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Counting the pennies as Melbourne burns – access block

Friday, October 31st, 2008

It’s fiscal year reporting season for the Victorian Govt, and according to The Age newspaper report, it seems governments have grown accustomed to ensuring all their annual reports (this time, a massive 250 reports) are tabled on the same day with only a day left of Parliament to scrutinise them. Perhaps Mr Brumby is correct – it just takes time to get all the fiscal data finalised and have these reports signed off.

The hospitals have had their fiscal year budget performances announced – see The Age report on these albeit without the actual published table.

Given the escalating crisis situation in bed access block in public hospitals in Victoria, one should expect the general result of hospitals being in the red otherwise they could be perceived as putting profits ahead of patient care which of course would be rubbing salt into the wounds of stressed ED staff. After all governments tend to run hospitals as a loss-making concern as a measure to encourage efficiency.

Perhaps next year, allow the budget run a little more into the red to allow opening enough beds in Winter to get the patients out of ED? But then again, perhaps it is cheaper to manage inpatients in the ED?

And in case you are not aware of the bed access crisis, I have trawled through the Victorian government website where you can see each individual hospital’s performance in an interface which makes it hard for viewers to see trends across time periods or between hospitals.

To make your life easier, I have created the following chart which is an average of the data for the general adult Melbourne metropolitan hospitals:

Melbourne metropolitan ED average bypass and triage 3 targets

As can be seen, percent time on bypass is escalating and I believe it may have become worse for the first 3 months of this fiscal year. In addition, one of the KPI’s sensitive to ED overcrowding is the triage 3 percent seen within 30min target – as can be seen, this is falling as bypass rates increase.

Unfortunately, the triage 3 patients are “core business” for ED’s and falling performance in seeing these patients is likely to result in significant clinical risk.

Government could make it easier for hospitals and improve their funding so the hospitals don’t have to risk being seen as complicit in rorting the TAC or otherwise forced to scrounge to maximise income streams which risks diverting valuable resources away from their core business.

How much apparent wasted effort for ED staff is involved in coding “ED Admits” to get extra WIES when other funding models could be more efficient?

Of course, Governments could also “solve” the bypass problem without paying out any extra money by putting in place measures which make going on bypass more difficult, or at least apparently shorten the time required by hospital ED’s to be on bypass – maybe they should ensure bypass periods are only 10min instead of 2hr by default, and make the ED call the CEO or health minister in person each time they request to go on bypass.

Patients need us to really make a difference, not just appear to make a difference!

HEWS and bypass guidelines 2006

Business rules 2004-2005 for hospital demand strategy – hospital payments for meeting these KPI targets (pdf).

Finally, are our levels of access block due to inadequate Government funding of hospitals or problems with bed management within the hospitals as alluded to in section 5.3 in the Vic. DHS auditor general’s report 2004 (pdf) which I quote here:

“Access block from the emergency department is integrally linked to hospital-wide bed management. It is related to a number of factors, including:

  • how effectively hospitals plan for and manage total bed availability, making use of bed substitutes (such as hospital in the home) where appropriate
  • how elective and emergency demands are balanced
  • how beds are allocated to demand groups
  • whether inpatient discharge practices maximise effective use of beds, discharging patients as soon they are medically ready
  • whether a hospital’s inpatient beds are tied up by patients who could be cared for elsewhere, such as in aged care centres.”

Don’t shoot me – I’m only the messenger and asking some pointed questions to try and improve patient care.

oh… and here are some resources on access block on the OZEmedicine Wiki