Optimising patient flow: reducing delay to discharge from acute wards to residential aged care facilities (RACF) to improve access block in the emergency department

Emergency departments (EDs) are overcrowded and unable to meet the ever-increasing demands for healthcare. Access block is the most significant contributor to ED overcrowding. Access block refers to delays in admitted patients leaving the ED due to an unavailability of inpatient beds. The consequences of access block can be catastrophic, including adverse events, higher mortality rates, reduced quality of care, and increased costs.

Large numbers of patients who occupy acute beds are non-acute and considered safe and ready for discharge. These patients are predominantly waiting for residential aged care facility (RACF) placement. In addition to financial and patient flow strain, hospital stays longer than required creates significant risk of functional decline.

As the largest public health service in Queensland, Metro North Health has made significant investments in various successful hospital avoidance, substitution and navigation programs. However, timely access and flow of patients to RAC, which increases availability of inpatient beds for patient admission from ED, remains a significant issue. Therefore, this research investigates: How can we reduce discharge delay from acute wards to RACFs to improve access block?

This research will characterise the cohort of patients who are ready for discharge and waiting for RACF placement, and understand the barriers and solutions to discharge delay. These findings can then be used in future phases of this research program to predict patients who will have a delayed discharge, target strategies and pathways at admission, model the impact of released acute bed capacity on access block, and develop metrics for inpatient stays.

Implementation and Evaluation of a Surgical Rapid Assessment Unit – Improving Emergency Department Flow with Timely Surgical Care

Emergency Departments (EDs) in Queensland hospitals are often overcrowded, leading to long wait times and reduced patient satisfaction. At Logan Hospital, patients with surgical problems currently go through a full ED assessment before seeing a surgical specialist, causing unnecessary delays. To address this, we’re creating a Surgical Rapid Assessment Unit (SRAU). This unit will be open on weekdays from 8 am to 4 pm and will directly assess stable patients with surgical issues, bypassing the usual ED process. This means patients will be seen faster by the right specialist.

Our research aims to evaluate how well the SRAU works. We’ll look at:
1. How it affects patient wait times and overall hospital stay
2. Patient safety
3. Whether it’s cost-effective
4. Challenges in implementation

This project is innovative because it fundamentally changes the patient journey, allowing direct surgical assessment without the usual step of ED evaluation. This approach could improve care quality and use hospital resources more efficiently. If successful, the SRAU model could significantly reduce ED congestion and improve patient flow. This model of care could be applied statewide and nationally to other Australian hospitals facing similar challenges.

We’ll use multiple research methods, including comparing data before and after SRAU implementation, surveying patients and staff, and analysing costs. The results will provide strong evidence on whether this model works and how it could be adopted by other Queensland hospitals, potentially leading to widespread improvements in emergency surgical care across the state.

Reducing delayed admissions from ED to ICU, ICU discharge delay and after-hours discharge through a co-designed multi-component intervention: A stepped wedge feasibility cluster randomised trial (the REDEEM-ED-ICU trial)

Hospitals and in particular, emergency departments (ED) are often overcrowded and unable to meet ever-increasing demand. The leading cause of overcrowding is access, or ‘bed-block’. This is a serious issue as it impacts the ability of staff to provide quality care to their patients.

Hospital patient flow is a nationwide problem that has attracted attention from researchers and policymakers, yet solutions to improve it, have been ineffective. As ED and Intensive Care Units (ICU) treat the most critically ill patients, it is unsurprising that the patient’s journey through these departments is closely connected. ED patient flow can be impacted by ICU bed capacity, delayed admission into ICU, and delayed and after-hours discharge from ICU. Bed-block can have significant consequences for the patient - including increased waiting time, prolonged length of ICU and hospital stay, more hospital-acquired complications, higher mortality and increased financial burdens for the health system. It is estimated that delayed discharges from ICU alone costs Australia $40 million/year.

