ED Time and Tide - the evolution of NEAT-

historical perspective. ACEM 1983

FRIST FELLOWSHIP EXAM 1986 DEVELOPMENT OF EMERGENCY

MEDICINE AS A DISTINCT SPECIALTY

ED OVERCROWDING-HISTORICAL PERSPECTIVE

1980s - Development of EDs as a specialty Training positions for registrars specialising in

Emergency medicine. Many more procedures done in ED. More senior capable staff. More time spent with patients by senior

clinicians. Diagnosis rather than disposition. Plenty of inpatient beds. EDs evolved to do a lot more ‘stuff’ and had time

to do that. Concept of the ‘fully packaged patient.’

ED OVERCROWDING:1990’s In early 1990s ED overcrowding was rare and

surge related rather than related to a lack of inpatient beds.

Rumours of ‘access block’ in NSW around 1992 but ‘we didn’t have that problem In QLD.’

Relative decrease of bed stock per head of population/ bed closure/ efficiency dividends etc.

Qld developed major ‘Access Block’ (inpatients waiting more than 8 hours for a bed) by the mid to late 1990s and EDs were compromised in their function by being filled with inpatients awaiting beds upstairs.

ED OVERCROWDING: 2000’s ED overcrowding/ ambulance ramping a major public

health issue in Qld. ‘Corridor Beds.’ Studies by Richardson and Sprivulis in different sites

in Australia showed a 15 to 17% increase in inpatient mortality for those patients admitted to inpatient wards who were access blocked.

Introduction of 4 hour rule in the UK with large financial investment.

Recognition that ‘Access Block is a hospital wide problem’. Access Block National Target was for less than 20% of admitted patients to wait more than 8 hours from arrival time to inpatient bed.

Many patients spent more than 24 hours in ED awaiting inpatient beds.

ED OVERCROWDING - THE TIMES THAT MATTER

1. Waiting Time per triage category based on urgency (original paper by Dr Gerry Fitzgerald had the 5 cats as Seconds/ minutes/ hours/ same day/ whenever- now compressed into a 2 hour time frame).

Access Block- Target was to have < 20% of admitted patients waiting more than 8 hours for an inpatient bed (from time arrival)- few larger centres, if any, in Qld achieved this target in this period

Little attention given to ED targets in general during this period.

ED OVERCROWDING: 2010-2014

The beginning of NEAT in Australia recommendations by national taskforce in response to ED overcrowding being recognised as a public health issue.

Staged and staggered target over several years. Initial early wins in patient flow particularly in

W.A. Decision to go to a 4 hour time frame. (NZ 6 hrs)

Changing models of care. MAUs etc. ‘Disposition rather than Diagnosis.’

ED OVERCROWDING PRESENT SITUATION - QLD

Major improvements in patient flow and reduction of ED overcrowding.

Target Driven. Improvement in Ambulance Ramping. Improvements have come at much lower

percentages than the anticipated 90% target.

Questions arising on quality of care- some patients need more time. Disposition vs Diagnosis.

ED OVERCROWDING WHERE TO NOW?

NEAT related initiatives have improved patient flow through most EDs in Queensland.

General opinion from most ED staff is that ‘things are better.’

We achieved the old previously unachievable access block target yet never celebrated!

(see data of access block here) Currently the best performing state in Australia as far as

NEAT performance is concerned. Because of NEAT, EDs have become a priority in the

eyes of executives, and a catalyst for reform in the areas of patient flow.

ED OVERCROWDING - RISKS OF NEAT.

NEAT MEASURES WHEN YOU ARRIVE AND WHEN YOU LEAVE AND NOTHING IN BETWEEN!

TARGET DRIVEN SYSTEMS NEED QUALITY INDICATORS.

MID STAFFORDSHIRE DISASTER. NO EVIDENCE BASE AS TO WHAT IS THE

OPTIMAL PERCENTAGE FOR THE BEST PATIENT CARE.

ADMITTED VS NON ADMITTED NEAT.

ED OVERCROWDING OUR NEW CHALLENGE!

QLD has been the lead state in national NEAT performance for the past 18 months.

We have made improvements that need to be maintained.

To get to 90% NEAT for large high volume high acuity EDs may require considerable investment for no extra benefit.

The current NEAT takes no account of volume or acuity or quality of care. ATS 5 patients have the same target effect as ATS 1 patients.

Spending too much time in an ED can be unsafe for patients, spending too little time in an ED can be unsafe for patients- the challenge is to set the right target and maintain quality of care.