Emergency Department Admin Issues

1. Admin issues in ED

2. Overview
• ED – by the numbers
• Our perception ’s of risk/ risk avoidance
• WEAT- why?
• Are the College/exam/examiners racist

3. ED – the specialty: by the numbers
• 35 years since College founded: Tom Hamilton (WA) 1st Pres
• 30 years since 1st trainee passed (WA)
• 25 years since recognised as specialty next year
• 20 years since 1st Professor (SCGH /UWA)
• 67 initial fellows- > 2000 now
• 6th largest specialty by numbers (GP, Phys, Anaes, Surg, Psych)

4. What % of your hospitals Dr. FTE are
employed by/in the ED.
• 1%
• 2%
• 4%
• 7%
• 10%
• 15%
• 20%
• 25%

5. What % of patient bed-days are used by
patients admitted via ED
• 15%
• 25%
• 35%
• 45%
• 55%
• 65%
• 75%

6. What % of hospital activity/funding is directly
ED generated.
• 1%
• 2%
• 3%
• 5%
• 8%
• 10%
• 15%
• 20%

7. ED- ? important in your hospital
• 55% of patient bed days via ED
• 20-25% of “non 24hr/day beds’ = ED cubicles (20?/100)
• 10% of all hospital WAU( weighted activity is ED)
• 10%~ of medical FTE in ED (75-85/780 FTE)
• 8% of nursing FTE in ED (10% of hospital nursing costs)
• 8% of hospital funding (ED generates $65M / $780)
• 5% of hospital budget directly allocated to ED: $42M
• 4-5% of inpatient beds are Obs (16) / virtual (5-10 IP; boarded)

8. Annual activity
• 70-71000 p.a. attendances; 150-240/day
• Attendances > by 40% in last 10 years
• <2.5% attendances this year, 5-6% < than hx activity
• 45-80 ambulances
• 30% (45-65 per day) admitted to IP (3% tfer)
• 20-25% fast track
• 10-15% Obs ward (15-25% then admitted)
Tests
• $1-1.5 M of pathology ordered
• 150-180 Radiology requests a day (40-60 CT)-
• $15-20000 per day; $6-7M p.a

9. ED- a risky environment?
• High volume
• High acuity
• High disability risk
• High expectations
• Low information
• Low certainty
• Low patient understanding

10. ER – 100 project decisions a day

11. Who generates most claims in public hospitals?
ED generates 17% of complaints, where site known

12. Which situations/areas sued most in Pub-Hosp:
AIHW claims data 12-13 ED , 120/706 (17%)

13. Claims for 3 high risk public service providers

14. Who has the biggest claims against them
Proportion of high to low
claims
• Emerg Med 3:1 x > %
• O and G/ ortho 2:1
• Gen Surg 2:1
• Others: 1:1
• GP 1:2

15. Private practice Florida- spend more get sued less!
Jena AB, Schoemaker L, Bhattacharya J, Seabury SA. Physician spending and subsequent risk of malpractice claims: observational study. BMJ. 2015 Nov 4;351:h5516.
0
0.1
0.2
0.3
0.4
0.5
0.6
0 1 2 3 4 5 6
Malpractice claim rate GP(%, 95%
CI)

16. Date of download: 6/6/2016
Copyright © 2016 American Medical
Association. All rights reserved.
From: Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment
JAMA. 2005;293(21):2609-2617. doi:10.1001/jama.293.21.2609

17. 4HR/ NEAT/WEAT-still (ever) important?

18. Evidence for 4HR; when 1st applied
• Overcrowding associated with many poor outcomes(not proof of effect)
• > mortality, morbidity, MRSA >, > ramping, complaints, DNW, slow/ poor care, >LOS
• UK- none (patient surveys?);
• WA – pollies-admin visited UK; agreed a great thing- times improved-media
better; just before mid-Stafford
• Timely care/ targets- advocated for by ACEM
• NEAT-national, still no real data re patient outcomes

