ObjectiveTo describe and compare characteristics and outcomes of patients who arrive by ambulance to the ED. We aimed to (i) compare patients with a delayed ambulance offload time (AOT) >30 min with those who were not delayed; and (ii) identify predictors of an ED length of stay (LOS) of >4 h for ambulance-arriving patients.MethodsA retrospective, multi-site cohort study was undertaken in Australia using 12 months of linked health data (September 2007–2008). Outcomes of AOT delayed and non-delayed presentations were compared. Logistic regression analysis was undertaken to identify predictors of an ED LOS of >4 h.ResultsOf the 40 783 linked, analysable ambulance presentations, AOT delay of >30 min was experienced by 15%, and 63% had an ED LOS of >4 h. Patients with an AOT <30 min had better outcomes for: time to triage; ambulance time at hospital; time to see healthcare professional; proportion seen within recommended triage time frame; and ED LOS for both admitted and non-admitted patients. In-hospital mortality did not differ. Strong predictors of an ED LOS >4 h included: hospital admission, older age, triage category, and offload delay >30 min.ConclusionPatients arriving to the ED via ambulance and offloaded within 30 min experience better outcomes than those delayed. Given that offload delay is a modifiable predictor of an ED LOS of >4 h, targeted improvements in the ED arrival process for ambulance patients might be useful.
An additional ED within the region saw an increase in the total volume of presentations at a rate far greater than local population growth, suggesting it either provided an unmet need or a shifting of activity from one sector to another. Future studies should examine patient decision making regarding reasons for presenting to a new or pre-existing ED. There is an inherent need to take a 'whole of health service area' approach to solve crowding issues.
Objectives. The aims of the present study were to identify predictors of admission and describe outcomes for patients who arrived via ambulance to three Australian public emergency departments (EDs), before and after the opening of 41 additional ED beds within the area.Methods. The present study was a retrospective comparative cohort study using deterministically linked health data collected between 3 September 2006 and 2 September 2008. Data included ambulance offload delay, time to see doctor, ED length of stay (LOS), admission requirement, access block, hospital LOS and in-hospital mortality. Logistic regression analysis was undertaken to identify predictors of hospital admission.Results. Almost one-third of all 286 037 ED presentations were via ambulance (n = 79 196) and 40.3% required admission. After increasing emergency capacity, the only outcome measure to improve was in-hospital mortality. Ambulance offload delay, time to see doctor, ED LOS, admission requirement, access block and hospital LOS did not improve. Strong predictors of admission before and after increased capacity included age >65 years, Australian Triage Scale (ATS) Category 1-3, diagnoses of circulatory or respiratory conditions and ED LOS >4 h. With additional capacity, the odds ratios for these predictors increased for age >65 years and ED LOS >4 h, and decreased for ATS category and ED diagnoses.Conclusions. Expanding ED capacity from 81 to 122 beds within a health service area impacted favourably on mortality outcomes, but not on time-related service outcomes such as ambulance offload time, time to see doctor and ED LOS. To improve all service outcomes, when altering (increasing or decreasing) ED bed numbers, the whole healthcare system needs to be considered. MODELS OF CAREWhat is known about the topic? Escalating growth in demand for emergency patient services has placed increasing strain on both ambulance and hospital resources. Poor patient outcomes can result from crowded EDs and hospitals. What does this paper add? This paper identifies that following the opening of a 41-bed ED within a health service area, there was an improvement in in-hospital mortality outcomes for those who arrived to the ED via ambulance. Data linkage enhanced our ability to report on and understand the impact on outcomes across several systems (ambulance, ED and hospital admission). This paper provides a foundation for further research regarding emergency services expansion from a geographical area-wide perspective. Easily identifiable predictors of hospital admission for ambulance-arriving patients that may be useful for informing patient flow strategies are highlighted. What are the implications for practitioners? Practitioners need to be aware that patients arriving by ambulance to the ED are more likely to require admission if they are older, triaged to higher acuity, have circulatory or respiratory conditions and have an ED LOS of >4 h. Service planners need to consider the whole system when planning expansion.
Time pressures need to be taken into consideration when introducing changes to current processes. Also, it is recommended that, in addition to ongoing education, senior clinicians are engaged during the planning and execution stages of changes to practice.
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