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Making National Emergency Access Target (NEAT) Work

Tamworth Rural Referral Hospital
Project Added:
12 October 2015
Last updated:
26 October 2015

Making NEAT Work

Summary

This project examined the sequence of events from arrival to the ward and transfer of patients admitted to an inpatient ward through ED, to identify improvements that would reduce the number of admitted patients with an ED length of stay of more than four hours. 

Aim

To achieve an ED length of stay of less than four hours for more than 50% of ED patients subsequently admitted to an inpatient ward, by April 2015.

Benefits

  • Avoid prolonged ED length of stay, which is associated with increased in-hospital mortality and hospital length of stay.
  • Improve efficiency of ED processes to achieve better staff and patient satisfaction.
  • Improve turnaround times for ambulances delivering patients to ED.

Project status

Dates

  • Start: October 2014
  • Finish: April 2015

Status 

Implementation - The initiative is ready for implementation, is currently being implemented, piloted or tested.

Background

There is abundant evidence in the scientific literature that prolonged ED length of stay for patients subsequently admitted to an inpatient ward has negative influences on patient outcomes, ED workflow, ambulance workflow, patient and staff satisfaction.

The National Emergency Access Target (NEAT) acknowledges this and attempts to drive process change in EDs nationally. In Tamworth, only 30% of admitted patients have an ED length of stay of less than four hours. The project team looked for processes contributing to increased length of stay that the ED can influence. The team then tried to implement sustainable change and process improvements while monitoring and maintaining patient safety.

Implementation 

The team identified three solutions to improve the workflow in the ED.

  1. To improve the way doctors were allocated to patients, a ‘zoning’ system was established, where doctors were allocated responsibility for a number of beds in ED. Several types of zoning were attempted before the best solution was identified. Zoning has now become part of everyday business in the ED.
  2. Policy Directive 2009_055 was re-implemented. Although this policy came from NSW Health in 2009, the practice in ED did not reflect it. The ED engaged the inpatient teams in an attempt to improve transfer of care. The Policy Compliance Procedure document is still in draft form and consultation with inpatient teams is ongoing.
  3. The team identified that the transfer of some patients to inpatient beds occurred because their ED documentation was not complete. Nurse educators are currently improving compliance with the timely completion of documentation, using education strategies to monitor the process in real time.

Implementation site

Emergency Department, Tamworth Rural Referral Hospital, Hunter New England Local Health District

Partnership

Clinical Excellence Commission Clinical Leadership Program.

Results

Results will be measured by monitoring the percentage of patients admitted to an inpatient ward with an ED length of stay of more than four hours. Patient safety will be monitored by looking at rapid response calls within six hours of a patient being transferred from ED. Staff and patient experience will also be monitored.

Results to date have shown steady improvement, with modest gains in the rate of ED patients achieving a length of stay less than four hours, from 29% in September 2014 to 36% in December 2014. There has been no increase in rapid response calls and staff and patient satisfaction remains high.

Lessons learnt

  • It is hoped that a revitalised admission policy will improve results further.
  • The project was ambitious, with many variables over which the ED has no influence, including availability of inpatient beds, inpatient team review times and availability of imaging.
  • Zoning was a surprising quick win.
  • For change that is likely to be controversial, genuine consultation and robust debate is essential and takes time.
  • The enthusiasm of ED staff involved in the change process was surprising and encouraging.

Further reading

  • NSW Health. Caring Together: The Health Action Plan for NSW (Garling Report). 2009.
  • NSW Health. Emergency Department - Direct Admission to Inpatient Wards, Policy Directive 2009_055. 2009.
  • Richardson, D. The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay. Medical Journal of Australia 2002; 177: 492-495.
  • Liew et al. Emergency department length of stay independently predicts excess inpatient length of stay. Medical Journal Australia 2003; 179: 524-526.
  • Spirivulis et al. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Medical Journal of Australia 2006; 184: 208-212.
  • Richardson, D. Increase in patient mortality at 10 days associated with emergency department overcrowding. Medical Journal of Australia 2006; 184: 213-216.
  • Chalfin et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Critical Care Medicine 2007; 35: 1477-83.

Contact

Dr Nick Ryan
Director of Emergency Department
Tamworth Rural Referral Hospital
Hunter New England Local Health District
Phone: 02 6767 7443
Nick.Ryan@hnehealth.nsw.gov.au 

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