Myth Busters Trial - ED access block


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The great enemy of the truth is very often not the lie ; deliberate, contrived and dishonest ,but the myth - persistent, persuasive and unrealistic

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Myth Busters Trial - ED access block

  1. 1. Access Block - the myth trial
  2. 2. Myth-quotes • What a man believes upon grossly insufficient evidence is an index into his desires - desires of which he himself is often unconscious. If a man is offered a fact which goes against his instincts, he will scrutinize it closely, and unless the evidence is overwhelming, he will refuse to believe it. If, on the other hand, he is offered something which affords a reason for acting in accordance to his instincts, he will accept it even on the slightest evidence. The origin of myths is explained in this way. • Bertrand Russell • The great enemy of the truth is very often not the lie ; deliberate, contrived and dishonest ,but the myth - persistent, persuasive and unrealistic. • JFK
  3. 3. • Creation myths : – An ED problem due to GP type patients and inefficient EDs • Outcomes / management myth : – Poor patient outcomes are rare – Poor outcomes have minimal consequences therefore – EDs are good places to store excess admitted patients • Solution myths: – Access block is inevitable and insoluble AND / OR – Can be sorted out by GP clinics, telephone lines or bigger/ better EDs Major Myth-conceptions of ED overcrowding
  4. 4. Causation myths for Access block: Caused by inappropriate / GP patients and poor ED practices In response to the state of our public hospitals AIHW report showing a 30% worsening in ED patients time to be seen in WA • “the pressure on emergency departments is caused by patients seeking help who did not need to be treated at hospital and should have seen a GP instead.” Acting Director-General Health WA 1/7/2008
  5. 5. GP patients – the evidence • Tertiary EDs <15% GP “inappropriate” • Use 3% or < of resources • Easy - quick to treat • 95% of stay in WR • Admissions < 1% (v 5% triage category 5) • Commonest attendance reason = GP referral • Think (know) they should be there! » Emerg Med Australas. 2005 Feb ;17 (1):11-5 15675899 Ambulance diversion is not associated with low acuity patients attending Perth metropolitan emergency departments. Peter Sprivulis » Australian Health Rev 2004;28(3):285:291 After-hours general practice clinics are unlikely to reduce low acuity patient attendances to metropolitan Perth emergency departments. Nagree Y, Ercleve TN and Sprivulis P.C
  6. 6. 0 100 200 300 400 500 600 Minutes ED LOS Awaiting bed Assessment time ED times for WA tertiary hospitals- proportion for assessment 1999 2005 ED “play” with patients: the Data
  7. 7. Sensory perception- why people see this as an ED problem?
  8. 8. Myth: System Capacity loss doesn’t cause ED overcrowding or poor outcomes
  9. 9. The Effect of Hospital Occupancy / Admissions in ED on: ED LOS, Overcrowding and Pt Disposition/ Diversion Research conclusions: Hospital occupancy (admitted pts.) strongly associated w ED LOS – Alan J. Forster MD, MSc , I Stiell et al; Academic Emerg Med Vol 10;2, p127 - 133 June-08 Admitted patients in ED are important determinant of ambulance diversion. Reducing volumes of walk-in patients is unlikely to < the use of diversion. – Michael J. Schull MD Ann Emerg Med. 2003;41:467-476. ED overcrowding (r = 0.96; 95% confidence interval (CI) 0.91 to 0.98), Ambulance diversion (r = 0.75; 95% CI 0.49 to 0.88), and ED waiting times for care (r = 0.83; 95% CI 0.65 to 0.93) were Strongly correlated with high ED occupancy by access blocked pts • Fatovich D et al Emerg Med J 2005; 22:351-354 Capacity loss isn’t the cause of overcrowding? The Evidence
  10. 10. Beds per 1000 of popn > 65 Australia
  11. 11. The data: BEDS v Access BLOCK 1999 to 2006 WA WA’s public beds have reduced 18% % of admitted patients Access Blocked Australian public beds have reduced 10% 3.1 2.9 2.5 2.6 2 2.2 2.4 2.6 2.8 3 3.2 WA Australia 1999 2005 Beds per 1000 population The state of our public hospitals, June 2006 report 0 10 20 30 40 50 60 FH RPH SCGH 2000 2001 2002 2003 2004 2005 2006 2007 DoH WA data
  12. 12. Access block in a department experiencing major improvements in efficiency
  13. 13. Reducing LOS almost all countries
  14. 14. Bed no’s and occupancy -OECD
  15. 15. The Truth • GP / “inappropriate” patients don’t • Cause Access Block • Use ED resource OR hospital capacity • EDs don’t “stay and play” with patients • Lack of Hospital and System capacity causes ED Overcrowding
  16. 16. Myth: Overcrowding- no consequences !
  17. 17. Myth: Overcrowding has minimal effect on patient care. A deliberate mythology? Standard DoH/ Health ministry responses minimising clinical compromise from overcrowded EDs/ hospitals “Western Australia now has some of the safest emergency departments in the country, contrary to the findings of a 2003 report published in the Medical Journal of Australia today. He said the report into overcrowding in EDs was based on three-year-old information and many of the issues raised were already being addressed”. 3/3/06 • Director Health Policy and Clinical Reform DoH WA in response to release of Sprivulis et al mJA 2006 study showing OR of death of 1.3 in overcrowded WA hospitals “All public hospitals have procedures in place to ensure that patients who present at emergency departments are promptly triaged and monitored, and patients requiring urgent medical treatment are seen immediately,” he said. 6/08 • A/DGH WA in response to concerns that an extra 2-300 patients a year were probably dying due to chronic overcrowding in ED and hospitals Access block from 2000-06 (worse again 2007)
