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

0

100

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Minutes

ED LOS Awaiting

bed

Assessment

time

ED times for WA tertiary hospitals- proportion for

assessment

1999

2005

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%

3.1

2.9

2.52.6

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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

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FH RPH SCGH

20002001200220032004200520062007

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: 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)

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, turnoverComplaints/ 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- mythsBest 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

The 2000 year old triage system

Myth- managing Access Block

Managing hospital overcrowding- mythsBest 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

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 EvidenceExamples: 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- dataClinics, 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/CasualtyLittle 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.

OutcomesLOS in ED↑

Access block↑

Time to be seen↑

The TruthED 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 practicesBUT 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, AthonyPublication: New Jersey Business