Better faster emergency care Improving emergency care and access in Victoria’s public hospitals 4 Clinical review of area mental health services 1997-2004 Intensive care for adults in Victorian public hospitals 2003 

Better faster emergency care Improving emergency care and access in Victoria’s public hospitals

Improving the health, wellbeing and quality of life for Victorians through improving emergency care and access in Victoria’s public hospitals ii Intensive care for adults in Victorian public hospitals 2003

Published by the Metropolitan Health and Aged Care Services Division, Victorian Government Department of Human Services, Melbourne, Victoria, Australia. © Copyright, State of Victoria, Department of Human Services, 2007 This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968. Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne. Published on www.health.vic.gov.au/emergency January 2007 (061013) Foreword from the Minister

Improving emergency care and access in Victoria’s public hospitals continues to be a key priority for the Victorian Government. Victoria’s public hospitals face significant demand for emergency care in line with pressures such as population growth, increased incidence of chronic disease, global workforce contraction, the changing nature of health care delivery and growing community expectations of what health care can achieve. We have one of the best health systems in the world. We need to continue to invest in, and strengthen existing emergency care and access in Victoria’s hospitals to assist our health system to deliver the best possible care to the community. Better faster emergency care: improving emergency care and access in Victoria’s public hospitals (2006) establishes firm directions and new approaches to further strengthen the capacity of the health system to meet the emergency care needs of our community. Health services have made significant improvements in emergency access since the Hospital demand management strategy commenced in 2001-02. The sustained increases in demand for health care services means that the system must continue to evolve in order to provide equitable, timely and quality emergency care. Leadership in quality and safety of emergency care will be important to ensure delivery of patient centred care. Innovation will be necessary to keep pace with the accelerating rate of changes in health care delivery. Strategic directions outlined in Better faster emergency care will lead the way for continued improvement in emergency care in the future. Improving emergency care and access in Victoria’s public hospitals will take a sustained commitment and appropriately targeted resources from the government and health services. The government is committed to continuing to work in partnership with health services to ensure we have an innovative, efficient and effective health system. I commend this policy framework to you, and look forward to continued collaboration to improve health outcomes for the Victorian community.

The Hon Bronwyn Pike MP Minister for Health Acknowledgements

Many people have participated in consultations and workshops to support the development of this policy framework. In particular, I would like to acknowledge the members of the Emergency Access Reference Committee (EARC) who gave their time to plan this policy and will provide a key monitoring and advice role for its implementation.

EARC 2005-06 membership included: Professor Peter Cameron (Chair) Bayside Health Dr Craig Winter Northern Health Ms Lucy Cuddihy Barwon Health Mr Andre Coia Metropolitan Ambulance Service Associate Professor Alex Cockram Southern Health Professor Joseph E Ibrahim Peninsula Health Dr John Ferguson Ballarat Health Associate Professor Ged Williams Eastern Health Dr Bill Newton General Practice Divisions - Victoria Mr Jon Evans Western Health

I would also like to thank departmental staff from Metropolitan Health and Aged Care Services, Rural and Regional Health and Aged Care Services and Portfolio Services and Strategic Projects who made a significant contribution to the development of this policy framework.

Lance Wallace Executive Director Metropolitan Health and Aged Care Services Department of Human Services Executive summary

Emergency care is provided in a range of settings within the community including general practice, community-based providers, ambulance services and hospital emergency departments. In 2005- 06, there were over one million presentations to Victoria’s public hospital emergency departments. Emergency departments in Victoria’s public hospitals have been under sustained pressure over the past decade in line with pressures such as population growth, increased incidence of chronic disease, global workforce contraction, the changing nature of healthcare delivery and growing expectations of what healthcare can achieve. Pressures experienced include overcrowding, delays in accessing hospital beds and instances of ambulance diversion. Analysis of the Victorian Emergency Minimum Dataset from 1999-2000 to 2005-06 shows there has been sustained demand for emergency care and a growing complexity of emergency department patient needs. In addition, decreased accessibility to general practitioners within the community has contributed to significant numbers of primary care type presentations in emergency departments. A range of initiatives have been implemented to address emergency care pressures as part of the Hospital Demand Management strategy including expanding emergency capacity, implementing new models of care, reducing avoidable use of hospitals and implementing strategies to ensure an emergency care workforce of sufficient size, skill and distribution. In addition, there has been significant investment in public health, health promotion, population health and primary health approaches to improve health outcomes for the Victorian community. Better faster emergency care recognises there is a need for continued system improvement to improve patient flow through hospitals and increase the number of patients that can be seen while minimising delays and improving the quality and safety of care. In 2004, the Victorian Auditor General released the audit report Managing emergency demand in public hospitals that included a range of recommendations in relation to managing emergency demand, ambulance presentations, patient flows within emergency departments, emergency department resources and data management. The Victorian Government recognises that ongoing work is required to strengthen the capacity of the health system to respond to the emergency care needs of the community. Better faster emergency care: improving emergency care and access in Victoria’s public hospitals sets a policy direction to support continued reform of the health system to ensure it best meets the emergency care needs of the community in the future. The aims of Better faster emergency care are to: • ensure equitable and timely access to emergency care within Victoria’s public hospitals • enhance the quality of emergency care in Victoria’ s public hospitals • support delivery of patient-centred emergency care • deliver improved health outcomes for the Victorian community. Better faster emergency care identifies ten key priorities and actions that will be undertaken from 2006-07 to achieve this vision. The ten priorities are:

1. develop new service options 2. improve coordination between emergency department and ambulance services 3. improve the patient experience 4. mainstream new models of care 5. explore new ways of working 6. enhance safety and quality of care 7. promote better systems of care 8. promote better management of care for people with mental health problems 9. promote better management of care for older people 10. promote better management and care of children.

To achieve the aims of this policy, there needs to be a system-wide approach that supports innovation, continuous quality improvement and is people-centred. Enablers to support implementation of the ten priorities are: • system improvement • service planning • funding policy reform • workforce development • information technology and data management solutions • partnership development.

Integral to successful implementation of Better faster emergency care is adoption of an integrated approach across the Department of Human Services. Work undertaken over the next five years will focus on development of a sustainable and innovative framework for government, health services, health professionals and the community to work together to ensure the health system best meets the emergency care needs of the community in the future.

Contents

1. Introduction 1 2. Purpose 3 3. Development of Better faster emergency care 5 4. Policy context 7 4.1. Victorian Government policy context 7 4.2. The role of the Department of Human Services 9 5. Victoria’s health system 11 6. Victoria’s emergency care system 13 6.1. General practice and community providers 13 6.2. Ambulance services 13 6.3. Victoria’s public hospital emergency departments 13 6.4. Emergency department care in Victoria’s public hospitals 15 7. Key challenges for the emergency care system in Victoria 19 7.1. Emergency department demand in Victoria’s public hospitals 19 7.2. Population demographic change 21 7.3. Demand for primary care in emergency departments 23 7.4. Demand for mental health services in emergency departments 23 8. Initiatives to date 27 8.1. Hospital demand management strategy (2001) 27 9. Public Hospital emergency care performance 33 9.1. Improving waiting times for emergency care 33 9.2. Department of Human Services performance monitoring framework 34 10. The way forward 39 10.1. The need for a system wide approach 40 10.2. The need for innovation 40 10.3. The need for a continuous quality improvement approach 41 10.4. The need for people-centred approaches 42 11. Enablers to move forward 43 11.1. System improvement 43 11.2. Service planning 45 11.3. Funding policy reform 45 11.4. Workforce development 46 11.5. Information technology and data management solutions 47 11.6. Partnership development 47 12. Ten priorities 49 12.1. Develop new service options 49 12.2. Improve coordination between emergency departments and ambulance services 53 12.3. Improve the patient experience 55 12.4. Mainstream new models of care 58 12.5. Explore new ways of working 63 12.6. Enhance safety and quality of care 66 12.7. Promote better systems for care 67 12.8. Promote better management of care for people with mental health problems 69 12.9. Promote better management of care for older people 72 12.10. Promote better management and care of children 74 13. Conclusion 75 Appendix 1 77 Appendix 2 79 Appendix 3 83 Bibliography 91 Better faster emergency care 

1. Introduction

Delivering emergency care is an integral part of the health system and the quality of emergency care has a key role in determining health outcomes for patients. Providing emergency care has unique characteristics, for example the majority of visits are unscheduled and, at times, decisions about treatment and actions need to be taken rapidly. As in other Australian states and in countries comparable to Australia, Victoria has experienced growing demand for emergency care over the past decade that has placed significant pressure on the hospital system. Pressures experienced by health services in all states and territories in Australia over the past decade include congested emergency departments, instances of ambulance diversion and delays in accessing hospital beds, now commonly referred to as ‘access block’. Since 2000, the Victorian Government has implemented a range of initiatives through the Hospital demand management strategy in partnership with health services and the community to address these pressures. This work has resulted in significant improvements to emergency care and access in Victoria’s hospitals.  Better faster emergency care Better faster emergency care 

2. Purpose

‘The Victorian Government will now take the next steps to build on the capacity of our world-class health system to deliver timely, quality emergency care to all Victorians.’ Hon Bronwyn Pike MP, Minister for Health, at the launch of the Better State of Hospitals Conference, April 2006

Better faster emergency care sets a policy direction to support continued reform of the health system to ensure it best meets the emergency care needs of the community in the future. It is also intended to assist health services to make the best use of available resources to deliver improved health outcomes for the Victorian community. The policy framework recognises that demand for acute care is growing and that appropriate balance needs to be maintained to meet the demand for both emergency and elective services.

The strategic aims of Better faster emergency care are to: • ensure equitable and timely access to emergency care within Victoria’s public hospitals • enhance the quality of emergency care in Victoria’s public hospitals • support delivery of patient-centred care • deliver improved outcomes for the Victorian community.

The document identifies the following enablers to achieve these aims: • system improvement • service planning • funding policy reform • workforce development • information technology and data management solutions • partnership development.

The document also identifies ten priorities to improve emergency care and access in Victoria’s public hospitals. Each of the priorities outline initiatives already underway and further actions that will be undertaken from 2006-07 and beyond.  Better faster emergency care

Strategic directions

Ensure equitable Enhance the Support delivery Deliver improved and timely access quality of of patient–centred health outcomes to emergency care emergency care emergency care for the Victorian in Victoria’s public in Victoria’s community hospitals public hospitals

Ten priorities

1. Develop new service options 2. Improve coordination between emergency departments and ambulance services 3. Improve the patient experience 4. Mainstream new models of care 5. Explore new ways of working 6. Enhance safety and quality of care 7. Promote better systems of care 8. Promote better management of care for people with mental health problems 9. Promote better management of care for older people 10. Promote better management and care of children.

Enablers to support

System improvement Service planning

Funding policy reform Workforce development

Information technology Partnership development and data management solutions Better faster emergency care 

3. Development of Better faster emergency care

Better faster emergency care has been developed in consultation with the Emergency Access Reference Committee, established by the Department of Human Services in 2005 to provide expert advice on strategies to improve access to emergency care in Victoria’s public hospitals. A discussion paper, Emergency access strategy (2005) provided a framework for consultation with health services and stakeholders. Following consultation and a series of workshops, priorities were developed that have formed the basis of Better faster emergency care. Better faster emergency care has also been informed by reviewing initiatives implemented to strengthen the capacity of public hospitals to meet demand for emergency care, and recommendations outlined in the Victorian Auditor General’s report, Managing emergency demand in public hospitals (2004). An analysis of Victoria’s public hospital emergency department profiles and health service performance was also undertaken.  Better faster emergency care Better faster emergency care 

4. Policy context

4.1. Victorian Government policy context Better faster emergency care aligns with key Victorian Government policy frameworks including:

4.1.1. Growing Victoria Together Growing Victoria Together - a vision for Victoria to 2010 and beyond, expresses the Victorian Government’s vision for the future of Victoria and outlines the challenges and important issues that Victoria is facing. One of the objectives identified inGrowing Victoria Together is: By 2010, Victoria will have further strengthened performance in relation to high quality, accessible health and community services. To complement this vision, A Fairer Victoria was released in 2005. This policy statement sets out actions to address disadvantage and improve access to services, reduce barriers to opportunity, strengthen assistance for disadvantaged groups and places, and ensure that people get the help they need at critical times in their lives. In June 2006, A Fairer Victoria: Progress and next steps was released, detailing progress to date and the next steps to achieve A Fairer Victoria. More information about Growing Victoria Together is available at www.growingvictoria.vic.gov.au

4.1.2. Victoria: A better state of health (2005) This document articulates the Government’s vision for health and is underpinned by five overarching principles: • the best place to treat • together we do better • patient-focussed technology • a better patient experience • a better place to work. 4.1.3. Directions for your health system: Metropolitan Health Strategy (2003) Directions for your health system: Metropolitan Health Strategy (MHS) is a five-year plan for development of health services in Victoria. It was developed to provide a strategic policy and planning framework that focuses on fundamental system changes required to achieve sustainable delivery of health services that are safe, of high quality, responsive to individual needs, timely and efficient. The MHS identifies the following four strategic directions to position the health system in Victoria to meet future demand for services: • increase capacity • redistribute and configurate capacity • service substitution and diversion • new service models. A key element of the MHS is capital planning required to provide a framework for provision of facilities, infrastructure and resources across the metropolitan area. Innovative models of care explored in the MHS included the roles of general practitioners (GPs), hospitals and community health services and establishment of super clinics and health precincts.  Better faster emergency care

In 2006, the Department of Human Services commenced an update and review of the achievements of the MHS since 2003. The aim of the Metropolitan Health Strategy Refresh is to ensure the public health system provides the optimal level, distribution and mix of services to meet growing and changing demand while ensuring safe and high quality services, sustainability of service provision and timely access.

