12 November 2021

Crowded hours: a day in the life of an ED

Comment Hospitals

“Cat 2 triage area!” 

A 79-year-old woman with chest pain and palpitations. 

Her name is Lorraine, but she doesn’t like being called that. “Call me Laurie or I’ll bite you!” she jibes, only half joking.

If meaningful treatment is not commenced within 10 minutes, the emergency department will have failed the first KPI – “seen on time”, per the triage score. The Australasian College for Emergency Medicine (ACEM) says the Australasian Triage Scale is “a clinical tool used to establish the maximum waiting time for medical assessment and treatment of a patient”. 

Chest pain gets a Cat 2 and staff get 10 minutes.

For Laurie, this will mean at least an ECG, if not aspirin and some pain relief. Usually, an emergency specialist or registrar attends each Cat 1 and 2 to ensure patient care is commenced; however, our saving grace is that nursing actions contribute to meaningful treatment as well.

Australasian Triage Scale CategoryTreatment AcuityPerformance Indicator Threshold
ATS 1Immediate100%
ATS 210 minutes80%
ATS 320 minutes75%
ATS 460 minutes70%
ATS 5120 minutes70%

Laurie had her ECG within 10 minutes and it showed atrial tachycardia at a rate of 120 beats per minute. The nursing team leader made a plan for Laurie to be transferred to Resus 1. Atrial tachycardia is hardly a life-or-death arrhythmia, but it is the only unoccupied monitored bed.

Because she self-presented, Laurie goes on the virtual “walk-ramp” while waiting for a bed in acute. The actual “ramp” is a corridor filled with patients on ambulance trolleys that cannot be offloaded into acute cubicles because there is none to spare. 

The Department of Health’s Protocol for Timely Transfer of Care in Emergency Departments dictates the timely transfer of care of the patients from the ambulance service to the emergency department.

Here it comes, the second KPI: POST (patient off stretcher time), which is the time between the point of triage and transferring the patient to an ED bed. In 90% of cases, it must be less than 30 minutes.

In September 2021, the Queensland audit office released a report on ED patient wait times. It demonstrated that since the previous report in 2014, walk-in presentations had increased by 21% and ambulance presentations by 46%, yet over that time frame, the Queensland population had increased by only 9.5%. During the reporting period, Cat 1 presentations increased by 41% and Cat 2 presentations by 50%. So, in addition to the increased numbers, it is apparent that our community’s health care problems are becoming more complex.

During the audit period, only one of the top 26 reporting hospitals met the KPI for POST. 

Ambulances that are delayed offloading in the ED cannot attend urgent calls in the community. 

“Cat 2, Resus 1!”

So much for Laurie making it to a monitored bed. 

A 49-year old-man, fall from horse, neck pain and right shoulder injury. 

Probably reasonable that he gets the resus bed.

Delays to accessing a bed space means delays to assessments, investigations and disposition decisions. 

Laurie makes it to an acute cubicle and is assessed by a registrar. She has some blood tests and a repeat ECG shows she is in sinus rhythm at a rate of 70 beats per minute. She was recently changed from a beta blocker to a calcium entry blocker to manage her atrial tachycardia, but it’s not yet well controlled and she’s very symptomatic. 

The third ED KPI is known by many names in Australia including NEAT (national emergency access target), ETP (emergency treatment performance) or ELOS (ED length of stay). Following the lead of the National Health Service (NHS) in the UK, Australia adopted the “four-hour rule” in 2012 to address the concerns about the quality and timeliness of care provided by hospital EDs. There is evidence that ED overcrowding is associated with suboptimal outcomes and patient dissatisfaction. 

The four-hour rule stipulates that at least 80% of patients must be treated and exit the ED within four hours. The literature shows that as NEAT compliance increases, in-hospital standardised mortality reduces … to a point. Overzealous pursuit of this time-based target may compromise patient care and safety.

During the audit period, only one of the top 26 reporting hospitals met the KPI for ELOS.

Ramping and prolonged length of stay are direct consequences of “access block” – the bane of every emergency physician’s working life. 

Access block is the situation where ED patients who have been admitted and need a hospital bed are delayed from leaving the ED for more than eight hours because of a lack of inpatient bed capacity. 

ACEM sums it up nicely: “Access block is a whole-health-system issue that essentially acts as a negative feedback loop. 

“Significant delays in emergency department patient flow (due to a lack of available beds) leads to delays in the treatment of new patients (as ED staff are managing access-blocked patients). This leads to ambulance ramping and longer wait times for newly arrived patients. More patients are therefore likely to leave the ED before receiving the essential treatment they need.”

Emergency clinicians want it to be known that it’s not the “GP-type patients” who present that create overcrowding and access block. While primary care in the community is desirable where possible, non-urgent presentations are usually managed quickly and discharged back to the community. Initiatives to reduce ED presentations, such as the Residential Aged Care Support Service (RASS) and Hospital in the Home (HITH), are an essential part of the way forward in reducing ED overcrowding. Telehealth has never been more pertinent than in the current covid era and these services are being utilised to support clinicians in both metropolitan and rural EDs.

In recent years, EDs have concentrated on streamlining processes, modifying models of care and implementing clinical pathways with some impact on patient flow issues. NEAT data for discharged patients and those remaining under the care of ED in short-stay units (SSUs) is universally superior to NEAT for admitted patients.

ED systems are imperfect, but robust. It’s the back door that needs focus now. Once the ED has completed emergency care and referred for admission, many patients don’t have a hospital bed to go to. ED overcrowding is a whole-of-hospital problem that needs a whole-of-hospital solution. It is heartening to see that after many years of ED campaigning, some health systems are taking such an approach to the problem.

Access block does not affect patients only. ACEM reported that, in 2019, their members named access block and overcrowding as their most significant workplace stressors. Workplace stress and dissatisfaction can lead to burnout, which in turn impacts on quality of patient care.

After discussing her presentation with my SMO colleague, the registrar admits Laurie to the SSU for observation of her heart rate and to enable a discussion to be had with her cardiologist. While in the SSU, Laurie, a retired nurse, assists a demented woman who wants to go to the bathroom but is unwilling to accept assistance from the delightful, but male, nurse who offers to attend her. 

With the dose of her medication increased, Laurie is discharged from the SSU for follow-up with her GP and the cardiologist. While I was not involved in her care, I apologise to Laurie that the whole process has taken much longer than I expected. She deflects the apology with gratitude that her emergency physician daughter helped navigate her visit to ED today. I finish my shift and take her home to Dad. 

Dr Bethany Boulton is an emergency physician working on the Sunshine Coast and a founding member of WRaPEM (Wellness Resilience and Performance in Emergency Medicine), dedicated to bringing the non-technical skills of medicine to the fore

Dr Boulton has her mother’s permission to share this story

Jeremy Knibbs is on leave

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