Targets alone won’t solve long waits for emergency care
Gerard Fitzgerald, Professor of Public Health at the University of Queensland, writes:
Data released today by the National Health Performance Authority (NHPA) shows just 54% of major metropolitan hospitals and 63% of major regional hospitals are treating or admitting patients within the recommended four hours.
Hospitals have two more years to reach the target of 90% of patients treated within four hours, which was agreed by the states and territories as part of the national health reform process.
It took an average of 15 hours for most (90%) of patients waiting in major metropolitan emergency departments to be admitted to a bed and almost 18 hours in regional hospitals. And while some states fared better than others – Western Australia being ahead of the game – there’s certainly a long way to go to reach the 2015 targets.
Emergency department congestion
Emergency departments (EDs) are at the core of health-care systems, providing immediate care and access to specialised services for patients suffering acute illness and injury. EDs developed rapidly in Australia in the 1980s and the subsequent decades have seen extensive investment in their resources and expertise.
Despite this rapid development, there is a high level of professional and community concern about the system-wide congestion and its impact on standards of care and clinical outcomes. ED congestion occurs because of a combination of growing demand for care, sicker patients and what’s known asaccess block. Put simply, more people are attending the ED, clinicians do more for them, and there are too few beds to admit patients for ongoing care.
On average, three in every ten people attend an ED each year and this is rising at a rate of 2% per annum. Almost a third (30%) of those patients require admission to hospital. This growth in demand is mostly among more urgent and complex patients, across all age groups, and appears mostly related to increased presentations for injury.
Most worryingly, insufficient numbers of inpatient beds means those who require admission to hospital often remain for many hours in the ED before they can be transferred to an appropriate location for ongoing care, thus “blocking” the ED beds.
While the need for operational and policy measures to alleviate the strain on EDs is seldom disputed, there is currently neither a systematic understanding of the challenges, nor a cohesive approach to accumulating and providing evidence to inform policy initiatives.
Public policy responses to date – such as co-located GP services, public awareness campaigns, 24-hour telephone advisory services – have been shown consistently to have failed to address the issue.
The national health reform program includes further initiatives such as additional funding for EDs, the implementation of four-hour targets for emergency care (one of the National Emergency Access Targets), the introduction of an activity-based funding mechanism for EDs and the development of a balanced performance indicator framework for EDs.
How do we fix the problem?
It’s not just about money for EDs. Indeed, the investments into EDs during the past three decades have been exceptional.
The real causes of the congestion are outside the control of the EDs: growing demand and access block. In addition, the future demographics of Australia, when one person will be working for each person who is not, demands more creative solutions than simply throwing more dollars at it.
Emergency health care of the future must operate more efficiently and effectively to accommodate both the growth in demand and the introduction of new clinical technologies which expand the scope of acute care. What’s needed is a more comprehensive approach based on a detailed understanding of the evidence.
First, nothing will work unless we address the issue of access block. Each year, Australia grows by roughly the population of Canberra. Logic demands that each year we must grow Australia’s health resources by that which currently exists in Canberra, just to mark time. We need more hospital beds (or other inpatient capacity), but we also need to be clever and creative about how we design that capacity so that the efficiency of the system also improves.
Second, we need to address the growth in ED demand. Not by abusing the patients and calling their decision to seek help as “inappropriate”, but by developing alternative sources of appropriate health care that may address the patient needs in a timely and appropriate fashion.
Third, we need to re-engineer the ED systems and redesign the departments to enable a smoother transition for patients and to improve the department’s efficiency. Principles can be drawn from other industries about the efficient flow of patients through the system.
Finally, we need to facilitate these developments through an appropriate funding model which recognises both the fixed and variable costs of EDs. And we need to evaluate progress through a balanced scorecard that incorporates process measures such as timeliness of care, with efficiency measures and clinical and other outcomes.
EDs of the future must look and operate differently to accommodate the very real challenges of the future. A more considered approach to policy development is urgently required.
** Gerard Fitzgerald is Professor, School of Public Health, Queensland University of Technology. He receives funding for this research from the ARC and the Qld Ambulance Service. He is affiliated with the Australasian College for Emergency Medicine and the Australian Medical Association.
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