4.1.4. Rural directions for a better state of health (2005) Rural directions for a better state of health provides a framework for rural health services to continue developing and enhancing their roles in the system of care across Victoria. It is intended to help health services orientate themselves towards the changing needs of communities and make the best use of available resources to deliver improvements in the health of rural Victorians. The three broad directions that have been identified are: • promote the health and wellbeing of rural Victorians • foster a contemporary health system and models of care for rural Victoria • strengthen and sustain rural health services. 4.1.5. Care in your community: A planning framework for integrated ambulatory health care (2006) Care in your community provides a ten-year vision for a modern, integrated and person and family-centred health system. It is about refocusing and investing in the best mix of hospital and community-based integrated care services to better meet the needs of Victorians. The framework includes a focus on service models that provide alternatives to presentations at emergency departments for urgent care. These include the co-location of general practice clinics with emergency departments and community–based health facilities providing a ‘minor injury unit’ model, with capacity for basic diagnostic, suturing and fracture work, and observation facilities. Other key Victorian Government policy frameworks that have informed Better faster emergency care include: • New directions for Victoria’s mental health services: The next five years (2002) • Better quality better health care - A safety and quality improvement framework for Victorian health services (2003) • Improving care for older people: a policy for health services (2003) • Quality plan 2003-04: Metropolitan health and aged care services (2003) • HealthSMART: Strategy for the modernisation and replacement of information technology (2003) • Primary Care Partnership strategic direction 2004-06 (2004) • Community health services: creating a healthier Victoria (2004) • General practitioners in community health services strategy (2004) • Cultural diversity guide: Multicultural strategy-Department of Human Services (2004) • Elective surgery access policy (2005)

Further information about these publications is available in Appendix 1. Better faster emergency care 

4.2. The role of the Department of Human Services The Department of Human Services is responsible for planning and funding a wide range of services including health, community and housing services to diverse client groups across Victoria. The Statewide Emergency Program (SEP), Access and Metropolitan Performance Branch, has program responsibility for emergency hospital access and care. The role of SEP is to improve the capacity of the Victorian public health sector to respond to, and actively manage increasing demand for emergency services across the Victorian public health sector. More information about the Access and Metropolitan Performance Branch is available at www.dhs.vic.gov.au/ahs/ metrobranch.htm SEP works closely with programs areas within Metropolitan Health and Aged Care Services, Rural and Regional Health and Aged Care Services and Portfolio Services and Strategic Projects to facilitate an integrated approach across the department to improve emergency care and access in Victoria’s public hospitals. 10 Better faster emergency care Better faster emergency care 11

5. Victoria’s health system

The Victorian public health system is a large, complex system comprised of a diverse range of service providers. Public hospitals are the largest component of the state health budget. The private health system also plays a role in providing hospital services to the community. There are 17 metropolitan public health services that include 36 metropolitan public hospitals providing a range and mix of services across a number of health service campuses. A range of ambulatory-based care services are also provided, either co-located with hospitals or in community- based facilities. Mental health inpatient services are provided in hospitals, extended care centres or integrated care centres. A diverse range of health services is also provided in rural Victoria. Publicly-funded rural health services range in size from large regional hospitals to community services including bush nursing centres in isolated areas. There are 96 hospital sites, 17 stand-alone community health services and 13 bush nursing centres. A distinctive feature of the Victorian rural public health system is the significant role it plays in providing residential aged care services. 12 Better faster emergency care Better faster emergency care 13

6. Victoria’s emergency care system

Emergency health care is provided in a wide range of settings within the community including general practice, community-based service providers, ambulance services and hospital emergency departments.

6.1. General practice and community providers General practice provides the majority of primary medical care in the community and plays an important role in offering emergency and unscheduled medical care. Other community providers, for example community health services and community-based mental health clinical response and support services, also provide assessment and treatment for people with urgent health care needs.

6.2. Ambulance services In Victoria the Metropolitan Ambulance Service (MAS), Rural Ambulance Victoria (RAV) and the Alexandra District Ambulance Service provide emergency and non-emergency treatment and transport for patients requiring medial services. In metropolitan areas, the Emergency Communications Centre Victoria receives all calls for emergency transport, prioritises requests and assigns a response appropriate to the urgency of the presenting problem. On average, there are 597 ambulance presentations a day at Victoria’s public hospital emergency departments (MAS and RAV).1 Ambulance services also provide (either directly, or through a system of contracted services) authorised non-emergency transport services to patients whose conditions are non-life-threatening but who require specialist transport officer skills or equipment, or where transport by any other means would be impractical. MAS and RAV have joint policies and procedures, including MAS-RAV clinical practice guidelines to ensure prompt and appropriate emergency care of people and transport to the nearest appropriate hospital as quickly as possible. More information about these guidelines is available at www.ambulance.vic.gov.au/opservices/guidelines.html

6.3. Victoria’s public hospital emergency departments The Australasian College for Emergency Medicine (ACEM) defines an emergency department as ‘the dedicated area in a hospital that is organised and administered to provide a high standard of emergency care those in the community who perceive the need for, or are in need of acute or urgent care including hospital admission.’2 Emergency departments in Victoria’s public hospitals are required to accept all presenting patients. There are 38 metropolitan and rural hospitals in Victoria with a designated emergency department.3 Of these, 37 provide a staffed 24-hour emergency service.4 There are six private hospitals offering a staffed 24-hour emergency department.

1 VEMD 2005-06 2 Australasian College for Emergency Medicine, 2001. Policy Document: Standard Terminology, Melbourne. 3 Hospitals which receive the Non Admitted Emergency Services Grant Victoria–Public hospitals and mental health services Policy and funding guidelines 2006-07, Melbourne. 4 Williamstown is not open 24 hours a day. 14 Better faster emergency care

There are also 50 urgent care centres and 28 primary injury services in rural hospitals that provide varying levels of emergency care supported by GPs on an on-call basis. Urgent care centres have capacity to provide initial resuscitation and limited stabilisation to critical patients prior to early transfer, and definitive care to non-critical trauma patients according to patient need and available local resources. A list of public hospital emergency departments, urgent care centres and primary injury services is included in Appendix 2. Figure 2 outlines the location of public hospital emergency departments and rural urgent care centres and primary injury centres.

Figure 1: Location of public hospital emergency departments, rural urgent care centres and primary injury services in Victoria. Better faster emergency care 15

6.4. Emergency department care in Victoria’s public hospitals In Victoria, emergency departments are designed to deliver short episodes of time critical care and treat people who are experiencing a medical emergency that is life threatening or could cause serious or ongoing disability. Approximately 23 per cent of emergency department presentations will require admission to an inpatient bed at a hospital.5 Some emergency departments in Victoria’s hospitals specialise in treating particular groups such as children or trauma patients in addition to the usual emergency department casemix. There are a small number of emergency departments providing only specialist care such as the Royal Victorian Eye & Ear Hospital and the Royal Women’s Hospital.

Emergency department care in Victoria’s hospitals–a snapshot

In 2005-06: • Victorians made over one million presentations to metropolitan and major regional Victorian public hospital emergency departments – an average of 3,416 presentations per day • Victorians were more likely to visit an emergency department on a Sunday • emergency department presentation rates were highest for those under five and over 65 years of age.

Overall, approximately: • 17 per cent of emergency department presentations were for non-urgent presentations • 20 per cent of emergency department presentations arrive by ambulance • 69 per cent of emergency department presentations returned home following assessment and management at the emergency department • Four per cent were admitted to a short-stay observation unit • 23 per cent of emergency department presentations were admitted to a hospital inpatient bed.

Source: Victorian Emergency Minimum Dataset 2005-06

The first priority in an emergency department is to treat patients with the most urgent medical needs. As in other states within Australia, all Victorians who present at emergency departments are ‘triaged’ or assessed for urgency. The triage nurse is generally the first contact for patients arriving at an emergency department. There are five triage categories in the Australasian Triage Scale (ATS) that range from patients who require resuscitation to patients whose medical needs are not urgent.6 Figure 1 presents the ATS triage categories and some examples of possible characteristics for each of the categories.

5 Department of Human Services, Victorian Emergency Minimum Dataset (VEMD), 2005-06. 6 Australasian College for Emergency Medicine, 2000. Policy Document: The Australasian Triage Scale, Melbourne. 16 Better faster emergency care

Figure 2: ACEM triage categories and possible characteristics

Triage category Possible characteristics

1. Resuscitation Cardiac arrest, life threatening injuries

2. Emergency Very severe pain, severe breathing difficulties, major priorities, major fractures, attempt at self harm

3. Urgent Moderate blood loss, persistent vomiting, dehydration, presence of psychotic symptoms

4. Semi-urgent Less severe symptoms or injuries, mild bleeding, foreign body in eye, sprained ankles, possible fractures, abdominal pain

5. Non-urgent Minor illnesses or symptoms

The triage system relates to urgency rather than severity or complexity. For example, some patients who meet triage categories four and five may still have conditions that require admission to an inpatient bed in hospital. Following assessment, stabilisation and management of their condition, patients may be discharged to their place of residence, be referred to another service or be admitted to an inpatient bed for further treatment.

6.4.1. Public hospital emergency department workforce Emergency department workforce staff includes emergency physicians, medical and nursing staff, allied health staff and support staff such as clerical and transportation staff. Emergency department staffing models vary depending on the size and location of the emergency department. A review of workforce models commissioned by the Department of Human Services in 2004, identified examples of innovation in workforce practice in Victoria’s public hospitals over recent years.7 These include: • evolving categories of staff to undertake some clinical tasks ordinarily undertaken by medical clinicians, for example nurse practitioners • greater use of allied health staff to improve discharge processes • greater use of non-clinical staff such as communications clerical staff • up-skilling of staff to enhance their skills in management of patients with psycho-social or complex care needs.

7 Bearing Point, 2005. Final Report Workforce Analysis Project: Emergency department, Intensive Care Unit and Radiology department, Melbourne. Better faster emergency care 17

6.4.2. Emergency departments as part of the broader health system

‘A hospital emergency department cannot be viewed in isolation from the wider health system.’ Source: Victorian Auditor General, Managing emergency demand in public hospitals, 2004

The emergency department is one of the multiple points of entry to the hospital and broader health system. A patient’s journey through the emergency department can become blocked because of delays in accessing inpatient hospital beds or community-based services. Establishing protocols and linkages between emergency departments and other parts of the hospital and broader health system is critical to ensuring effective patient flow and continuum of care for patients who require emergency care. Figure 3 presents a diagrammatic view of emergency department flow that shows entry and exit points from the emergency department.

Figure 3: View of Victoria’s public hospital emergency department points of entry and exit

Source: The Department of Human Services, 2006 18 Better faster emergency care

6.4.3. Collection of emergency department data In Victoria, de-identified demographic, administrative and clinical data for metropolitan and regional emergency department presentations at Victoria’s public hospitals is collated through the Victorian Emergency Minimum Dataset (VEMD), which is managed by the Metropolitan Health and Aged Care Services Division, Department of Human Services.8 Analysing demand data is instrumental to achieving a shared view of emergency demand pressures. Literature identifies that effective monitoring of emergency departments assists with benchmarking and design of interventions to address emergency demand pressures.9 The VEMD provides information to support epidemiological studies, health service funding, planning and coordination, policy assessment and formulation, clinical research, quality improvement, patient management, emergency department operation and management and reporting obligations under the National Health Information Agreement and the Australian Health Care Agreement.10 A committee (comprised of representatives from the Department of Human Services, participating hospitals, Victorian Injury Surveillance and Applied Research Centre and the metropolitan and rural ambulance services), reviews VEMD specifications and business rules annually. Victorian hospital emergency data is supplied to the Commonwealth Department of Health and Aging (DoHA) and the Australian Institute of Health and Welfare (AIHW). Comparative results are published annually. The Department of Human Services will continue to work with DoHA and AIHW to improve the scope, relevance and comparability of the National Minimum Emergency Department Dataset. Proposed improvements include collection of emergency department presenting problem and diagnosis. As part of VEMD continuous quality improvement initiatives, an audit of the data submitted by Victorian public hospitals will be undertaken by the department in 2006-07. Commentary and observations about patterns of emergency department use from 1999-2000 to 2004-06 for 38 metropolitan and rural hospitals using data sourced through the VEMD is presented in Appendix 3.

8 There are also 75 other rural urgent care and primary injury services that do not report to VEMD. Emergency care provided by these services is not reflected in data analysis presented within this document. 9 Canadian Agency for Drugs and Technologies in Health, 2006. Technology Overview: Emergency Department Overcrowding in Canada: What are the issues and what can be done? Issue 21, May 2006, Ottawa. 10 Department of Humans Services VEMD Manual 2005-06. Better faster emergency care 19

7. Key challenges for the emergency care system in Victoria

‘Demands on emergency departments have increased significantly in recent years and this trend is likely to continue...A significant proportion of patients presenting to emergency services are elderly, and have complex, chronic health problems or mental health and other problems not traditionally seen as the domain of emergency care.’ Source: Australian Health Workforce Advisory Committee Occasional Paper, Emergency Care Workforce Forum, June 2003

The practice of emergency medicine has been undergoing constant evolution over the past decade as technological changes continue to drive increasing sophistication of investigative and treatment modalities and health services utilisation. Over recent years there has also been increased consumer expectations of health systems, particularly in relation to ease and timeliness of access to services, freedom of choice and informed participation in care. In line with other Australian states and territories, global health workforce retraction has impacted on all parts of the Victorian health system. It is acknowledged nationally and internationally that one of the greatest challenges for provision of any type of health care, including emergency care, is the shortage of medical, nursing and allied health expertise. Victoria’s public emergency departments have faced sustained demand for emergency care over the past ten years. Pressures have included congested emergency departments and delays in accessing hospital beds. Factors impacting on bed availability are complex – examples include a decrease in the availability of informal carers within the community and a shortfall of residential aged beds. The core business of emergency departments has also undergone change over the past decade. Significant numbers of emergency department presentations are now older people with chronic health needs and patients with complex needs including psycho-social needs. There are also significant numbers of primary care type presentations11 at emergency departments.

7.1. Emergency department demand in Victoria’s public hospitals The following section outlines commentary and observations about emergency department demand from 1999-2000 to 2005-06 for 38 metropolitan and rural hospitals using data sourced through the VEMD.12 Rural urgent care centres and primary injury services do not report to the VEMD.

11 Triage categories 4 and 5, not referred by a GP and not arriving by ambulance, were not admitted and had a total stay in emergency department of less than 12 hours 12 Only 29 hospitals reported to the VEMD in 1999-2000; one small metropolitan hospital began reporting presentations in 2000-01 and six rural hospitals and one small metropolitan hospital began reporting in 2003-04. Rural urgent care centres and primary injury services do not report to the VEMD. The activity for the hospitals that did not report to VEMD from 1999-2000 has been estimated for earlier years based on their actual VEMD data submission for the most recent years. Casey Hospital opened and began reporting data in 2004-05. 20 Better faster emergency care

There has been sustained and consistent growth in demand for emergency department care over the past decade. From 1999-2000 to 2005-06, the total number of emergency department presentations in Victoria’s metropolitan and rural hospitals increased from approximately 945,000 in 1999-2000 to 1,247,060 in 2005-06 – an annual increase of 5.3 per cent. Between 1999-2000 and 2005-06, the rate of growth in emergency department presentations was greater for metropolitan hospitals (6.2 per cent) compared to rural hospitals (3.5 per cent). Emergency department demand has grown at a stronger rate than the population growth, and is projected to increase to approximately 1.3 million in 2006-07. Figure 4 presents the number of emergency presentations for 38 public metropolitan and rural hospitals, from 1999-2000 to 2005-06 and projected increase in 2006-07 using data sourced through the VEMD.

