Myth Busters Trial - ED access block

Access Block - the myth trial

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

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

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

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

ED “play” with patients: the Data

Sensory perception- why people see this as an ED problem?

Myth: System Capacity loss doesn’t cause ED overcrowding or poor outcomes

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

Beds per 1000 of popn > 65 Australia

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%
Beds per 1000 population The state of our public hospitals, June 2006 report DoH WA data

Access block in a department experiencing major improvements in efficiency

Reducing LOS almost all countries

Bed no’s and occupancy -OECD

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

Myth: Overcrowding- no consequences !

Myth: O vercrowding 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)

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 ↑

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

Reduced capacity in health systems – not bad for patients?

Managing hospital overcrowding- myths Best place for patients without a bed is ED

Q- who needs most expert, specialised care?
Acutely unwell, possibly deteriorating and undiagnosed
OR
Patients who are stable, diagnosed and close to discharge
Myth- managing Access Block The 2000 year old triage system

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 -4m 2 3-8 m 2 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

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.”

What ED boarding really says

Solution myths

Myth
ED overcrowding in Western health systems is Inevitable AND Insoluble

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.

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

SCGH :doubled ED capacity- attendances from 40000 to 50000/ admit rate 45-47%

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
http://www.medeserv.com.au/acem/open/documents/after_hoursgp.pdf
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 ↑

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

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

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 )

Acknowledgements
ED staff
AMA federal
AMA WA
Despair.com (demotivational posters)
DoH and MfH everywhere for making it happen!

Hospitals Expand Emergency Rooms as Patient Volumes Rise
By Birritteri, Athony Publication: New Jersey Business

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Myth Busters Trial - ED access block

by Mike Cadogan on Dec 04, 2008

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Myth Busters Trial - ED access block — Presentation Transcript