Objective. To implement and evaluate strategies for improving access to emergency department (ED) care in a tertiary hospital.Methods. A retrospective pre-post intervention study using routinely collected data involving all patients presenting acutely to the ED of a major tertiary hospital over a 2-year period. Main outcome measures were changes in: the percentage of patients exiting the ED (all patients, patients discharged directly from the ED, patients admitted to inpatient wards); mean patient transit times in the ED; inpatient mortality rates; rates of ED 'did not wait' and re-presentations within 48 h of ED discharge; and selected safety indicators. Qualitative data on staff perceptions of interventions were also gathered.Results. Working groups focused on ED internal processes, ED-inpatient unit interface, hospital-wide discharge processes and performance monitoring and feedback. Twenty-five different reforms were enacted over a 9-month period from April to December 2012. Comparing the baseline period (January-March 2012) with the post-reform period (January-March 2013), the percentage of patients exiting the ED within 4 h rose for all patients presenting to the ED (from 32% to 62%), for patients discharged directly from the ED (from 41% to 75%) and for admitted patients (from 12% to 32%; P < 0.001 for all comparisons). The mean (AEs.d.) time all patients spent in the ED was reduced from 7.2 AE 5.8 to 4.4 AE 3.5 h (P < 0.001) and, for admitted patients, was associated with reduced in-hospital mortality (from 2.3% to 1.7%; P = 0.045). The 'did not wait' rates in ED fell from 6.9% to 1.9% (P < 0.001), whereas ED re-presentations within 48 h among patients discharged from the ED rose slightly (from 3.1% to 3.8%; P = 0.023). Improvements in outcome measures were maintained over the subsequent 12 months.Conclusions. Multiple reforms targeting processes both within the ED and its interface with inpatient units greatly improved access to ED care over 12 months and were associated with decreased in-hospital mortality.What is known about this topic? Prolonged stays in the ED result in overcrowding, delayed ambulance access to ED care and increased adverse outcomes for admitted patients. The introduction in Australia of National Emergency Access Targets (NEAT), which stipulate at least 70% of patients in the ED must exit the department within 4 h, have spurred hospitals into implementing a wide range of reforms with varying levels of success in achieving such targets. What does this paper add? This study demonstrates how multiple reforms implemented in a poor performing tertiary hospital caused the proportion of patients exiting the ED within 4 h to double within 9 months to reach levels comparable with best performing peer hospitals. This was associated with a 26% reduction in in-hospital mortality for admitted patients and no clinically significant adverse effects. It demonstrates the importance of robust governance structures, executive sponsorship, cross-disciplinary collaboration, regular feedback of N...
In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in‐hospital and after‐hospital care, patient self‐care, and hospital–community integration. A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF. Quality improvement interventions were implemented over 17 months after a 6‐month baseline period and included: ➢clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways); ➢educational interventions (seminars, academic detailing); ➢regular performance feedback; ➢patient self‐management strategies; and ➢hospital–community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs). Using a before–after study design to assess program impact, significantly more program patients compared with historical controls received: ➢ACS: Angiotensin‐converting enzyme (ACE) inhibitors and lipid‐lowering agents at discharge, aspirin and β‐blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation. ➢CHF: Assessment for reversible precipitants, use of prophylaxis for deep‐venous thrombosis, β‐blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels. Risk‐adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P = 0.06) and from 13.4% to 10.1% (P = 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P = 0.005) for patients with CHF. Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.
Objective. The aim of the present study was to identify patient and non-patient factors associated with reduced mortality among patients admitted from the emergency department (ED) to in-patient wards in a major tertiary hospital that had previously reported a near halving in mortality in association with a doubling in National Emergency Access Target (NEAT) compliance over a 2-year period from 2012 to 2014.Methods. We retrospectively analysed routinely collected data from the Emergency Department Information System (EDIS) and hospital discharge abstracts on all emergency admissions during calendar years 2011 (pre-NEAT interventions) and 2013 (post-NEAT interventions). Patients admitted to short-stay wards and then discharged home, as well as patients dying in the ED, were excluded. Patients included in the study were categorised according to age, time and day of arrival to the ED, mode of transport to the ED, emergency triage category, type of clinical presentation and major diagnostic codes.Results. The in-patient mortality rate for emergency admissions decreased from 1.9% (320/17 022) in 2011 to 1.2% (202/17 162) in 2013 (P < 0.001). There was no change from 2011 to 2013 in the percentage of deaths in the ED (0.19% vs 0.17%) or those coded as in-patient palliative care (17.9% vs 22.2%). Although deaths were not associated with age by itself, the mortality rate of older patients admitted to medical wards decreased significantly from 3.5% to 1.7% (P = 0.011). A higher mortality rate was seen among patients presenting to ED triage between midnight and 12 noon than at other times in 2011 (2.5% vs 1.5%; P < 0.001), but this difference disappeared by 2013 (1.3% vs 1.1%; P = 0.150). A similar pattern was seen among patients presenting on weekends versus weekdays: 2.2% versus 1.7% (P = 0.038) in 2011 and 1.3% versus 1.1% (P = 0.150) in 2013. Fewer deaths were noted among patients with acute cardiovascular or respiratory disease in 2013 than in 2011 (1.7% vs 3.6% and 1.5% vs 3.4%, respectively; P < 0.001 for both comparisons). Mode of transport to the ED or triage category was not associated with changes in mortality. These analyses took account of any possible confounding resulting from differences over time in emergency admission rates.Conclusions. Improved NEAT compliance as a result of clinical redesign is associated with improved in-patient mortality among particular subgroups of emergency admissions, namely older patients with complex medical conditions, those presenting after hours and on weekends and those presenting with time-sensitive acute cardiorespiratory conditions. HEALTH SERVICE RESEARCHWhat is known about the topic? Clinical redesign aimed at improving compliance with NEAT and reducing time spent within the ED of acutely admitted patients has been associated with reduced mortality. To date, no study has attempted to identify subgroups of patients who potentially derive the greatest benefit from improved NEAT compliance in terms of reduced risk of in-patient death. It also remains unclear as t...
Traditional markers of patient flow do not correlate with inpatient NEAT compliance in contrast to two new markers of inpatient boarding in ED (PANE and ICE). Standardised mortality rates for both emergency and all patients show a strong inverse relation with inpatient NEAT compliance.
Opportunities exist for improving quality of in-hospital care of patients with CHF, -particularly for optimal prescribing of: (i) DVT prophylaxis, (ii) ACEi, (iii) second-line vasodilators, (iv) beta-blockers and (v) warfarin. More research is needed to identify methods for improving quality of in-hospital care.
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