Figure 4: Number of emergency department presentations by year, 1999-2000 to 2006-07 forecast (metropolitan and rural hospitals)

7.1.1. Ambulance services Demand for emergency ambulance transports has also experienced significant growth in recent years. The number of emergency cases in the MAS catchment has increased from 209,000 in 1999-2000 to 254,000 in 2004-05 – an increase of almost 21 per cent over the period or an annual average increase of 4.2 per cent. The number of emergency cases in the RAV catchment increased from 60,000 in 1999-2000 to 100,000 in 2004-05 - an increase of 65 per cent over the period or an annual average increase of 13 per cent. Figure 5 shows the number of emergency MAS and RAV ambulance cases from 1999-2000 to 2004-05. Better faster emergency care 21

Figure 5: Number of emergency MAS and RAV ambulance cases in Victoria: 1999-2000 to 2004-05.

Source: Programs Branch, Department of Human Services, September 2006

7.2. Population demographic change

‘One particularly significant issue associated with ageing will be having more older people increasingly dependant on health and age-related services.’ Source: Beyond Five Million: the Victorian Government’s Population Policy (2004)

There have been significant changes in the demography of Victoria over the past decade. Since 1960, the population has been gradually ageing, with the median age rising from 29.6 to 35.4 years.13 As the population grows older and life expectancies increase, there will be a greater proportion of older people who have greater health needs and greater prevalence of chronic and complex diseases. In Victoria, chronic diseases are the leading cause of illness and death and include diabetes, cardiovascular disease, asthma, cancer, and chronic obstructive pulmonary disease. Figure 6 presents Victoria’s changing age structure: 1971-2031 (projected).14

13 Department of Premier and Cabinet, 2004. Beyond Five Million: the Victorian Government’s Population Policy, Melbourne. 14 ibid 22 Better faster emergency care

Figure 6: Population aged over 65 years as a percentage of Victoria’s population; 1971, 2001, 2031.

The increase in the proportion of older people in the community has correlated with an increasing number of emergency department presentations and admissions for people aged over 65 from 1999-2000 to 2005-06. The number of emergency presentations for people over 65 increased from 147,284 in 1999-2000 to 230,468 in 2005-06 – an increase of 47 per cent or average annual growth of eight per cent. The number of emergency admissions for people over 65 increased from 66,223 in 1999-2000 to 110,746 in 2005-06 - an increase of 67 per cent or average annual growth of 11 per cent. Figure 7 presents the actual number of reported emergency department presentations from 1999-00 to 2004-05 and compares this with the number that would be expected as a result of demographic changes only.15 Demographic changes have contributed to 16 per cent of total growth.

Figure 7: Number of emergency department presentations expected due to demographic change only compared to total growth. Better faster emergency care 23

7.3. Demand for primary care in emergency departments Primary care type presentations16 now constitute 45 per cent of presentations in metropolitan emergency departments, and 51 per cent of all emergency department presentations at larger regional hospitals.17 Primary care type emergency presentations occur more frequently in the evenings and at weekends. These trends have correlated with decreased accessibility to GPs in the community who are main providers of primary medical care in Victoria and are often the first point of contact for health care services. There is a recognised GP workforce shortage particularly in rural areas and outer metropolitan areas. There has also been a reduction in average GP working hours and increasing numbers of patients referred to locum services after hours. Access to GPs can also be problematic due to a reduction in bulk-billing. Between 1996-97 and 2001-02, bulk-billing has declined across the socio- economic spectrum.18 Due to the funding and regulatory arrangements for the GP workforce, many aspects of GP workforce reform require change to be addressed at the national level. It is recognised that some people with primary care type health needs are most appropriately cared for in emergency departments. However, timely access to GPs in the community is critical to ensure the health system can respond more appropriately to people who occasionally need care for short- term illness or injury. In 2006-07, the Department of Human Services will undertake a more detailed analysis of primary care type presentations in Victoria’s public hospital emergency departments and their impact on emergency departments, and identify some models for their most appropriate management.

7.4. Demand for mental health services in emergency departments The prevalence of mental health problems is a significant issue in Australia. The Australian Bureau of Statistics identified that, in 2001, 9.6 per cent of the Australian population (1.8 million people) reported having a long-term mental or behavioural problem that lasted, or was expected to last for six months or more.19 Mental health emergency presentations include people with depression and other mood disorders, anxiety conditions, psychotic disorders, substance abuse, suicide attempts and other acts of deliberate self-harm, and reactions to personal crisis. Patients may also present at emergency departments with a physical problem that may mask underlying mental illness.

15 VEMD data and forecasting undertaken by Workforce and Planning, Department of Human Services (July 2006). The hospitals that did not report in 1999-2000 account for 8 per cent of the growth in emergency presentations. 16 Triage categories 4 and 5, not referred by a GP and not arriving by ambulance, were not admitted and had a total stay in emergency department of less than 12 hours 17 VEMD data 2005-06 18 National Health Performance Committee, 2004. National Report on Health Sector Performance Indicators: A Report to Australian Health Ministers’ Council 2003, CAT.NO.hw178, Australian Institute of Health and Welfare. Canberra. 19 Australian Bureau of Statistics, 2001. Mental Health in Australia: A Snapshot, Canberra. CAT 4824.0.55.001 24 Better faster emergency care

Emergency departments have a role in providing emergency care to people with mental health needs. The Auditor General’s report (2004) noted that patients needing psychiatric care might be challenging to manage in the busy emergency department environment. The report also noted that some hospitals had long delays in placing psychiatric patients needing admission usually because of access to specialist beds. The Department of Human Services recognises there is a need to strengthen the emergency care response in emergency departments for people with mental health needs. There has been increasing numbers of mental health presentations at emergency departments from 1999-2000 to 2005-06. The rate of mental health presentations at emergency departments is consistent with the overall rate of growth of emergency department presentations. This is represented in Figure 8.

Figure 8: The number of mental health and non-mental health emergency department presentations between 1999-2000 and 2005-06. Better faster emergency care 25

There has been an increase in the proportion of mental health presentations requiring admission to an inpatient bed, with a corresponding decrease in the proportion of discharges from the emergency department to place of residence. Figure 9 shows the proportion of mental health and non-mental health emergency department presentations admitted to a hospital inpatient bed from 1999-2000 to 2005-06.

Figure 9: Percentage of emergency department presentations who are admitted to a public hospital inpatient bed.

Mental health presentation and admission trends have occurred within a context of increased awareness of mental illness in the community, decreased GP accessibility and mainstreaming of mental health services since the 1990s. 26 Better faster emergency care Better faster emergency care 27

8. Initiatives to date

A range of initiatives have been implemented by the Victorian Government to improve the capacity of the health system to meet the emergency care needs of the community as part of the Hospital demand management strategy (HDMS) implemented in 2001. In addition to initiatives funded under the HDMS, the Victorian Government has also made a significant investment in public health, health promotion, population health, integrated management of chronic disease and primary health approaches to support a ‘whole of system’ approach to addressing demand for health care services.

8.1. Hospital demand management strategy (2001) In response to unprecedented and sustained increases in demand for health care services that was placing significant pressures on hospitals, the Victorian Government committed $582 million as an initial investment over four years from 2001-02 to 2004-05 to implement the HDMS. The HDMS commenced with a round of funding for public health services to implement and pilot specific changes in activity, process and structure to improve emergency performance. The HDMS implemented many of the recommendations of the Patient Management Taskforce that was established in 2000 to undertake a short focussed review of patient management practices across the metropolitan health system. The taskforce was convened for six months in 2000 to examine challenges to the acute health system and develop a strategy to meet them. In 2001, the taskforce produced a series of eight papers, commissioned two literature reviews and identified essential patient management practices, priority areas for improvement and recommendations on measures to support necessary change in practice and enable ongoing monitoring.20 The HDMS’s focus has been on the service system as a whole, promoting the development of appropriate pathways for people using health services, and encouraging establishment of models of care that effectively meet the community’s emergency care needs. From 2001-02 to 2005-06, the HDMS aimed to strengthen the capacity of the health system to manage increasing demand pressures through: • funding targeted growth in the activity performed within hospitals • substitution through expansion of models of care that use alternatives to traditional inpatient beds • encouraging clinical practice change to achieve best practice • funding the Hospital Admission Risk Program (HARP) to improve health outcomes and reduce the avoidable use of hospitals • providing improved working conditions that will attract and retain nurses • expanding opportunities for people to access elective surgery.

20 Department of Human Services, 2001. Patient Management Task Force Paper No 8 A Ten Point Plan for the Future, 2001, Melbourne. 28 Better faster emergency care

8.1.1. Growth in emergency capacity Efficient and effective delivery of emergency care is dependant on the availability of appropriate physical facilities and resources. Under the HDMS, there has been significant investment in increasing hospital capacity through emergency department upgrades, increasing inpatient bed capacity, opening the largest medical precinct in Australia comprising the new Austin Hospital and new Mercy Hospital for Women, and construction of the new Casey Hospital. Health services have also received additional funding to treat more emergency patients based on analysis of where emergency and other priority demand is greatest. In 2005-06, there were 207,512 more people treated in Victorian public hospital emergency departments of the 14 major metropolitan and five major rural hospitals than in 1999-2000.21

New look emergency department at Casey Hospital The new $80 million Casey Hospital includes a state-of-the-art emergency department. The emergency department is a modern, purpose-built 28-bed department. Over the past five years, the City of Casey has been Victoria’s fastest-growing municipality. More than 180 people move into the area every week. It was also the third fastest in Australia behind the Gold Coast and Brisbane City councils over the same period. The City of Casey is Victoria’s largest and most populous municipality. Approximately 70 per cent of people who live there are aged under 40 years. The new emergency department is designed to handle up to 30,000 patients annually and will accommodate current and future demand. Facilities include 10 high-acuity beds (resuscitation and monitored), a paediatric zone, negative pressure room, two dedicated mental health rooms and three cubicle spaces for rapid medical assessment. There is a co–located primary care area adjacent to the department.

Source: Department of Human Services, 2006

8.1.2. New emergency department models of care The HDMS has placed emphasis on new emergency department models of care that provide diversion and substitution of more appropriate care options for people who would be traditionally managed in hospital. These models of care aim to ensure patients receive the most timely and appropriate care possible, with greater flexibility in patient choice in treatment and service provision. They have supported maximising inpatient bed availability by preventing further emergency department presentations, preventing admissions from emergency departments, reducing length of stay in acute beds and preventing unplanned readmissions. Examples of new emergency department models of care funded under the HDMS include: • fast track or enhanced triage service for uncomplicated non-admitted patients in the emergency department

21 Department of Human Services, 2006. Your hospitals: A six month report on Victoria’s public hospitals July to December 2005, Melbourne Better faster emergency care 29

• emergency department care coordination for patients with complex needs, including psycho-social needs • short-stay observation units and medical assessment and planning units to provide intensive medical treatment and supervision to selected emergency patients.

Example in practice–New emergency department model of care

Emergency department clinical decision making unit (CDMU) Barwon Health The CDMU commenced in late 2002. It was designed to allow continuous evaluation of patients over a more extended period, and to avoid unnecessary admissions or inappropriate discharges from the emergency department. The aim of the CDMU is to improve the quality of medical care to patients through extended evaluation and treatment while reducing inappropriate admissions and health care costs. Literature demonstrates that selected patients can be better managed in a short-stay environment for example, patients requiring short-term investigation to determine the severity of illness such as undifferentiated chest pain, those requiring short course therapy such as asthma and with a length of stay of less than 48 hours, and patients who require a brief admission for social or other reasons while alternative care is arranged. Key features of the Barwon Health observation medicine model are: • location with the emergency department (purpose-built area) with strict admission and discharge criteria • management by emergency department duty consultant • priority access to radiology and pathology investigations • monitored beds • shared infrastructure and staffing with the emergency department • clinical protocols and pathways for management of common and high volume conditions • frequent medical review of patients through partnerships with physicians • admission of patients with an expected length of stay of up to 48 hours • similar physical amenities to other inpatient wards.

Evaluation findings include: • since February 2004, over 4,500 patients have been admitted to the CDMU • from February 2005 to February 2006, CDMU admissions averaged more than 200 per month - this represents more than 19 per cent of all inpatient admissions from the emergency department and six per cent of total emergency department attendances overall • for 2004-05 the average length of stay for patients in the CDMU was less than 24 hours, with only four per cent extending beyond the maximum 48 hours • 92 per cent of patients admitted to the CDMU are discharged home with 2.5 per cent of these patients receiving support from Barwon Health’s Hospital in the Home program. • from 2003-04 to 2004-05 there has been a decrease in the number of patients with undifferentiated chest pain admitted to inpatient cardiology beds.

Source: Barwon Health Service, May 2006 30 Better faster emergency care

8.1.3. Patient Flow Collaborative Victoria has adopted the breakthrough collaborative methodology to improve delivery of health care, for example through the National Medication Safety, Adult Intensive Care and Blood Matters breakthrough collaboratives. Breakthrough collaborative methodology brings clinical teams together to work on common aims, adapting and implementing existing knowledge to improve patient care.22 Building on this methodology, the Patient Flow Collaborative (PFC) was undertaken by the Department of Human Services in 2003-04. As part of the PFC, initiatives were undertaken to diagnose system constraints on patient movement, develop and test innovations and build system improvement skills within health services. A total of 23 health services from metropolitan and rural Victoria were funded to participate in the program. The aims of the PFC were to remove unnecessary waits and delays in the patient’s progress, build the skills needed for successful innovation within health services and embed and mainstream service innovations and change.23 Innovations tested included improving flows through emergency departments. The PFC developed the following criteria for success in improving hospital systems: • engagement of senior management and clinicians • collaborative approaches between local project officers, clinicians and health services executive • attention to making project outcomes sustainable over time • focus on whole system issues, not single areas one at a time • response to systemic drivers and move away from ‘fire-fighting’.

22 Department of Human Services, 2003. Quality Plan 2003-04: Metropolitan Health and Aged Care Services, Melbourne. 23 Department of Human Services, 2006. Patient Flow Collaborative Final report, Melbourne. Better faster emergency care 31

Example in practice–Patient flow collaborative

Emergency department waits and bed management Western Health Problems identified at Western Health included long lengths of stay in the emergency department resulting from delays in accessing radiology services and inpatient hospital bed availability. Interventions included: • computer based paging for orderlies with messages left on pagers for next patient transfer requirements • streaming of patients to identify patients likely to require admissions • implementation of a bed management tool which identified when bed availability was a problem • development of an escalation process to facilitate actions that would lead to increased bed availability • bed access was reported to executive team at 9am daily with attendance by unit managers at the daily bed management meeting.

Outcomes: • decrease in time for transfers to radiology department from 40 minutes to 10 minutes • patients in emergency departments streamlined, resulting in 75 per cent of patients identified as needing a bed within four hours of their arrival in the emergency department.