19. Monthly WA 4 hr performance tertiary acute -7/8
to 10-11

20. More recent data suggests > flow, better
outcomes
• WA data: 2007-2011; - as access block decreased at
tertiaries, reduced mortality seen in 2011(but not
2010) vs 2007-09 (1.12% to 0.98%- 13% <)
• Emergency department overcrowding, mortality and the 4-hour rule in Western Australia Gary C Geelhoed and Nicholas H de
Klerk Med J Aust 2012; 196 (2): 122-126. || doi: 10.5694/mja11.11159
• National data comparing hospital mort data (HSMR) vs
4HR performance
• The National Emergency Access Target (NEAT) and the 4-hour rule: time to review the target Clair Sullivan, Andrew Staib,
Sankalp Khanna, Norm M Good, Justin Boyle, Rohan Cattell, Liam Heiniger, Bronwyn R Griffin, Anthony Jr Bell, James Lind and Ian
A Scott Med J Aust 2016; 204 (9): 354. || doi: 10.5694/mja15.01177

21. NZ and WA data
• NZ 6 Hour rule data (95%)- national data
set; less deaths in ED and elective; but not
admits
• Impact of a national time target for ED length of stay on patient outcomes; Jones P et al NZMJ 2017
• Unpublished WA data- NHMRC funded study
• NB other 3 states did not show sig. change
• Forero Mountain Ngo Fatovich Man et al

22. Important to stay on track?
• Improved flow clearly improves LOS/ reduces access
block etc.
• No proven benefits of overcrowding
• Strong associations with poor outcomes when ED OC
• 4 current Australasian studies (1 weak UK study as
well) –suggest reversibility
• Which target?
• 4hr:, 80,90,95
• 6hr ; 95

23. WEAT performance last 2 years-
tertiary adults

24. ACEM- institutional racism?
• Issues raised in press
• V low pass rates for non-A/Saxon bckgd
• Basis was “non-white” pass rate 6.8% vs 85% for “cauc”
• Claimed “clearly not due to English skills”
• Claims that exam was overtly racist- “the only explanation”
• A follow up story in the Australian added fuel to fire with comments
leaked from an examiners blog:
“This may be a language issue such as failing to recognise subtle differences in meaning ... or may
be due to the methods used in their basic medical training,” Dr Dunn writes.
“a key problem facing graduates of overseas medical schools was a lack of “specialist level
knowledge”,
“Particularly troublesome were specialist trainees who had inadequate skills but did not realise it,
who “barrel on confidently with the wrong diagnosis, treatment and make errors that will harm
patients”. “They need to be brought back to earth very clearly,”

25. Exam pass rates in context?
• What is the history of the ACEM exam?
• Low overall pass rates 45-70%
• Problems considered for:
• Objectivity/ reproducibility/ writing/
• Examiners interaction- influence; too subjective ? standard
• Major format changes 2015/1 ? AMC driven:
• MCQ/SAQ only- written; std setting
• No short/longs-SCE’s only (12 ; mainly communication)
• Minimal examiner interactions- with candidates/ can’t intervene
• 2015/1 had a v high pass rate (80% +)- 2015/2 <50%

26. Exam pass rates:
written /clinical
• Written- always different pass
• Difficult to discriminate
• No candidate details-info
• No change in proportions after
• Clinical:
• Increasing non-anglo pass
• Greater pass rate since 2011
• Massive drop on 2015 onwards
• What changed
• Not examiners/ make up
• Written ? a bit easier
• Candidates –v unlikely
• EXAM +++

27. Other Colleges/ high stake exams have seen
similar (but not as severe differences)

28. What % of hospital activity/funding is ED
generated
• 1%
• 2%
• 3%
• 5%
• 8%
• 10%
• 15%
• 20%

29. What % of public hospital Dr. FTE are
employed by/in the ED.
• 1%
• 2%
• 4%
• 6%
• 10%
• 15%
• 20%
• 25%

30. What % of patient beds are patients admitted
via ED
• 15
• 25
• 35
• 45
• 55
• 65
• 75

31. Are USA - ED physicians risk averse

32. US data re being sued-2.5 x risk if ED (

34. Stereotypes

37. CVA thrombolysis; 2017 updatehttps://acem.org.au/getattachment/8321986e-bb5a-470b-b947-c646573f2b08/Systematic-Review-of-Intravenous-Thrombolysis-in-A.aspx
• 2016 ACEM review with independent meta-analysis
• Agreed that there was level 1A evidence of benefit for Tlysis
• NNT- 7-18 depending for improved functional outcome 0-1 (mRS)
• By 90 days no more deaths, > early deaths / more late deaths
• Equal numbers of severe dependence
• Quality of evidence was moderate (heterogeneity/ risk of bias)
• 2017 ACEM will not be endorsing current Stroke guidelines
• Concerns with agressive