The proposed study aims to co-design and test a multi-component intervention to address patient flow, building on a foundation of our preliminary collaborative research looking at hospital priorities, current strategies and practice, and barriers and enablers to ICU discharge processes.

We expect the impacts of this work will include,
• Improved patient outcomes
• Improved patient flow through ICUs, including admission from ED to ICU
• Reduced cost to the Australian healthcare system.
• Informing future national competitive grant applications for national implementation of the multi-component intervention

Acceptability, feasibility and efficacy of the Activity Level and Flow Report – Emergency Department (ALFRED) tool. Measurement of capacity, overcrowding and escalation reporting in a tertiary paediatric emergency department

Emergency department (ED) overcrowding and subsequent impacts on patient safety and quality of care is a global public health challenge. Capacity measurement and risk assessment tools play a vital role in capturing and communicating ED overcrowding to trigger escalation strategies, mitigate risk and facilitate patient safety and flow. Currently, there is no universal definition of ED crowding and tools developed to measure crowding and quality of care in paediatric EDs are largely based on research undertaken in the adult setting.

The Queensland Children’s Hospital (QCH) ED currently use the Staffing Acuity Physical Transfer/Disposition Environment (SAPhTE) tool, manually calculated by the Emergency Flow Coordinator (EFC) and designed to assess and escalate ED capacity, access block and departmental risk. Audits and staff surveys have identified challenges in the SAPhTE tool including timely completion especially during peak ED activity, inter-operator variability in interpretation and scoring, limited central visibility and poor shared understanding around escalation. QCH ED have co-designed the Acuity Level and Flow Report - Emergency Department (ALFRED) dashboard which provides near real-time capacity metrics from FirstNet to provide an automated and visual report of ED capacity, patient flow challenges and risk assessment. As a measure of overcrowding, ALFRED incorporates the single-site validated Pediatric Emergency Department Overcrowding Scale (PEDOCS). Further research is required to evaluate the acceptability, feasibility and efficacy of the ALFRED tool in a paediatric ED. This will facilitate potential translation to other pediatric centers and mixed emergency departments to promote a proactive approach to capacity risk assessment and improve patient flow.

optimiSed PAtient Flow using prEhoSpital Triage (safest)

There have been significant increases in system pressure for unscheduled public healthcare in Australia. Likewise, ambulance services have seen an unprecedented increase in demand for services along with a change in ambulance utilization. These pressures affect all aspects of patient flow, from triple zero call through to hospital admission and discharge. Improvements in the integration of prehospital services into the healthcare system can reduce time delays at their interface. Triage and clinical deterioration tools guide clinicians' decisions when directing patients to clinical streams within the emergency department whilst balancing patient safety. Paramedics are highly trained clinicians, that are well placed to assess and determine a patient’s clinical priority and potential for deterioration. If paramedics can demonstrate their application of validated triage and clinical deterioration tools to efficiently and safely direct patients to the most appropriate facility and/or clinical stream within a facility, then there would be potential time savings across the system. Furthermore, this would provide a validated tool to identify patients that are safe to be referred to the virtual emergency department. This study proposes to assess paramedics' ability to apply triage and clinical deterioration tools to identify the clinical stream either within an emergency department or via the virtual emergency department. If successful, this process could improve patient safety while reducing delays at the ambulance and emergency department interface.