Source: Department of Human Services, 2006. Patient Flow Collaborative Final report

8.1.4. Hospital Admission Risk Program The Hospital Admission Risk Program (HARP) was the prevention component of the HDMS. From 2001-04, HARP implemented a range of prevention initiatives that focussed on people with chronic or complex conditions by providing new approaches to care for these people at the time of emergency department presentation and more targeted support when they were discharged home. An evaluation of HARP undertaken from 2001-05 identified that HARP patients experienced on average 35 per cent fewer emergency department presentations, 52 per cent fewer emergency admissions and 41 per cent fewer days in hospital.24 Many of the initiatives commenced under HARP have now been mainstreamed under the Hospital Admission Risk Program-Chronic Disease Management (HARP-CDM) service framework.

24 Department of Human Services 2006, Improving Care–HARP Public Report, Melbourne. 32 Better faster emergency care Better faster emergency care 33

9. Public Hospital emergency care performance

‘...work by the Department of Human Services and metropolitan hospitals to manage growing demand, prevent hospital bypass, enhance patient flow within the emergency department and to move patients out of the emergency department (either to an inpatient bed or home) is making a difference.’ Source: Auditor General Victoria in Managing demand in public hospitals, May 2004

Ongoing service review by government, health services and the community is critical to ensure resources are directed to best meet the emergency care needs of the Victorian community. In response to the recommendations of the Governance Reform Panel established by the Minister for Health in 2003, the Statement of Priorities (SoP) was established as the key accountability agreement between public health services25 and the Minister for Health. The SoP sets out the key financial and service performance targets using statewide benchmarks, allows for locally generated planning and service priorities and incorporates system-wide government priorities. It is reviewed annually by the Department of Human Services in partnership with public health services.

9.1. Improving waiting times for emergency care

‘Victoria performed better than the national average...’ Source: Your hospitals: A six month report on Victoria’s public hospitals July–December 2005

Improving waiting times for emergency care has been a key policy objective of the Victorian Government. For each emergency department triage category the Australian College of Emergency Medicine (ACEM) has set desirable treatment times. The Victorian Government sets targets for the three most urgent categories encouraging emergency departments to achieve the desirable times set by the ACEM. Overall, for all triage categories, Victoria had the highest proportion of patients receiving emergency department care within required times in 2004-05.26 Figure 10 outlines the proportion of patients seen within desired waiting times for each triage category in 2004-05.

25 Public health services defined under Schedule 5Health Services Act 1988 and Mercy Health and Aged Care, Calvary Healthcare Bethlehem and St Vincent’s Health 26 Australian Institute of Health and Welfare, 2006. Australian Hospital Statistics 2004-05, Canberra 34 Better faster emergency care

Figure 10: Desirable treatment times for triage categories

Proportion of patients seen within standard for National standards- desirable treatment times Triage category desirable treatment times Targets 2004-05 1. Resuscitation Seen immediately 100 per cent seen 100 per cent within desirable time 2. Emergency Seen within 10 minutes 80 per cent seen 86 per cent within desirable time 3. Urgent Seen within 30 minutes 75 per cent seen 81 per cent within desirable time 4. Semi-urgent Seen within 60 minutes No target set 73 per cent 5. Non-urgent Seen within 120 minutes No target set 89 per cent

Source: AIHW 2006

9.2. Department of Human Services performance monitoring framework A performance monitoring framework has been established by the Department of Human Services to monitor public hospital performance against SoP indicators. In 2005-06, a new set of key performance indicators and statewide benchmarks for health services was implemented to support the Government’s policy’s to reduce the number of long-waiting patients in emergency departments and improve access to elective surgery. A bonus funding system is in place to provide a financial incentive to encourage health services to improve their performances in these areas. Hospital emergency performance is assessed against statewide performance indicators outlined in Figure 11.

Figure 11: 2005-06 Key performance indicators statewide benchmarks

Indicator Description Statewide benchmark KPI 1 Percentage of operating time on hospital bypass 3 per cent KPI 2 Percentage of emergency patients requiring admission 80 per cent who are admitted to an inpatient bed within 8 hours KPI 3 Percentage of emergency patients not admitted to a 80 per cent bed at any hospital, with length of stay in the emergency department of less than 4 hours KPI 4 Number of patients with a length of stay in the emergency 0 department greater than 24 hours KPI 9 Percentage of category 1 triage patients seen immediately 100 per cent Better faster emergency care 35

The following section provides commentary on health service performance for 19 metropolitan and regional health services against the Department of Human Services emergency key performance indicators using data sourced through VEMD from 1999-2000 to May 2005-06. Difference over time in the scope and methods of collection of VEMD data should be considered when interpreting this data.

9.2.1. Hospital bypass All emergency departments can experience sudden and unprecedented demand caused by a major incident involving a number of casualties, a sudden surge in attendances or a high workload associated with an inability to transfer patients out of the emergency department. During periods of high occupancy levels in emergency departments, metropolitan hospitals may ask MAS to bypass their hospital and go to another hospital emergency department taking into account patient acuity. The Hospital Early Warning System was introduced in 2003 where hospitals are able to identify pressures likely to result in a bypass episode, and activate an internal hospital response. This may include diversion of some ambulance patients to an alternative emergency department. Figure 12 demonstrates the reduction in time hospitals spent on bypass since 2000. Although performance continues to fluctuate seasonally, the 13 major metropolitan hospitals measured against this indicator have successfully brought their bypass performance to within acceptable limits of three per cent of total operating time during the period.

Figure 12: Percentage of time on hospital bypass 36 Better faster emergency care

9.2.2. Percentage of emergency patients requiring admission who are admitted to an inpatient bed within eight hours This indicator is a measure of access from the emergency department to hospital inpatient beds. A statewide benchmark of 80 per cent was set for this indicator in 2005-06 to encourage more timely treatment of emergency patients who require admission to an inpatient bed.27 Even though the benchmark was not met in 2005-06, results for this indicator were consistently higher than the previous year. Performance against this indicator is presented in Figure 13.

Figure 13: Percentage of patients admitted to a hospital bed within eight hours

27 The previous indictor was percentage of patients admitted to a hospital within 12 hours with a benchmark of 90 per cent. Better faster emergency care 37

9.2.3. Percentage of emergency patients not admitted to a bed, with length of stay in the emergency department of less than four hours A statewide benchmark of 80 per cent was set for this indicator in 2005-06. Performance for this indicator has improved from a range of 72 per cent to 75 per cent between 1999-00 and 2004- 05, to a range of 74 per cent and 80 per cent in 2005-06. Performance against this indicator is presented in Figure 14.

Figure 14: Percentage of emergency patients not admitted to a bed, with length of stay in the emergency department of less than four hours. 38 Better faster emergency care

9.2.4. Number of patients with a length of stay in the emergency department greater than 24 hours. This indicator was introduced to assist in focusing health services on reducing the number of patients with an extended length of stay in the emergency department. In 2005-06 there were an average of 341 patients waiting over 24 hours in the emergency department per month, compared with 890 patients per month during 2000-01. Performance against this indicator is presented in Figure 15.

Figure 15: Number of patients with a LOS in the emergency department greater than 24 hours

9.2.5. Percentage of category 1 patients seen immediately All health services met the 100 per cent target for the percentage of category one triage (highest acuity) patients seen immediately. A patient is categorised as having been seen immediately if the time interval between either first being seen by a doctor or nurse and arrival, is less than or equal to one minute. Better faster emergency care 39

10. The way forward

Work undertaken by the Victorian Government and public hospitals is making a difference and has assisted in managing demand for emergency care by reducing length of stay, improving patient flow and providing more appropriate alternative services including substitutes for traditional inpatient beds. However challenges still remain. Although health service performance against the emergency service performance indicators has improved, emergency demand pressures are expected to be a continuing challenge. Better faster emergency care recognises that a sustained commitment is required for continued reform of the health system through funding targeted new capacity and growth in essential services, and continued reconfiguration of services to meet changing service demand and expectations. The 2006-07 Victorian Budget has provided an additional $508 million over four years to support continued implementation of initiatives and sustain improvements in public hospital system performance. Investment will focus on: • increasing the hospital system’s capacity to meet community demand for essential services including emergency and intensive care, inpatient and outpatient services, maternity and neonatal services, dialysis and cancer treatment services • expanding chronic disease management programs to divert people with chronic and complex needs from inpatient care • providing substitution and community based services to relieve pressures on hospital emergency departments. To support continued implementation of initiatives to improve emergency care and access in Victoria’s public hospitals, there is a need for the following approaches: 40 Better faster emergency care

10.1. The need for a system wide approach

‘Finding solutions means examining the health system beyond just the emergency department.’ Source: Australian College for Emergency Medicine April 2004, Access Block and Overcrowding in Emergency Departments, April 2004

Better faster emergency care recognises the need for a continued focus on a system-wide approach to ensure the Victorian health system can respond effectively to the emergency care needs of the community. This moves away from an episodic approach and encompasses the continuum of care coordinated across healthcare providers and settings. Approaches to managing increasing demand for emergency care should include interventions corresponding to different stages in the continuum of care from prevention in healthy populations to management of established disease. At the hospital level, there also needs to be a focus on opportunities to improve coordination between emergency departments and the rest of the health system. Hospitals will need to continue to work collaboratively, not only with each other but also with other parts of the health system to facilitate delivery of coordinated and effective emergency care to the Victorian community.

10.2. The need for innovation

‘Innovation will be important to ensure Australians are able to experience more years of good health; to increase active participation in society by an ageing population; and to enhance independence and autonomy.’ Source: CSIRO May 2006 Innovation in preventative health: an economic imperative

Better faster emergency care builds on previous work undertaken as part of the HDMS, but also recognises that new approaches are required in the future to keep pace with the accelerating rate of changes in health care delivery. The health system is not static and emergency care should evolve and change as service models and options for care develop. The Victorian Health Service Management Innovation Council, which was established by the Victorian Government following recommendations of the Victorian Public Hospital Governance Reform Panel in 2003,28 will focus on innovation and change management to support system improvements in the operational effectiveness and efficiency of health services. A key area of work will be to support health service transformations by championing new service models, supporting effective management improvement processes and building an evidence base of best buys.

28 Department of Human Services, 2003. Victorian Public Hospital Governance Reform Panel Report, Melbourne Better faster emergency care 41

10.3. The need for a continuous quality improvement approach

‘Quality improvement means improving the services, care and the results of treatment provided to all patients. To do this, we take account of the scientific evidence, the needs and preferences of patients, and the experience of health professionals,’ Source: National Health Service, Scotland

Better faster emergency care has been framed within a context of continuous quality improvement. There has been an increasing emphasis on continuous quality improvement in health systems over the past decade. Literature clearly demonstrates that commitment to quality improvement results in benefits for patients and organisations, including improved clinical outcomes, lower costs and greater efficiency.29 The Department of Human Services requires public hospitals to maintain accreditation to support continued maintenance of appropriate standards of care and quality improvement and all Victorian hospitals and health services are also required to produce an annual quality of care report. Examples of minimum reporting requirements include health service language services and culturally appropriate service provision. The Victorian Quality Council (VQC) was established in 2001 to undertake a statewide role in fostering quality and safety in health services in Victoria and aims to work with stakeholders to identify and act on opportunities for improvement. Two key result areas in the VCQ 2005-08 strategic plan include enhancing leadership in health care quality and safety and reducing harm in health care. Better quality, better health care (2003), prepared by the VQC includes a safety and quality framework that provides an overview of the principles and practices necessary for effective monitoring, management and improvement of health services.30 The six interdependent dimensions of quality identified in the framework are: • Safety of health care: harm arising from care is avoided and risk minimised • Effectiveness of health care: health care interventions deliver measurable benefit and achieve the desired outcome • Access: there is timely, equitable access to services on the basis of need irrespective of cultural or linguistic background, gender, age or socio-demographic status • Acceptability: health services meet the expectations of patients and feedback is encouraged • Appropriateness: selection of health care interventions is based on the likelihood that the intervention will produce the desired outcome for a patient and on using evidence and established professional standards • Efficiency: resources are utilised to achieve value for money within health settings.

29 Department of Human Services and Victorian Quality Council, 2003, Better Quality, Better Health Care: A Safety and Quality Improvement Framework for Victorian Health Services, Melbourne. 30 ibid 42 Better faster emergency care

10.4. The need for people-centred approaches

‘Transforming the culture of emergency care is a journey, moving from prescriptive and defensive routines towards quality, creative patient-centred care.’ Source: Royal College of Nursing/Department of Health 2003, Freedom to Practise: dispelling the myth, London.

The emergency care system needs to be people and community-centred, with a system responsive to the needs of individuals. Examples of people-centred approaches include: • providing an environment and care that is responsive to people’s needs • providing information in a meaningful style and language • making services simple to understand • helping patients to navigate the system • involving family members in care • informing, communicating and educating • understanding the course of illness and patients’ experience in the emergency department • empowering patients to engage with health professionals to play an active part in their care. Integral to people-centred approaches is ensuring that health service delivery is culturally appropriate. The department’s Cultural diversity guide (2004) provides guidance to agencies on strategies to improve cultural responsiveness and supports for managing cultural diversity.31 As part of whole-of-government reporting processes, all public hospitals will be required to develop cultural diversity plans and establish and report on, the activities of hospital cultural diversity committees in 2006-07. Consumer, carer and community participation is an important way of ensuring health services best meet the needs of their community and is a process that constitutes best practice in health care. Health services have established a range of mechanisms to monitor client satisfaction and respond to feedback, for example patient liaison officers and community advisory committees in metropolitan health services. A new strategic direction in consumer, carer and community participation in health care has been provided by the department’s ‘Doing it with us not for us’ policy, which explains the contribution of consumer participation to improved health outcomes and quality of health care.32 Health services are required to develop a consumer participation plan covering a one to three year period as part of their strategic plan. A report monitoring the progress towards meeting targets and outcomes outlined in the plan is lodged annually with the department.

