The latest MJA journal has several papers relating to hospital access block in Australia and New Zealand:

Access block: it’s all about available beds – Daniel M Fatovich, Geoff Hughes and Sally M McCarthy

Access block can be managed – Peter A Cameron, Anthony P Joseph and Sally M McCarthy – abstract:

• Hospitals cannot manage their emergency patients when there is significant access block.
• There are solutions that should be implemented but require national leadership to be effective.
• These solutions include an immediate increase in the number of acute hospital beds, improved coordination and increased community capacity to manage medical patients with complex conditions outside acute public hospitals, improved hospital processes, and better standardisation of treatment within emergency departments.
• There is little evidence that telephone triage, ambulatory care clinics or disaster management techniques, including ambulance diversion, reduce access block.

Myths versus facts in emergency department overcrowding and hospital access block – Drew B Richardson and David Mountain abstract:

• Overcrowding occurs when emergency department (ED) function is impeded, primarily by overwhelming of ED staff resources and physical capacity by excessive numbers of patients needing or receiving care. Access block occurs when there is excessive delay in access to appropriate inpatient beds (> 8 hours total time in the ED).
• Access block for admitted patients is the principal cause of overcrowding, and is mainly the result of a systemic lack of capacity throughout health systems, and not of inappropriate presentations by patients who should have attended a general practitioner. Overcrowding is most strongly associated with excessive numbers of admitted patients being kept in the ED.
• Excessive numbers of admitted patients in the ED are associated with diminished quality of care and poor patient outcomes. These include (but are not limited to) adverse events, errors, delayed time-critical care, increased morbidity and excess deaths (estimated as at least 1500 per annum in Australia).
• There is no evidence that telephone advice lines or collocated after-hours GP services assist in reducing ED workloads.
• Changes to ED structure and function do not address the underlying causes or major adverse effects of overcrowding. They are also rapidly overwhelmed by increasing access block.
• The causes of overcrowding, and hence the solutions, lie outside the ED. Solutions will mainly be found in managing hospital bedstock and systemic capacity (including the use of step-down and community resources) so that appropriate inpatient beds remain available for acutely sick patients.

Interventions to circumvent intensive care access block: a retrospective 2-year study across metropolitan Melbourne – Graeme J Duke, Michael D Buist, David Pilcher, Carlos D Scheinkestel, John D Santamaria, Geoff A Gutteridge, Peter J Cranswick, David Ernest, Craig French and John A Botha

DHS Victoria has notified Victorian hospitals of a new parliamentary inquiry:

The Legislative Council’s Standing Committee on Finance and Public Administration has resolved to inquire into and report on:

“The capacity of hospitals to meet demand, standards and quality of care, resourcing and access levels, and the accuracy and completeness of performance data for Victorian hospitals.”

The Age reported today on the submission to the inquiry by Victorian ED registrar Dr Andrew Buck whose allegations support a survey of Victorian ED directors by the ACEM which stated that hospital administrators were fudging computer data and admitting patients to “virtual wards” or “ghost wards”.

In other words, patients waiting long periods for an inpatient bed due to access block were allocated a Short Stay Unit bed on the computer system even though they were left on ED trolleys with their risk of bed sores and discomfort, not to mention the delay in definitive care by a dedicated nursing and medical team on the wards such as a stroke unit.

This practice is clearly not in the best interests of patients as KPI data will erroneously suggest everything is going well when it clearly is not, and thus means levels of poor patient care cannot be easily identified.

From my experience, doctors and nursing staff in the ED find such manipulation of data abhorrent, and it is a pity that hospital administrators appear to have been forced into such measures by government funding rules to retain a reasonable level of funding.

Fortunately, the Victorian government seems committed to increasing acute inpatient beds which hopefully will reduce the bed access block and ED overcrowding which is the prime issue in emergency departments at present.

The DHS annual report for 2007-2008 can be found here.

NSW health department looks like they may be requesting a “please explain” from doctors who admit patients to hospital with a diagnosis that can often be treated in the community such as pneumonia, UTI, DVT, etc.

See The Sydney Morning Herald article Dec 17th 2008.

NSW Health’s Acute Care Taskforce has identified 12 medical conditions, including pneumonia, bronchitis, urinary tract infections, chest pain and gastroenteritis.

Hmmm… chest pain Mx in the community for trial of death?

Sounds like the bureaucrats think we are lazy and irresponsibly unnecessarily adding to bed access block by admitting low risk patients.

Certainly there is a place for encouraging some of these patients to be treated in the community, but I would be surprised if most avenues to community treat appropriate patients are not already being tried.

At the end of the day, the patients we admit are almost always needed to have inpatient care either because they have a more severe form of the illness that warrants close medical or nursing care, or their social situation mandates it, or there is a lack of community support (unavailability of hospital in the home resources or availability of adequate GP follow up), or evening presentations where home care overnight becomes less safe.

Many EDs utilise their Short Stay Observation Unit for lower risk patients as long as hospital administration has not usurped this beds as interim care for patients needing inpatient care.

Creating more paperwork will just make us more frustrated and inefficient – the ED environment is already overloaded with bureaucratic processes that adversely impact ED staff efficiencies without demonstrably improving patient care, please don’t add more!

Sounds like just more political smoke screen to disguise the fact that there just are not enough acute hospital beds for the population and not enough community resources to allow community care.