  18. 18. Published adverse events from ED overcrowding Deaths: 60-100 extra per 1 M population p.a. Patients with time critical illness e.g. Heart attack, trauma, stroke, pneumonia etc • Delays to hospital ↑ • Delayed diagnosis and tx • Complications, recurrence, deaths ↑ Pain relief ↓ amount ,↑ time Starvation / dehydration Errors ↑ LOS and Costs ↑ Complications ↑ (e.g. pressure sores/ DVT/ poor healing,,wrong tx) Did not Waits ↑ Staff stress , burnout, turnover Complaints/ legal issues/ press↑
  19. 19. The true effects of overcrowding Delayed discharge costing operations- Qld Courier Mail RIP 1200-3000pa Nurses resign, 8 beds closed- WA News 'Demoralised' doctors leaving NSW hospitals- ABC
  20. 20. Reduced capacity in health systems – not bad for patients?
  21. 21. Managing hospital overcrowding- myths Best place for patients without a bed is ED
  22. 22. Q- who needs most expert, specialised care? Acutely unwell, possibly deteriorating and undiagnosed – OR Patients who are stable, diagnosed and close to discharge The 2000 year old triage system Myth- managing Access Block
  23. 23. Managing hospital overcrowding- myths Best place for patients without a bed is ED Differences in: ED Wards (across hospital) Beds/ space (% of hosp) 1-6% 50-90% Space per patient 2 -4m2 3-8 m2 Additional spaces Minimal Spare rooms/ wait areas Patient acuity Generally unwell –critical Stable- occas unstable Standard bed Trolley- hard (bed sores >) Bed -soft (< bed sore) Environment Noisy, light, no privacy, poor access, frightening, irregular food Darkened, quiet, good access, less frightening, regular meals 20 extra patients: Effects on function Functional capacity ↓40-80% 120-200% occupancy Double/ triple rooms-corridor functional capacity ↓ 2-5% Run at 100-105% occupancy Extra space 1 room- occas corridor Work practice alters? Yes- dramatic, change function and nursing ratios ++ Minimal- moderate (worse if patients on wrong units) Staff morale Severe +++ Mild-moderate
  24. 24. The Truth • Canadian Association of Emergency Physicians Position Statement : – “Emergency departments are loud, brightly lit environments where patients lie on hard stretchers with limited privacy or dignity, poor access to bathroom facilities, and little or no opportunity for sleep. These are not reasonable, safe or humane conditions for sick people. Patients requiring hospital admission should not be held in emergency departments, hallways or waiting rooms for more than 6 hours.”
  25. 25. What ED boarding really says
  26. 26. Solution myths
  27. 27. Myth • ED overcrowding in Western health systems is Inevitable AND Insoluble
  28. 28. The truth- avoidable / fixable Key features of interventions that can work are: Capacity ↑ Activity ↓ and System buy in Overcrowding is a feature of overzealous application of the “efficiency” mantra that rations using bed/ capacity cuts.
  29. 29. The Evidence Examples: Before 1999 Access Block was minimal in WA/ Qld/ ACT UK A+E turned around with 4 hr targets- >90% achievement When capacity ↑ activity ↓ e.g. holiday periods / strikes then Access Block ↓ : » Reduced access block causes shorter emergency department waiting times: An historical control observational study – Dunn et al » Effect of a holiday service reduction period on a hospital's emergency department access block. Thomas J Moving patients at 6 hrs to wards (overcensus): ED function ↑ +++ / hospital LOS reduced by 1 day! » Innes G et al Acad Emerg Med 2007 14(5) S1-8 Abs 206
  30. 30. SCGH :doubled ED capacity- attendances from 40000 to 50000/ admit rate 45-47%
  31. 31. Solution myths- data Clinics, Call Centres and Colossal EDs Call centres 7 studies 5 RCT No ↓ : 1 ↑ ED attendances – Bunn F et aL Br J Gen Pract. 2005 December 1; 55(521): 956–961. GP Clinics/Casualty Little evidence for need No ↓ local EDs attendances Not Cost Effective – Family Practice Vol. 20, No. 3, 311-317 – /open/documents/after_hoursgp.pd f Bigger-better ED* Tennessee / WA 100% increase ED size – Han JH Acad Emerg Med. 2007 Apr;14(4):338-43. Outcomes LOS in ED↑ Access block↑ Time to be seen↑
  32. 32. The Truth ED overcrowding is not reduced by: Co-located / alternative GP emergency services Call centres- phone triage Bigger / more efficient EDs The reason is obvious: They treat myths OR symptoms but not the Disease
  33. 33. Conclusions: Myths are very bad for patients, staff and systems health Access block causation: Not “inappropriate” GP patients or ED practices BUT a Systemic lack of capacity Access block and overloaded EDs are associated with: Severe avoidable adverse events and Deaths (> 1200 a year) EDs are grossly inappropriate environments to “store” patients
  34. 34. Conclusions 2 ED Access Block is neither Inevitable nor Insoluble It is a self induced disease of “efficiency” driven systems GP clinics, call centers or bigger, better EDs can’t stop ED overcrowding because they have little effect on the true cause Things that we know do work (for a while): Increased capacity – obs wards, strikes, stop surgery Moving the patients to wards (share the problem) Reduced in flows of sick patients ( ? Holland )
  35. 35. Acknowledgements ED staff AMA federal AMA WA (demotivational posters) DoH and MfH everywhere for making it happen!
  36. 36. Hospitals Expand Emergency Rooms as Patient Volumes Rise By Birritteri, Athony Publication: New Jersey Business
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