31 Department of Human Services, 2004. Cultural diversity guide: Multicultural Strategy, Melbourne. 32 www.health.vic.gov.au/consumer Better faster emergency care 43

11. Enablers to move forward

A number of enablers provide direction for continued re-orientation of the health system in order to improve emergency care and access in Victoria’s hospitals. These include:

11.1. System improvement Increasingly, hospitals within Australia are using business tools and process redesign principles to improve the patient experience in the emergency department and patient outcomes more generally. There is a recognised need to streamline patient flow through hospitals and increase the number of patients that can be seen while minimising delays and improving the quality and safety of care. Process redesign principles such as ‘lean thinking’, are adapted from the manufacturing industry and focus on a localised and team approach to design, evaluate and implement system improvements. Process redesign methodology draws on various tools that analyse current processes and provides potential to improve patient flow and eliminate delays, duplication and potential for error. Key principles of service redesign include: • involve staff and patients who deliver and receive care to facilitate ownership of problems and solutions • empower through knowledge to ensure change decisions are based on fact rather than assumptions • ensure commitment across all levels of the organisation to new ways of working to sustain change. 44 Better faster emergency care

Example in practice–Process redesign

Emergency care access improvement– Monash Medical Centre (MMC), Southern Health A review was undertaken by the emergency department team at MMC in 2004-05. Methodology included establishment of a senior leadership team, action plan, principles to facilitate change, regular review meetings and staff engagement. Practice changes included: • allocation of adult emergency department presentations at triage into likely admission and likely discharge streams • admit and discharge streams managed by specific teams with clear guidelines • lower acuity patients seen in time order • redesign of nurse and emergency physician in charge coordination role • hourly monitoring of patient flow • introduction of a system to identify and track delays in patient flow, escalation and action plans • staff mentoring and coaching • nursing and medical staff match to demand by time of day • allocation of a nurse to triage ambulance arrivals • change to layout to ensure emergency department ‘fit for purpose’ with cubicles allocated to set patient groups • establishment of links with other hospital services • bed management processes and planning built into expected emergency department demand • display of performance. Outcomes for the period December 2004–April 2005 compared to December 2005– April 2006 include: • percentage of patients treated within four hours increased from 62.6 per cent to 80.3 per cent • percentage of admitted patients treated within eight hours increased from 61.9 per cent to 75.7 per cent • percentage of patients who did not wait decreased by 6.85 per cent to 3.64 per cent

Source: Monash Medical Centre June 2006 Better faster emergency care 45

11.2. Service planning The Department of Human Services will continue to review the community’s emergency care needs, service levels and service relationships in consultation with health services, health professionals and the community. As part of the Metropolitan Health Strategy Refresh 2006, analysis will be undertaken of priority areas for further development, including for emergency services. A role delineation framework for emergency departments in Victoria’s metropolitan public hospitals will be developed during 2006-08 to provide direction for health service emergency department planning over the next five years. Role delineation frameworks are currently in place for trauma, neonatal services and cancer services to support health services in planning services appropriate to the needs of the community. The level of service outlined in the emergency department role delineation framework will describe the complexity of clinical activity undertaken and will promote best practice management and care coordination within existing resources and infrastructure. The department is also developing a capability-based planning framework for rural emergency services during 2006-07. This framework will complement the rural birthing services framework released in 2005 and the rural procedural services framework currently being developed.

11.3. Funding policy reform The way funding is provided is one factor that influences the approach health services take to delivering health care. From 2005-06, funding that has previously been provided on a project basis under the HDMS has been converted into recurrent funding and included in standard funding arrangements, for example through mainstreaming of HARP initiatives. New approaches have also been taken to support health services to use funding more flexibly and to support new emergency models of care, for example through funding of short-stay observation units and medical assessment and planning units. Although the majority of funding for the patients admitted to these units comes through normal output funding arrangements, additional funding has been provided in recognition of the costs associated with the model of care and maintenance of bed availability. In 2005-06, conditions of funding for observation medicine were amended to enable health services to configure beds according to demand, with the potential to flex beds between the models. More flexible approaches and partnerships between state, territory and federal governments will be required to meet the demands of the health care system and challenges they present, and to support new approaches to meeting demand for emergency care. The Department of Human Services will continue to explore appropriate funding models and their associated accountability and reporting issues, to allow health services to manage funding more strategically. 46 Better faster emergency care

11.4. Workforce development

‘Australia will have a sustainable health workforce that is knowledgeable, skilled and adaptable. The workforce will be distributed to achieve equitable health outcomes, suitably trained and competent. The workforce will be valued and able to work within a supportive environment and culture. It will provide safe, quality, preventive, curative and supportive care, that is population and health consumer-focused and capable of meeting the health needs of the Australian community.’ Source: Vision - National Health Workforce Strategic Framework, Australian Health Ministers’ conference 2004.

As in other states and territories, Victoria faces challenges in ensuring the health workforce can provide equitable, accessible, sustainable, timely and safe health care. Challenges include health workforce shortages, maldistribution, changing models of care, increasing specialisation of some sections of the health workforce as technology defines new approaches to treatment, and maintaining a culture of continuous improvement and flexibility.33 The National health workforce strategic framework (2004)34 outlines principles to guide the states and territories in responding to workforce challenges. Victoria has adopted the framework with inclusion of eight principles in the promotion of workforce quality and safety. These are: • ensure and sustain self-sufficiency in workforce supply • workforce distribution optimises access and is aligned with need • ensure attractiveness of workplaces • ensure workforce is skilled and competent • optimal use of skills and workforce adaptability • policy and planning to be informed by best evidence and linked to requirements • stakeholders to work collaboratively • promote workforce quality and safety. The Victorian Government invests in a range of initiatives to maintain a skilled and high performing health workforce across Victoria and recognises that structures to support capability such as education and training programs in areas such as emergency care will also need to change.

33 Australian Health Ministers’ Conference, 2004. National Health Workforce Strategic Framework, Sydney. 34 ibid Better faster emergency care 47

11.5. Information technology and data management solutions

‘Health is an information dependant industry that will continue to increase its use of, and dependence on, ICT. It will not be able to meet the future challenges and demands without a more strategic and active adoption of these technologies...’ Source: HealthSMART: Strategy for modernisation and replacement of information technology (Department of Human Services 2003)

Health systems are increasingly dependant on information and communication connectivity to support integration of systems to allow for sharing of patient information, delivery of clinical care through electronic access, telehealth and timely access to specialist advice and support. Increased use of information technology will contribute to greater hospital efficiency and increased safety and quality of emergency care. The Department of Human Services has established the HealthSMART program that is responsible for replacing core applications across the acute and sub-acute sector, delivering these applications via a shared delivery model and commencing the automation of clinical processes within the acute sector. Applications to be implemented include patient and client management, clinical, human resources and financial and supply management information systems. These applications will systematically change the way health care information is managed throughout the state. For the first time, access will be provided through shared infrastructure that allows health care professionals to quickly and easily access a range of patient data. The Department of Human Services also supports the development of infrastructure and processes required to allow agencies to share information securely in an electronic environment. The Department of Human Services is an active participant in the program of work being undertaken by the National e-Health Transition Authority. This work program includes the initiatives supported by the Council of Australian Governments, to develop an individual health identifier that will allow speedy identification of patients in emergency situations, a healthcare provider identifier that will improve flow of information and agreed clinical terminologies.

11.6. Partnership development As the health system is a complex mix of organisations, services, professional disciplines and governance arrangements, approaches to improving emergency care and access in Victoria’s public hospitals will need to be managed through a partnership model. The Department of Human Services has invested significant resources into a partnership model through thePrimary care partnership strategy, which has facilitated a system approach to coordination of care and services. The Department of Human Services will continue to actively seek new opportunities for working in partnership with health services and the community to design and deliver emergency care that is responsive to community needs. This will require a focus on shared visions, clear roles and team- based approaches to delivery of emergency care. 48 Better faster emergency care Better faster emergency care 49

12. Ten priorities

‘We need to find innovative and creative solutions to reform the system to meet the needs of the future.’ Hon Bronwyn Pike MP, Minister for Health, launch of Better State of Hospitals conference 27-28 April 2006

Future work will focus on implementation of a sustainable and innovative framework for government, health services, health professionals and the community to work together to continue reform of the health system to ensure it best meets the emergency care needs of the community. The following section outlines ten priorities and key actions that will be undertaken to support continued reform of the emergency care system over the next five years. The ten priorities are:

12.1. Develop new service options Key service options to be implemented or enhanced include after-hours co-located GP clinics, emergency primary care centres, NURSE-ON-CALL and the Hospital Admission Risk Program: Chronic Disease Management.

After hours co-located GP clinics After hours co-located GP clinics currently operate at Frankston Hospital, Dandenong Hospital and Northern Hospital and the Royal Children’s Hospital. This service option provides substitution and diversion of primary care-type presentations at emergency departments and provides greater flexibility in patient choice in treatment and service provision. Following the signing of the Australian Health Care Agreement in 2003, the hospital-GP interface was identified as a key reform. As part of this process, the establishment of 10 co-located GP clinics nationally was announced. A key focus of these co-located clinics has been on enhanced collaboration with local GPs and local divisions of general practice. A formal review of after-hours co-located GP clinics will be undertaken by the department in 2006-07 to inform future directions for models of care to meet the needs of primary care type patients presenting to emergency departments. 50 Better faster emergency care

Example in Practice–Co-located GP clinic

Northern Hospital co-located GP clinic The clinic opened in April 2005 and operates seven days a week to ease the pressure on the emergency department at Northern Hospital. It was established to address emergency department demand for primary care type presentations that could potentially be managed by a general practitioner.

The service aims to: • focus on the role of appropriate and effective hospital diversions for primary care type patients • provide greater choice and availability in the provision of after hours primary medical care for consumers • play a significant role in assisting consumers to access appropriate and timely medical care • provide an efficient and quality after hours medical service • focus services and reduce waiting time in emergency departments • impact favourably on those patients requiring after hours pathology and medical imaging services. Patients who would be more appropriately treated in an emergency department are referred to the emergency department at Northern Hospital. The clinic has established protocols with regular general practitioners, The Northern Division of General Practice, Northern Hospital and emergency departments and radiology, pathology and pharmacy providers. In the twelve months it has been open, the clinic has seen 2,646 patients.

Source: Northern Hospital May 2006

Emergency primary care centres Emergency primary care centres aim to provide timely access for patients with emergency primary care needs. Extended hours emergency primary care centres are planned for the Melton, Craigieburn and Lilydale super clinics in 2006-2008. Services will be provided by multidisciplinary teams, and will be promoted through a number of settings such as general practice, community health and hospitals. Emergency primary care centres will focus on establishing a model of extended primary care that meets the specific needs of local communities, engaging with local divisions of general practice and establishing close links and partnerships between emergency departments, community health, other organisations and the local community. In 2007-08, the department will commence development of the Emergency primary care service guidelines. Better faster emergency care 51

NURSE-ON-CALL NURSE-ON-CALL is a statewide service staffed by registered nurses providing a 24-hour telephone- based health information to the community. The service commenced in March 2006, initially taking calls redirected from emergency departments. Transferring these calls frees up nurses and other staff to care for patients already at emergency departments. NURSE-ON-CALL directs callers to the appropriate level of care for their circumstances, for example an emergency service, hospital emergency department, GP or self-care. Nurses are supported by sophisticated clinical decision support software and utilise the department’s Better Health Channel and the Human Services Directory for health and service information. The service will have access to interpreting services and the National Relay Service to assist the hearing or speech impaired.

Hospital Admission Risk Program – Chronic Disease Management Many of the initiatives commenced under HARP have now been mainstreamed under the Hospital Admission Risk Program–Chronic Disease Management (HARP-CDM) service framework, which provides care to people with chronic diseases or complex needs who are at risk of avoidable hospitalisation. HARP-CDM services provide more appropriate and timely care for people in the community and provide assessment, monitoring, education, self-management, service coordination and a flexible service response through brokerage. The target group for HARP-CDM is people who are at risk of avoidable hospitalisation with chronic respiratory disease, chronic heart failure, complex needs, complex psycho-social needs and complications as a result of diabetes. In 2005-06, 21 health services were funded to deliver HARP-CDM services. The focus of HARP- CDM is on embedding the key lessons from the HARP phase, while working towards more equitable service provision across Victoria. Health services are required to develop local alliances with community-based agencies as a mechanism for decision making, sharing responsibility and managing risk. It is anticipated that HARP-CDM will contribute to providing an integrated, effective and sustainable chronic disease and complex needs service for a target population, thereby reducing avoidable hospital presentations and admissions and contributing to better health outcomes for Victorians. The Improving care-HARP chronic disease management guidelines will be finalised in 2006. An indicator that measures emergency department attendance by HARP patients will be developed in 2007-08. 52 Better faster emergency care

Example in practice

HARP–CDM: South West Healthcare As part of mainstreaming of HARP initiatives, the department provided HARP-CDM funding to South West Healthcare in 2005. Services commenced in April 2006 following implementation of two workshops and development of an implementation plan. The aims of the program are to reduce avoidable emergency department presentations, hospital admissions and length of stay of the target group through use of best practice principles to support client centred care and support. The program operates Monday to Friday from 8.30 to 5.30pm and receives referrals from hospital inpatient wards as the highest priority, in addition to referrals from GPs, health professionals and self-referrals. Services provided to clients include referral, screening, initial assessment, development of a care plan, liaison with GPs, referrals to other health providers as appropriate, and review. The program targets people with chronic heart failure, chronic lung disease and other chronic and complex conditions. An advisory committee comprising medical specialists, GPs, divisions of general practice, health providers and community representation has been established to provide expert advice and set strategic directions for the program, and systematically monitor and assess the care and services provided. Key success features of this model identified to date include: • organisational structure across South West Healthcare supports continuum of care and continued opportunities to configure the model to ensure it best meet client’s needs • mobility of the HARP-CDM team allows staff to move across clients’ homes and health and community settings • development of partnerships between the HARP-CDM team and health and community centres including GPs supports a multi-disciplinary care for people with chronic and complex conditions • assignment of care coordinators to clients following referral supports care coordination • capacity to allocate resources for counselling. In the short time the service has been operating, 124 clients have been screened with 53 admitted to the program. Planned future directions include: • expansion of the number of clients participating in the program • expanded focus on other medical conditions, for example diabetes • specific focus on better planning for clients with polypharmacy issues • training across the sector in adult learning principles • further collaboration with other health and community sectors to ensure understanding of the role of HARP-CDM • continued review of the program to ensure it meets the needs of clients • further time spent in emergency to promote HARP and access clients.

Source: South West Health Care, June 2006 Better faster emergency care 53

Key actions Undertake more detailed analysis of ‘primary care type’ emergency department presentations across Victoria’s public hospitals and their impact on emergency departments. Continue to expand and develop patient-centred emergency care service models that support flexibility and patient choice. Undertake a formal review of after-hours co-located clinics in 2006-07. Open extended-hours emergency primary care centres at Melton, Craigieburn and Lilydale super clinics in 2007–08. Commence development of the Emergency primary care service guidelines in 2007-08 to support development of a ‘best practice’ model. Continue to mainstream and expand HARP-CDM services in 2006-07 including expanding the focus of services to include the management of people with diabetes. Develop an indicator that measures emergency department attendance by HARP type patients in 2006-07.