SAFE STEPS – SAFE and Seamless Transition through Enhanced Proactive Support

The physical health equivalent of a relapse in a mental health patient would be a repeat stroke or heart attack. Episodes may be fatal and the chances of full recovery decreases with each episode. Every effort must be made to detect and prevent emerging crisis in the community. Currently, patients present to Emergency Department (ED) despite being open to community case management, using precious ED resources. There is limited evidence regarding reducing unplanned ED presentations, with some needing psychiatric inpatient care. Princess Alexandra Hospital employed a Transition Coordinator to support the care of people who are deteriorating in the community. The Transition Coordinator has been collating a unique dataset, names of patients who have been flagged as deteriorating and have received support successfully, as well as those who have had unplanned presentations to ED or have needed admission. Our proposed study will analyse this dataset and identify key defining characteristics of planned and unplanned admissions. We will also survey patients, families and staff regarding what helps in a crisis and why they presented to the ED rather than to the community clinic. A clinical audit of the notes will also provide information on what happened in the lead up to an unplanned admission. In-depth interviews with patients and supporting family and staff will provide further insights. The findings will inform service changes. They will be pulled into a replicable package to free up ED resources and inpatients beds through provision of early detection and treatment in the community.

Criteria Led Discharge from Emergency Department Short Stay Unit

The Emergency Department Short stay unit (EDSSU) is used to facilitate flow through the Emergency department (ED) for patients requiring further investigations, treatment or period of observations, with the likely disposition of home. Current access block issues and increasing patient presentations means the SSU is consistently full, with multiple patients waiting to be transferred to this unit. Furthermore, limited medical staffing with only one junior doctor to follow up on these patients creates an exit block during periods of increased activity. Criteria Led discharge (CLD) is a proposed strategy that allows for safe and timely discharge of patients by nursing staff from the EDSSU once diagnosis-specific criteria have been met without the need for final medical review. Post initial assessment and investigations, medical staff can identify specific patient cohorts for the CLD pathway. Nursing staff can then discharge patients once criteria is met. CLD is not a new concept; being used among wards and paediatric centres statewide, however it has not been utilised within the adult emergency space in Queensland to the best of our knowledge. This process will decrease length of stay (LOS) within the ED and EDSSU, increasing patient satisfaction with the healthcare service, redirecting medical resources allowing medical staff to prioritise acute patient presentations or perform critical emergency procedures, and alleviate pressures created by medical sick leave when no residents can be allocated to SSU as nursing staff can manage and discharge this cohort of patients using the CLD pathway.

Paeds with a wheeze – Improving patient flow with Nurse Led Stretching of Inhaled Salbutamol (NLSIS)

Wheeze is one of the most common emergency department presentations for pre-school aged children. The typical treatment regime involves early review by a medical officer or nurse practitioner and an intensive “burst” of inhaled salbutamol therapy, followed by an admission to a short stay unit to wean inhaled salbutamol therapy to 3-hourly. The medical officer or nurse practitioner will review the child hourly to establish the need for further treatment or the capacity to increase the interval between salbutamol therapy. As they manage a concurrent case load in both the emergency department and short stay unit, there are often delays in bedside assessment and administration of salbutamol. During the COVID-19 pandemic, the substantial increase in wheezing presentations caused significant bed pressure, waiting room overcrowding and poor patient flow. Nurse Led Stretching of Inhaled Salbutamol (NLSIS) is a pathway that optimises registered nurse’s skills and scope of practice to perform a detailed respiratory assessment on a child presenting with a wheezing illness and determines when the next dose of salbutamol should be administered. The aim of the project is to evaluate whether NLSIS reduces short stay unit length of stay optimising patient care and patient flow in a children’s emergency department and short stay unit.

Study to Analyse Patient Flow in Queensland Public Hospitals

This study will adopt a system-wide view to capture relationships and interactions between flow metrics to identify access issues and inform the design of interventions/solutions to improve patient flow at a system level. A system-wide approach covering prehospital and ED services offers the potential for improving patient flow at the ambulance/hospital interface. By integrating ambulance, ED and inpatient data, it is possible to identify blockages along the entire patient journey that have a flow-on effect on ED access. It is also possible to identify critical hospital and ambulance service levels when performance starts to degrade, suggesting where the system would benefit from revised strategies.

The project ‘Study on Patient Flow in Queensland’s public hospitals’ is conducted by a research team comprising experts from CSIRO, Queensland Health, UQ and QAS.