The factors responsible for overcrowding and access blocks within emergency departments (EDs) are complex and often interrelated. Amid a growing population and increasing demands on EDs over the past 20 years, the Australian government has utilized different strategies to improve patient flow and decrease wait times in EDs around the country. For example, the National Emergency Access Target (NEAT) requires most ED patients to be transferred or discharged from the ED within four hours. The effects of NEAT and similar policies on outcomes such as quality of care, length of patient stay, and staff experience have yet to be comprehensively analyzed and quantified.
To investigate the different initiatives being implemented in hospitals around Australia to improve patient experiences in EDs, and to provide recommendations for healthcare professionals working to maintain quality care in the current healthcare system.
- A literature review was conducted through Proquest, Medline, Pubmed and Scopus. Searches were made of related Australian EDs and used a combination of the following key terms: access block, overcrowding, emergency department, four or 4-h rule or target, Australia, National Emergency Access Target, initiatives or innovations, fast track, lean thinking from 1992 to 2013, and streaming.
- Key strategies adopted by different EDs were highlighted so that their effectiveness with regard to reducing delays and streamlining patient flows could be analyzed through the literature review. These strategies included: nurse-initiated interventions, rapid assessment teams, patient streaming, waiting room nurses, short-stay observation units, and care coordination programs.
Nurse-initiated interventions, which allowed nurses to enact blood tests and radiography, reduced patient quality of care indicators as well as patient length of stay. Waiting room nurses, who reassess and report patient conditions before reporting their findings to triage nurses, helped improve patient length of stay, reduce the number of patients who left without treatment as well as the number of adverse occurrences in the waiting room, and helped induce higher levels of patient satisfaction. Patient streaming, which directs those with minor illnesses and injuries to separate areas apart from those with major illnesses and injuries, seemed to benefit all ED patients by getting them to doctors more quickly and reducing wait times. Rapid assessment teams, which help expedite patient flow with early requests for interventions and quick dispositions to appropriate ED areas, also reduced waiting times and contributed to batter patient outcomes and ED flow. Care Coordination teams, who target high-risk patients such as the elderly, homeless, and those with substance abuse problems, generated notably high rates of staff satisfaction. Short-stay observation units, which accommodate patients needing over four hours of treatment but are not likely to require hospital admission, were effective when protocols for treating common conditions were well developed and nurses had the power to advance patients to the next step in treatment pathways.
This paper presents a literature review and accordingly does not conduct any original testing through designed interventions. All literature reviewed in this study was sourced from Australia and published between 1992 to 2013, so some of the findings, including those describing the effectiveness of certain procedures and policies, may not be as effective in different countries with different healthcare systems.