12.2. Improve coordination between emergency departments and ambulance services There will be a focus on improving coordination between emergency departments and ambulance services to reduce waiting times and improve patient outcomes. Key initiatives are:

Ambulance patient reception at emergency departments The At Destination Patient Management project was funded by the Victorian Patient Flow Collaborative to provide an analysis of improvement opportunities in ambulance turnaround (or ‘at destination’) times at hospital emergency departments. Draft guidelines developed for the reception and handover of ambulance patients have been evaluated and will form the basis for developing statewide guidelines for implementation in 2007.

The Ambulance-Emergency Department Interface project In June 2005, the EARC Ambulance Interface Committee was established by the department to investigate ways to improve the interface between ambulance services and emergency departments. The committee includes representation from MAS, RAV, the Australasian College for Emergency Medicine, Australian College of Emergency Nurses and Programs Branch. One of the areas identified for priority action is better communication between ambulance services and hospitals, and how this can improve ambulance decision-making about the right destination for an individual patient. The Auditor General’s report (2004) noted the next challenge for MAS and emergency departments was to implement better coordination of ambulance presentations to better distribute the load of ambulance arrivals. 54 Better faster emergency care

In 2006-07, the department will undertake a feasibility study to identify options to improve communication and collaboration between ambulance services and emergency departments, and improve patient flow. The study will identify options to improve the communication between ambulance services and emergency departments, and management of capacity and peak demand in emergency departments and patient distribution between hospitals. This project will include a review of practices in other systems, including information technology options.

MAS referral service The MAS referral service was introduced in 2003 and provides an alternative to ambulance dispatch and transport to hospital for low priority 000 calls. In 2004-05, approximately five per cent of all patients calling 000 were directed to the referral service for secondary triage. Of these, 53 per cent did not go to an emergency department and were referred for a more detailed assessment by an alternative service provider such as their GP or nursing service.35 In 2006-07 the department, in conjunction with MAS, will undertake an independent review of the service to determine future strategic directions.

Key actions Undertake the Ambulance-Emergency Interface project in 2006-07. Implement the Ambulance patient reception guidelines for metropolitan health services in 2006-07. Continue to work closely with the Metropolitan Ambulance Service to explore further options to enhance the capacity of the Metropolitan Ambulance Service referral service. Continue to explore opportunities to further improve emergency and critical care patient transportation.

35 Provided by MAS May 2006–unpublished Better faster emergency care 55

12.3. Improve the patient experience Priority initiatives to ensure emergency care is responsive to patient and carer needs are:

Improving the patient experience

‘You know...you read everything 100 times over and I can’t remember one bit of it... new information would go a long way.’ - Department of Human Services volunteer workshop 2006 as part of consultation process undertaken to improve the patient experience in the waiting room

Following an audit of waiting room facilities in 25 hospital emergency departments in Victoria’s public hospitals, a range of interlinked strategies commenced in 2005-06 to improve the patient experience in the emergency departments. The Auditor General’s report (2004), noted that waiting room management in hospitals was minimal and that hospitals should document and implement procedures for improved monitoring and communication with waiting room patients. Initiatives to be undertaken to improve the patient experience include: • improvements to emergency department physical amenities (for example, comfortable seating, new colour schemes, televisions and DVDs and drinking fountains to make waiting more comfortable) • development of new signage for emergency departments to improve communication and ensure clear directions are provided to patients upon their arrival at the hospital, and about what to do when they get there • implementation of the emergency department communication enhancement workshops for frontline emergency department staff to facilitate improvements in interactions between patients and staff • development of patient information materials in a range of formats, including a DVD and written brochure Welcome to the emergency department to ensure patients have access to clear easily understood and culturally appropriate information.

Welcome to the Emergency Department

Welcome to the emergency department patient information brochure

What should I do?

1 See Triage Nurse 2 See Administration Clerk 3 Wait to be called 4 Tell us if you ar e feeling worse 56 Better faster emergency care

Patient friendly signage improvements in Victorian emergency departments

Photo 1: The effectiveness of signage is improved by reducing clutter and removing aggressive or controlling signage such as ‘DO NOT’ type signs.

Photo 2: A dominant red colour is consistently used for directions and medical test to avoid confusion.

Photo 3: Simple and direct patient-focussed language such as ‘What should I do?’ and ‘While you wait’ provides reassurance and sets expectations.

Photo 4: Cardinal direction signs are red with white arrows to provide a ‘breadcrumb trail” that leads to the triage desk. Better faster emergency care 57

Patient satisfaction survey Monitoring patient satisfaction and feedback is an important way of ensuring health services meet the expectations of the community. The Department of Human Services has implemented the Patient Satisfaction Monitor in Victoria’s public hospitals to provide regular monitoring and reporting of patient satisfaction. In 2006-07, the department will implement the Emergency Department Patient Satisfaction Monitor to specifically monitor elements of the patient journey through the emergency department and complement existing measures of patient satisfaction used across the public health system.

Departure before treatment project The proportion of patients who leave the emergency department before completion of treatment is an important quality marker of accessibility to health care. Currently there is limited information about characteristics of these patients including reasons patients leave, their risk for adverse health outcomes, whether they seek care elsewhere, or what services would best suit their needs. The Auditor General’s report (2004) noted that there was a lack of information on this group and that hospitals should develop protocols to identify and follow up high risk patients who choose to leave the emergency department before completing their treatment. In 2006-08, the department will undertake research to identify the characteristics of people who presented at emergency departments but left before receiving or completing treatment, and outcomes for this group. The project will provide recommendations to strengthen communication with waiting room patients and to identify, and follow-up these patients to maximise their health outcomes.

Key actions Continue to work with health services to ensure the emergency care system is patient-centred and responsive to people’s needs. Continue implementation of Improving the patient experience initiatives across Victoria’s public hospital emergency departments. Develop and implement the Emergency Department Patient Satisfaction Monitor in 2006-07. Undertake the ‘departure before treatment’ project in 2007-08. 58 Better faster emergency care

12.4. Mainstream new models of care Actions will focus on ensuring development and implementation of best practice models of care including:

Fast track and enhanced triage services

‘We arrived at approximately 7.30pm. With the fast track system were quickly seen to and assessed. My son had five stitches and we were on our way by 7.45pm. This was fantastic as I left my other four boys at home with my husband.’ - Sunshine hospital patient, Fast track patient satisfaction survey, Sunshine Hospital May 2006

Under the HDMS, a range of projects were funded to improve emergency department triage processes, improve patient flow for patients who have conditions that are relatively simple to treat and speed up the progress of patients with more complex conditions. Fast track and enhanced triage services identify low-complexity emergency department presentations and refer them to a designated team for assessment and management. Fast track models of care allow hospitals to provide an effective response to differing emergency presentations patterns. Literature suggests that fast tracking those with minor injury or illness can reduce overcrowding in emergency departments.36 Examples of appropriate fast track patients include people who present with simple wounds, fractures, sprains and strains or foreign bodies in the eye. Most emergency departments in metropolitan and regional hospitals operate their fast track services at times of peak demand. In 2006-07, the department will develop the Emergency Department Fast Track Service Guidelines to support development of a ‘best practice’ model.

36 Canadian Agency for Drugs and Technologies in Health, 2006. Technology Overview: Emergency Department Overcrowding in Canada: What are the issues and what can be done? Issue 21, May 2006, Ottawa. Better faster emergency care 59

Example in practice

Sunshine Hospital emergency department fast track Fast track was introduced by Sunshine Hospital in 2002 to provide rapid care for defined groups of emergency department patients. The service operates 24 hours a day. Eligible fast track patients are identified by the triage nurse and are defined on the basis of the ATS triage complaint code. This includes those with a predicted length of stay of less than 60 minutes, and not requiring trolley care, intravenous analgesia, fluids or sedation. Examples of suitable patients include those with minor wounds, ankle injuries, minor burns and eye complaints. Fast track patients are cared for in the designated fast track clinical area by senior nursing and medical staff. To improve workflow and efficiency, the fast track area was refurbished in 2006 to provide improved clinical space, enhanced privacy and a small work station for staff. The eye examination room was also relocated to this area. Other innovations have included incorporation of advanced practice nurses and more recently, nurse practitioner candidates practicing under clinical practice guidelines. From 2002-03 to May 2005-06, the numbers of emergency department patients seen under fast track increased from 1,988 to 4,351 patients. The proportion of patients treated under fast track increased from 3.8 per cent to 8.9 per cent in 2005-06 to date. The average length of stay for fast track patients in 2005-06 was 134 minutes. However, increasing adoption of this model of care has meant that not all treated patients are classified as fast track patients for data collection purposes. As a consequence the data reporting underestimates the true numbers of emergency department patients managed through the fast track model. Comments in responses to patient satisfaction surveys have been positive. There has also been significant practice change within the emergency department with staff appearing to now automatically use this model of care for defined groups of patients. Critical success factors identified for this model of care include: • large casemix of suitable patients • senior medical and nursing support • enhanced nursing skills and senior medical staff participation • separate physical area at front of emergency department with stand alone medical equipment and staff workstation.

Source: Sunshine Hospital May 2006 60 Better faster emergency care

Care coordination Care coordination is a collaborative process that is patient focussed and supports an interdisciplinary approach to ensuring continuum of care for patients. Examples of care coordination activities include assessment, treatment, multidisciplinary team meetings, providing information and developing common protocols. Literature suggests that multidisciplinary teams in hospitals have a positive impact and have been found to be associated with reduced lengths of stay in hospitals.37 A total of 19 metropolitan and regional health services currently receive funding to support care coordination services within emergency departments. Current care coordination services primarily target older people, people with complex and chronic conditions, people requiring complex discharge planning and frequent attendees. In 2006-07, the department will develop the Emergency department care coordination service guidelines to support development of a best practice model.

Example in practice–Care coordination

ALERT: Assessment, Liaison and Early Referral Team - St Vincent’s Hospital The ALERT program was introduced in 2001 to promote joint care planning between acute and community providers, and enhance the capacity of the emergency department to more effectively manage patients with complex medical and social needs. ALERT is an interdisciplinary team comprising a social worker, physiotherapist, occupational therapist, nurses, dietician and case managers. ALERT provides risk screening and care coordination in the emergency department seven days a week between the hours of 8.30am and 9pm. It targets frequent emergency department presenters or people who are at risk of representation who present to the emergency department with aged care issues, disability, history of drug and alcohol problems, history of homelessness and mental health issues not within the scope of mental health services. ALERT screens about 650 patients per month who attend the emergency department. The ALERT team has developed partnerships with a number of community-based services including local community health centres and the Royal District Nursing Service Homeless Persons’ Program. The program also offers flexible brokerage and supports disadvantaged clients at Ozanam House and Sumner House which provides flexibility to provide appropriate accommodation based on client need. A key feature of success has been the establishment of a comprehensive database that is both a client management system and a data collection system and has facilitated availability of high quality data to monitor service standards. Outcomes identified in the evaluation of the Hospital Admissions Risk Program conducted by Bearing Point included: • significant reduction in numbers of emergency department presentations • increased service system capacity evidenced through the number of direct diversions • improved communication with community and primary care services • high consumer satisfaction • initiation or participation in research activities.

Source: St Vincent’s Hospital Service Plan ALERT/HARP Evaluation Bearing Point December 2004

37 Birmingham and Black County Strategic Health Authority, 2006. Reducing unplanned hospital admission: What does the literature tell us? Better faster emergency care 61

Medihotels As the trend towards ambulatory care models increases, the need for hospital-based overnight accommodation for patients has also grown. Medihotels currently operate at eight locations - the Austin Hospital, The Alfred, Royal Children’s Hospital, Royal Melbourne Hospital, Royal Victorian Eye and Ear Hospital, Monash Medical Centre and Box Hill Hospital. Medihotels cater for patients who are not suitable as day-only cases and require overnight accom– modation at the hospital. This creates capacity to manage demand from patients requiring acute care. In general, some low level supervision is provided in medihotels but not direct clinical care. A variety of different service models have been established in Victoria in response to local demands including on-site facilities and off-site third party providers. Similarly, there are differences in the target groups medihotels cater for, including those that focus on medical patients requiring multiple treatments over several days to other facilities aimed at improving peri-operative patient flows. In 2005-06 the department commenced a review of medihotels that will include recommendations on future funding models. In 2006-07, the department will commence development of the Medihotel Service Guidelines to support development of a ‘best practice’ model of care.

Example in practice

Medihotel and Medical Ambulatory Day Unit (MADU) The Alfred The MADU and medihotel commenced in 2001. Both units were established to provide comprehensive day treatment for medical patients with supported accommodation overnight to directly focus on medical patients who would otherwise have occupied a traditional inpatient bed. The MADU now operates seven days a week from 7am to 9pm and includes capacity for eight chairs and four trolleys. It provides treatment for patients with a wide range of medical clinical conditions such as those requiring abdominal paracentesis, lumbar puncture or blood transfusion. During the day, the medihotel often converts to expand the MADU model. The medihotel now operates seven days a week, 24 hours a day with 15 beds and flex capacity to 18 beds. It offers services to patients who are undergoing treatment, are required within the campus and in need of limited supported care overnight. In principle, patients are ambulant, self caring, self medicating, alert and orientated and accountable for their care. However at times, flexibility is required in the clinical criteria for medihotel patients and patients may require minimal intervention overnight for example intravenous antibiotics. In 2004, the medihotel implemented a preadmission medical screening service run by MADU clinical staff for all admissions into the MADU-medihotel to ensure effective flow and placement of patients. continued 62 Better faster emergency care

continued Over 350 patients are accommodated per month in the medihotel overnight and approximately 800 episodes of care are provided per month in the MADU. Consistent with an ambulatory model of care, both medical and allied health staffing is provided by the inpatient clinical units with additional pharmacy, medical resonance and pathology support. Outcomes identified include: • significant improvement in patient care and flow • clinical practice change • sustained bed substitution • high consumer and service system satisfaction • improvement in patient access through the emergency department and reduction in time on HEWS/bypass.

Source: The Alfred, May 2006

Observation medicine The concept of observation medicine has attracted significant attention over recent years. Currently, there are almost 250 observation medicine beds across Victoria’s public hospitals. Short-stay observations units (SOUs) typically care for patients who, with early assessment and intervention, are able to be discharged within 24 hours. This includes patients who require tests to determine the seriousness of their condition such as chest pain, or a short course of treatment that may be rapidly resolved such as asthma. SOUs also provide a location for patients who require allied health and social support before discharge. Medical assessment planning units (MAPUs) are also designed for a short stay but are aimed at more complex patients who are likely to require multi-day inpatient stay. They generally geographically co-locate emergency general medical admissions. By providing intensive multidisciplinary assessment including in the first 48 hours of the patient episode, the MAPU aims to reduce total length of stay. Emergency medical admissions requiring specialty services such as coronary care and intensive care are not managed through MAPUs. Evidence suggests that front loading of resources for accurate assessment and appropriate management can significantly reduce the patient’s length of stay.38 There are strong similarities between observation medicine models which all provide a dedicated environment where intensive multidisciplinary assessment and care planning can be carried out in a timely manner. Observation medicine models have the potential to improve the management of patients, reduce length of stay and improve patient flow and access to the emergency department.39

38 Melbourne Health, Clinical Epidemiology and Health Service Evaluation Unit, 2004. Models of Care to Optimise Acute Length of Stay: Short Stay/Observation Unit, Medical Assessment and Planning Unit and Emergency Medical Unit, Melbourne. 39 ibid Better faster emergency care 63

In 2005-06, enhancements were made to the VEMD and VAED to ensure datasets are able to capture all transfers from emergency departments to observation medicine beds. In 2006-07, the department will develop the Observation medicine service guidelines to support development of a ‘best practice’ model of care.

