. DHBs and hospitals also put resources and effort into leadership initiatives and social marketing.

However, as these changes in ED staffing, monitoring of information, and social marketing only kicked in after 2010 in most hospitals, such initiatives did not lead to reductions in the total length of stay in EDs.

The researchers argue that these findings have some important implications for policy and practice. According to Dr Tenbensel: “The increasing use of short-stay units means that time spent waiting in ED is becoming less useful as a way of measuring hospitals’ responses to demand for acute services. Without including short-stay unit waiting times, we don’t get the full picture.”

“Our analysis questions the value of ED targets as a long term approach. To the extent that ED targets work in improving timeliness of care, it is in the form of a short, sharp shock.”

“Given that ED demand continues to increase at rates above population growth rates and increases in health sector funding, additional policy and organisational strategies will be required in order to meet the challenges of increasing acute demand.”

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