Day treatment centres Day treatment centres were developed in response to demand for more convenient health care services and advances in treatment options. The centres provide a range of services on an outpatient or day basis with after-care occurring in the community. Patients may be referred from the community, emergency department or inpatient areas. Day treatment centres currently operate at six locations - Austin Hospital, The Alfred, Monash Medical Centre (Clayton), St Vincent’s Hospital, Box Hill Hospital and the Royal Children’s Hospital. In 2007-08, the department will commence a review of day treatment centres to inform future service planning.

Key actions Continue to expand and develop new patient-centred emergency models of care to improve patient care. Continue to explore appropriate funding models for new models of care. Develop the Emergency department care coordination service guidelines in 2006-07 to support development of a best practice care model of care. Complete medihotel review in 2006-07 and develop the Medihotel service guidelines in 2007-08. Develop Emergency department observation medicine guidelines in 2006-07. Undertake a review of day treatment centres and commence development of the day treatment centres service guidelines in 2007-08. Develop the Emergency department fast track service guidelines in 2006-07.

12.5. Explore new ways of working Workforce initiatives undertaken by the Victorian Government to strengthen the capacity of the emergency care workforce include:

Education and Training There are a number of stakeholders involved in education of the health workforce. For example, the Commonwealth Government is responsible for undergraduate places, the Victorian Government has a role in supporting post graduate training and professional associations and colleges define standards of practice, accreditation and contribute to post graduate training. Recently the Commonwealth Government announced an increase in the number of places for undergraduate medical students from 2007. Given the time lag between making new places available and having an additional pool of medical practitioners, eduction and training initiatives to support emergency care workforce capability are critical. The department provides funding to support professional development of health professionals. In 2005-06, 97 scholarships were offered to nurses undertaking postgraduate study in critical care nursing, including emergency nursing. 64 Better faster emergency care

The department also supports the Advanced procedural training for GPs and Extended skills for GPs initiatives to support GPs and GP registrars to develop recognised skills in emergency medicine. Under the Advanced Procedural Training for GPs initiative, recurrent funding was provided in 2005 to support four procedures posts, one of which was in emergency medicine. Under the Extended skills for GP program, subsidies were provided for four emergency medicine positions in 2005-06. All medical interns are required to undertake a minimum eight-week rotation in an emergency department as part of their internship training to achieve general registration. As part of education and training support provided to interns, the department provides funding for medical education officers at all intern teaching hospitals. In 2006, the department is funding a pilot videoconferencing initiative for interns based at Echuca Hospital emergency department. As part of this pilot program, the Echuca emergency department will be linked to the Austin Hospital emergency department. The department has also developed a consortia model that links metropolitan and rural hospitals under a set of governance arrangements to manage the distribution and training of junior doctors. This model is being piloted with basic physician trainees. There is potential in the future for this model to be adapted to support the needs of emergency department staff.

Better Skills, Best Care workforce design strategy Providing quality emergency care requires an adequate supply of a suitably trained workforce. However, increasing the workforce alone will not be enough to meet future demand and achieve sustainable services. The Better skills, best care strategy has been developed to progress long term workforce change to improve the sustainability of the health system by: • integrating role design workforce initiatives with current and planned departmental strategies • encouraging locally responsive workforce review and design by encouraging health services to explore changed work roles • facilitating tailored competency-based training for new and amended roles • working with stakeholders to explore workforce issues and role design initiatives • building an evidence base for role design and evaluation measures. A total of 37 pilots in health services across Victoria were funded in 2005-06 to test amended professional and support roles in a variety of settings, including emergency departments. Evaluation is being undertaken inform implementation across the health system in 2006-07 where appropriate. In addition to evaluation of these individual amended roles, there are opportunities for more systemic change that comprehensively addresses all roles within selected service delivery streams. Workforce design projects will identify and trial innovative workforce models within emergency departments with a view to applying innovations to other Victorian public hospitals. Four service wide workforce design projects commenced at emergency departments in 2006 – at the Austin Hospital, Casey Hospital, Kyabram and District Hospital and Warrnambool Hospital. The projects will examine all roles within the emergency service stream including medical, nursing, allied health, support and administrative staff. Better faster emergency care 65

Emergency care nurse practitioner project There has been an increasing presence of nurse practitioners within Australia’s health system and many jurisdictions have developed, or are in the process of developing, the nurse practitioner role in emergency departments. The role of the emergency department nurse practitioner involves the management of patients from presentation to discharge from the emergency department including advanced assessment, ordering and interpreting diagnostic investigations, ordering of medicines, education and discharge of patients. The department funded a number of Victorian hospitals in 2005-06 to establish the nurse practitioner role in emergency nursing including the Austin Hospital, The Alfred, Northern Hospital, Royal Children’s Hospital, Sunshine Hospital, Monash Medical Centre, Dandenong Hospital, Box Hill Hospital and The Angliss. Following the success of these projects, five regional emergency departments received funding to establish the nurse practitioner role at Latrobe Regional Health, South West Healthcare Warrnambool, Goulburn Valley Health, Bendigo Health and Barwon Health. The objectives of these projects are to enhance health care delivery, strengthen the capacity of the health system and develop nurse practitioner models that demonstrate efficiency and quality outcomes. As a result of these projects it is expected that there will be more than 15 nurse practitioners working in Victorian emergency departments. The first nurse practitioners in emergency nursing will be endorsed in the near future. The project’s aim to allow staff to work to their maximum skill level or to a higher level when supported by appropriate training. The roles will be developed with a focus on improving the patient journey and quality of care.

The Emergency department workforce project To support enhanced understanding of the emergency department workforce, the department will undertake the Emergency department workforce project in 2006-07. As part of the project, staffing profiles and energency department activity levels will be identified across 19 metropolitan and five regional emergency departments. This initiative will contribute to development of a measure to assist health services to determine appropriate staffing levels and skills mix in relation to emergency department throughput and acuity.

Key actions Continue to identify initiatives to support emergency care workforce capability. Continue to support re-entry and refresher programs in 2006-07 to assist nurses to return to the workforce in 2006-07. Continue to support post-graduate training scholarships in emergency nursing in 2006-07. Continue to support the Advanced procedural training for GPs and Extended skills for GPs in 2006-07. Explore further opportunities to support medical interns undertaking emergency department rotations as part of their internship. Explore the potential development of the nurse practitioner role to improve emergency access for example in rapid response teams in super clinics, aged care, community care and mental health in 2006-07. Continue to investigate systematic workforce redesign opportunities in emergency care in 2006-07. Undertake the Emergency department workforce project in 2006-07. 66 Better faster emergency care

12.6. Enhance safety and quality of care Increasingly emphasis is placed on changing the culture of organisations, and the support they provide for using evidenced based practice. Initiatives include:

Promoting evidenced-based practice The department’s Clinician’s Health Channel is a clinical information access portal that is made available by the Department of Human Services for clinicians working in the Victorian public health sector. It provides access to citation data bases, detailed drug and prescribing information, clinical practice and other information resources. The Safer Systems Saving Lives project, which was undertaken in selected public hospital sites across Victoria in 2005-06, uses a ‘bundle of care’ approach to increase the uptake of widely accepted best practice. This approach builds on the concept that while each component is of value, if all elements in the ‘bundle’ are used, the benefit to patients is increased. Opportunities to disseminate best practice also occurs through the Department of Human Services Sentinel Event and Limited Adverse Occurrence Screening programs. Events reported through these programs are examined for lessons that have applicability across the wider health sector.

Safety of care The Auditor General’s report Managing patient safety in public hospitals (2005) noted the need for organisations to ensure that an integrated risk management framework is in place and that a range of indicators on safety and quality are reported to Directors/Boards of Management on a regular basis. In 2006-07, the department will trial a suite of safety and quality indicators along with minimum standards for clinical incident policies and incident reporting systems.

Quality of care indicators Effectiveness is a key performance dimension of health care and refers to the degree of achieving desirable outcomes, given the correct provision of evidence based health care services to all those who would benefit, but not to those who would not benefit.40 Literature suggests that although there is some evidence on clinical effectiveness of certain interventions in specific circumstances, there are gaps in knowledge in this area. Current indicators for emergency care included in the National health performance framework41 currently address access rather than effectiveness. Commencing in 2007-08, the department will work with health services to explore the feasibility of emergency care clinical effectiveness indicators.

‘Improvement in the health system must strengthen the involvement of clinical leaders working with other stakeholders within the health system.’ - Independent Pricing and Regulatory Tribunal of New South Wales 2003, NSW

40 Organisation for Economic Cooperation and Development Health Working Papers, 2006. Health Care Quality Indicators Project: Conceptual Framework Paper, Unclassified 41 National Health Performance Committee, 2004. National report on health sector performance indicators 2003. AIHW cat.no. HWI 78, AIHW, Canberra. Better faster emergency care 67

Key actions Identify opportunities to further strengthen the quality of emergency care, for example, enhancing access to up to date evidence based clinical guidelines, telemedicine and videoconferencing. Explore the feasibility of developing clinical facilitator roles across health services, clinical networks and further specialisation of emergency departments. Promote leadership by engagement of clinicians and public health services in delivery of best practice emergency care. Commencing in 2007-08, work with health services to explore the feasibility of developing emergency care quality and clinical effectiveness performance indicators.

12.7. Promote better systems for care Key initiatives to promote better systems of care and improve patient flow include:

General practice liaison program An informal network of general practice liaison officers (GPLOs) was established in Victoria’s public hospitals in the late 1990s to assist hospitals to facilitate communication with general practice. In 2001, the GPLO network was expanded across nine metropolitan health services through acute primary care liaison activities funded through HARP. In 2006, the department undertook a review of the GPLO program that examined the current roles and functions of the GPLOs, explored the program structure, operation and outcomes, and provided recommendations to inform future service planning.

Electronic bed management systems Delays in accessing inpatient hospital beds is widely recognised as a factor contributing to ‘access block’ in emergency departments. Hospital bed management and admission practices impact on emergency department patient access to hospital inpatient beds. Currently public health services utilise a range of strategies and tools to manage patient flow. In 2006-07, the department will examine the feasibility for an integrated statewide bed management system in Victoria that will provide public health services with the capability for ‘real time’ organisation wide monitoring and management of bed capacity.

Streamlined discharge and referral systems It is recognised that continued investment will be required to streamline emergency department discharge and referral protocols between emergency departments and the broader health system to facilitate seamless continuum of care for patients. An important area to target in ensuring continuity of care will be the level of integration between the emergency department other health care providers, including minimum information, communication standards and compatible information communication technology. Systems and practices have been developed through the Primary care partnership strategy to allow the effective implementation of electronic referral. 68 Better faster emergency care

Example in practice

Electronic referral project: Melbourne Health and Western Health community health providers Melbourne and Western Health services and primary care agencies in the north and west of Melbourne have identified a number of discharge referral issues between acute and primary care. These issues include lack of information about available services, numerous referral forms, complex administrative processes, lack of multidisciplinary planning and a void of information about referral outcome once the patient left the hospital. To address these issues, electronic referral was introduced between Western and Melbourne Health services including emergency departments and primary care agencies in 2004. Melbourne Health identified that work had already been done in the primary care sector through the Primary care partnership strategy to establish partnerships, develop protocols and a common set of forms for referral, and that these were readily adaptable to the emergency department environment.

Evaluation findings included: • improved coordination of services and referral between acute and primary care agencies • improved communication between acute and primary care agencies • facilitated multidisciplinary approach to discharge planning allowing multiple staff to contribute to the same referral • referrals were more useful to community agencies, generally containing more detail of emergency department and inpatient assessments • improved continuity of care through more formalised referral acknowledgement and feedback which allowed better monitoring of referral outcomes • use of the service coordination tool templates meant that only one form was needed to refer to community agencies • sending referrals through secure electronic referral reduced paperwork and improved efficiencies • greater choice of referral options on discharge because easy access to accurate information about community services was enabled through electronic services directory.

Source: Melbourne Health June 2006

Emergency care service planning In 2006 to 08, a role delineation framework for emergency departments in Victoria’s metropolitan public hospitals will be developed. The level of service outlined in the framework will describe the complexity of clinical activity undertaken and will promote best practice management and care coordination within existing resources and infrastructure. Better faster emergency care 69

Key actions Continue to work with health services to promote person-centred approaches in the way people move through the emergency department. Undertake a review of the GPLO Program in 2006-07 and commence development of the GPLO program service guidelines in 2006-07. Undertake an electronic bed management system pilot in 2006-07 in up to four selected metropolitan and regional public hospitals. Commencing in 2006-07, identify opportunities to streamline and improve emergency discharge and referral protocols, including shared electronic health records and care coordination initiatives to support multidisciplinary care planning arrangements. Develop an emergency department role delineation framework in 2006 to 08.

12.8. Promote better management of care for people with mental health problems The Victorian Government’s mental health strategy seeks to ensure the long term sustainability of the mental health system by enhancing capacity to manage unavoidable demand and more effectively manage consumers to avert crisis and relapse, and manage demand pressures. Actions to improve mental health care in emergency departments include:

Victorian emergency department mental health triage project The Victorian emergency department mental health triage project was undertaken in 2005-06 to enhance emergency department staff triage skills in the initial assessment of mental health patients presenting to emergency departments, and to support collaboration between emergency departments and specialist mental health services. The project consisted of development of a triage tool and training manual followed by implementation across 15 metropolitan and five regional public hospital emergency departments.

Hospital Admission Risk Program-Chronic Disease Management (HARP-CDM) As part of HARP, funding was provided to improve the health system’s response to people who presented with suicidal or self-harming behaviours, complex psychosocial problems and substances misuse. HARP-CDM is now embedding the models of care that have emerged through HARP since 2001 into the Victorian service system. This program will focus on continuing to improve the management of people with defined chronic diseases and complex needs who frequently use hospitals or who are at risk of hospitalisation, including people with complex psychosocial needs.

Enhanced crisis assessment and treatment services (ECATS) ECATS were established in 1998 to provide a mental health response for emergency departments. The services aim to provide a 24-hour integrated, timely and flexible mental health crisis assessment and treatment response to the emergency department. Key service partnerships include emergency department staff, area mental health services, primary care and other community and specialist agencies and police and ambulance. 70 Better faster emergency care

Enhancements to the Victoria emergency minimum dataset (VEMD) New fields were added to the VEMD in 2005-06, with data collection commencing in 2006- 07 to accurately identify and record the number of patients requiring specialist mental health consultation within emergency departments. This will support better understanding of mental health service requirements in emergency departments and inform mental health service policy development and funding, planning and coordination.

Example in practice

The mental health program patient flow project – Southern Health The mental health program (MHP) patient flow project commenced in May 2005 to address concerns about long emergency department waits for mental health clients, improve bed management practices, better plan discharges from the ward and improve communication between clinicians, consumers and carers. There was an identified need to work collaboratively with an agreed understanding about the role of mental health services in the emergency department. The project aimed to increase access for consumers with the greatest need, to reduce waits and to improve coordination of services with the MHP that was better communicated to consumers and their carers. It also aimed to facilitate organisational change. In conjunction with emergency department partners, the MHP developed agreed processes and timeframes around mental health responses in the emergency department, and agreed escalation plans. A daily teleconference call was made between the three teams responsible for the mental health responses to the emergency department and the wards to manage bed flow. A care management group developed agreed to discharge ‘golden gules’, an agreed flow rate of discharges in each ward to reduce variability, targets for the timing of discharges and senior clinician led planning of all anticipated discharges for the next week. Protocols are well communicated to the team, consumers and their carers. A key feature of the success was MHP executive support, committed champions who led the change, improved understanding of community needs, clinician buy in and processes that were transparent, understood and well communicated. Outcomes identified include: • reduced emergency department waiting times for mental health presentations • reduced number of patients being moved to out of area beds • improved discharge planning • improved satisfaction by consumers and carers • reduced variability in the daily discharge numbers for each ward making the planned workload for staff more reliable • development of partnerships.

Source: Southern Health June 2006 Better faster emergency care 71

Bed management Access to timely bed information is especially important for hospital emergency departments and crisis assessment and treatment services. Departmental funding was provided to agencies in 2005 to assist in changing information management processes across general and mental health services and enable improved data entry. By updating the frequency of data entry, more timely bed vacancy information becomes available to clinicians, thus facilitating admission of a client to a mental health bed.

Improving hospital based care In 2005-06, funding was allocated to expand hospital based care and alternatives to inpatient care. This includes: • expansion of adult acute inpatient beds at Casey Hospital, Werribee Hospital, and Austin Health • additional step up/step down prevention and recovery care places for people who require short term sub-acute care • establishment of mental health short stay units at Melbourne Health and Monash Medical Centre • building on existing Mental Health and Statewide Emergency Program investment, expansion of extended hours mental health assessment, consultation and liaison response in emergency departments at Western Hospital, Werribee Mercy Hospital, Royal Melbourne Hospital, Northern, St Vincent’s Hospital, Dandenong Hospital and Monash Medical Centre.

Key actions Develop emergency department mental health service guidelines in 2006-07. Undertake formal evaluation of mental health short-stay units in 2006-07, and in 2007-08 develop guidelines for mental health short-stay units to support development of a best practice model. Commencing in 2006-07, explore the feasibility of specific mental health performance indicators. Expand extended hours mental health, assessment, consultation and liaison response in 2006-07 at Austin Health, The Alfred, Royal Children’s Hospital, Geelong Hospital, Bendigo Hospital and Mildura Hospital. Develop and implement strategies to improve coordination between emergency departments and specialist mental health services, community health services, general practitioners and private mental health professionals. Continue to improve emergency department clinician’s skills in the assessment and management of mental health problems they are likely to encounter. 72 Better faster emergency care

12.9. Promote better management of care for older people Key initiatives to better manage care for older people include:

Improving care for older people Older people and people who have multiple and complex needs, often require access to specialist assessment and treatment and a variety of support services to be able to regain or maintain their independence in the community. As part of the Victorian Government’s policy Improving care for older people: a policy for health services, health services are working closely with the department to address five key impact areas: • delivering person-centred care by ensuring the older person is an informed and valued participant in their health care • building best practice in the care of older people by the use of an evidence-based approach to understand the complexity of their specific health care needs • modifying environments ensuring they are ‘older person friendly’ • providing training and development as a catalyst to culture change and a platform for staff training and up-skilling • developing partnerships and networks within and between health services, to improve the coordination and integration of care for older people. The department funded four statewide projects in 2005-06 to further support public health services to improve the way care is delivered to older people and people with complex care needs. These projects aim to identify best practice in person-centred care, enhance person-centred practice, improve the environment for older people in health services including the emergency department, and improve the way older people with dementia are managed in hospitals. This initiative aims to increase our focus on meeting the specific needs of older people and improving the culture within our health system, including in emergency departments to provide a better experience for older patients. Better management both within hospitals and in community based health care settings will also help prevent unnecessary emergency department admissions. Better faster emergency care 73

Example in practice

Fit and active in the emergency department Eastern Health The Fit and active in the emergency department project was introduced by Eastern Health and the InformED program during 2005 in response to the increasing number of older people presenting to the emergency department. The project aims to provide a holistic and multidisciplinary approach to minimise poor functional outcomes for elderly patients presenting to the emergency department. In particular, it aims to reduce the rate of pressure site development, maintain optimal physical functioning, maintain cognitive function and maintain functional status for this client group. Key features of the program include: • education of emergency department staff to equip them with an understanding of broader health issues for elderly patients and strategies for maintaining functionality • screening and holistic assessment using a screening tool which has been developed to identify patients at risk and guide the development of care plans • activities to support nutritional status including assessment by a dietician, nutritional advice, supplements, provision of adequate food and drink by volunteers in the emergency department, meal vouchers and referral to Meals on Wheels • activities to support physical mobility including assessment by allied health staff and provision of equipment and aids • activities to maintain cognitive function for example provision of newspapers, magazines and games • activities to prevent pressure site development including staff awareness programs and wider availability of protective equipment. Positive outcomes demonstrated from this study include reduced emergency department length of stay, reduced pressure sore rate, improved mobilisation, access to cognitive stimulation, nutritional improvements and increased early allied health intervention. Providing multidisciplinary holistic care for older people in emergency departments improves hospital experience and health outcomes for this patient group.

Source: Maroondah Hospital, June 2006

74 Better faster emergency care

Transition Care services Transition Care services target older people at the conclusion of a hospital admission who require more time and support in a non-hospital environment to complete their restorative process, optimise their functional capacity and finalise and access their longer-term care arrangements. In Victoria, the Transition Care program will be operated by major metropolitan and regional health services, and will be delivered in the older person’s home or within a bed based service such as a residential aged care facility. The Transition Care program is jointly funded by the Commonwealth and Victorian governments.

Key actions Explore further opportunities to strengthen delivery of emergency care for older people. Continue to work closely with health services to implement Improving care for older people: a policy for health services. Develop, trial and evaluate resources to support person-centred practice. Implement the audit tool developed to improve the environment for older people in health services. Evaluate the rollout of the Dementia management in hospitals program to eight health services.

12.10. Promote better management and care of children Children often have needs that require access to specialised assessment and treatment. The needs of paediatric patients should be taken into account in developing protocols for triage and transport of paediatric patients, organising delivery of emergency care and development of emergency care clinical guidelines. In 2004-05, 260,349 (23 per cent) emergency department presentations were children less than 15 years of age. Emergency education and training programs should ensure staff are competent and comfortable providing care to children. In 2007-08, the department will develop the Paediatric emergency care service guidelines to promote implementation of best practice paediatric emergency care across Victoria’ s public hospitals.

Key actions In 2007-08, develop the Paediatric emergency care service guidelines. Further explore opportunities to improve clinicians’ emergency paediatric emergency care skills for example enhancing access to up-to-date evidence-based clinical practice guidelines, teleconferencing and telemedicine. Better faster emergency care 75

13. Conclusion

This document describes initiatives already underway, and key actions that will be undertaken to further improve emergency care and access in Victoria’s public hospitals over the next five years. It also presents key enablers and approaches required to achieve this vision. Both the Department of Human Services and public health services will have a significant role in facilitating system improvement and supporting implementation of this policy framework. Progress with implementation of the key actions will be reviewed by the department in partnership with the Emergency Access Reference Committee on an ongoing basis. This will include development of new measures to monitor delivery of emergency care in Victoria’s public hospitals. As reform of the emergency care system continues, it is anticipated that additional initiatives, and new and more efficient ways to deliver quality emergency care will continue to be developed during this time. 76 Better faster emergency care Better faster emergency care 77

Appendix 1

Further information: Department of Human Services policy frameworks

New Directions for Victoria’s Mental Health Services: The Next Five Years (Department of Human Services, 2002) www.dhs.vic.gov.au/health/mentalhealth/publications/plan02/mhp.pdf

Directions for your health system: Metropolitan Health Strategy (Department of Human Services, 2003) www.health.vic.gov.au/metrohealthstrategy/strategy.htm

Better Quality Better Health Care: A Safety and Quality Improvement Framework for Victorian Health Services (Department of Human Services, 2003) www.health.vic.gov.au/qualitycouncil/pub/improve/framework.htm

Primary Care Partnerships Strategic Directions: Better health–stronger communities, 2004-06 (Department of Human Services, 2004) www.health.vic.gov.au/pcps/downloads/strategy/pcp_strat_2004_06.pdf

Community Health Services—creating a healthier Victoria (Department of Human Services, 2004) www.health.vic.gov.au/communityhealth/downloads/chs_policy.pdf

Improving care for older people: a policy for Health Services (Department of Human Services, 2003) www.health.vic.gov.au/older/improvingcare.pdf

Health SMART: Strategy for the modernisation and replacement of information technology (Department of Human Services, 2003) www.health.vic.gov.au/healthsmart/documents/healthsmart_strategy.pdf

General Practitioners in Community Health Services Strategy (Department of Human Services, 2004) www.health.vic.gov.au/communityhealth/downloads/gps_in_chs_strategy.pdf

Cultural diversity guide: Multicultural Strategy (Department of Human Services, 2004) www.dhs.vic.gov.au/multicultural

Rural Directions for a better state of health (Department of Human Services, 2005) www.health.vic.gov.au/ruralhealth/hservices/directions.htm

Elective Surgery Access Policy (Department of Human Services, 2005) www.health.vic.gov.au/electivesurgery/access_pol.pdf

Care in your community: A Planning Framework for integrated ambulatory care health care (Department of Human Services, 2006) www.health.vic.gov.au/ambulatorycare/downloads/care_in_your_community.pdf 78 Better faster emergency care Better faster emergency care 79

Appendix 2

Victorian public hospitals with 24-hour emergency department funded through the non-admitted emergency services grant

Angliss Hospital Austin Hospital

Barwon Health Ballarat Health Service

Bendigo Health Care Group Box Hill Hospital

Casey Hospital Central Gippsland Health Service (Sale)

Dandenong Hospital Frankston Hospital

Goulburn Valley Health (Shepparton) Latrobe Regional Hospital

Maroondah Hospital Mercy Hospital for Women

Werribee Mercy Hospital Mildura Base Hospital

Monash Medical Centre The Northern Hospital

Rosebud Hospital Royal Children’s Hospital

Royal Melbourne Hospital Royal Women’s Hospital

Royal Victorian Eye and Ear Hospital St Vincent’s Hospital

Sandringham & District Memorial Hospital Sunshine Hospital

Swan Hill District Hospital The Alfred

West Gippsland Healthcare Group (Warragul) Northeast Health Wangaratta

South West Healthcare (Warrnambool) Western District Health Service (Hamilton)

Western Hospital Williamstown Hospital42

Wimmera Healthcare Group (Horsham) Wodonga Regional Health Service

Bairnsdale Regional Health Service Echuca Regional Health

42 Williamstown Hospital is not open 24 hours a day 80 Better faster emergency care

Urgent care centres

Casterton Memorial Hospital Colac Area Health

Coleraine District Health Services Hesse Rural Health Service (Winchelsea)

Lorne Community Hospital Moyne Health Services (Port Fairy)

Portland District Health South West Healthcare – (Camperdown)

Terang & Mortlake Health Service (Terang) Timboon & District Healthcare Service

Western District Health Service (Penshurst) East Grampians Health Service (Ararat)

East Wimmera Health Service (St Arnaud) Edenhope & District Hospital

Hepburn Health Service (Daylesford) Stawell Regional Health

West Wimmera Health Service (Nhill) Boort District Hospital

Cohuna District Hospital Inglewood & District Health Service

Kerang District Health Kyabram & District Health Service

Kyneton District Health Service Maryborough District Health Service (Maryborough)

Mount Alexander Hospital (Castlemaine) Alexandra District Hospital

Alpine Health (Bright) Alpine Health (Mount Beauty)

Alpine Health (Myrtleford) Benalla & District Memorial Hospital

Cobram District Hospital The Kilmore & District Hospital

Mansfield District Hospital Nathalia District Hospital

Numurkah & District Health Service Seymour District Memorial Hospital

Upper Murray Health & Community Services (Corryong) Yarrawonga District Hospital

Yea & District Memorial Hospital Bass Coast Regional Health

Orbost Regional Health Gippsland Southern Health Service (Korumburra)

Gippsland Southern Health Service (Leongatha) South Gippsland Hospital (Foster)

Yarram & District Health Service West Gippsland Healthcare Group (Warragul) Better faster emergency care 81

Primary injury services

Heywood Rural Health Otway Health & Community Services (Apollo Bay)

Beaufort & Skipton Health Service (Beaufort) Beaufort & Skipton Health Service (Skipton)

Djerriwarrh Health Service Dunmunkle Health Service

East Grampians Health Service (Willaura) East Wimmera Health Service (Donald)

East Wimmera Health Service (Birchip) East Wimmera Health Service (Charlton)

East Wimmera Health Service (Wycheproof) Hepburn Health Service (Creswick)

Rural Northwest Health (Hopetoun) Rural Northwest Health (Warracknabeal)

West Wimmera Health Service (Jeparit) West Wimmera Health Service (Kaniva)

West Wimmera Health Service (Rainbow) Wimmera Health Care Group (Dimboola)

Mallee Track Health & Community Service (Ouyen) Maldon Hospital

Manangatang & District Hospital McIvor Health & Community Services (Heathcote)

Robinvale District Health Services Rochester & Elmore District Health Service

Beechworth Health Service Tallangatta Health Service

Central District Health Service (Maffra) Omeo District Health 82 Better faster emergency care Better faster emergency care 83

Appendix 3

Emergency department use in Victoria’s public hospital emergency departments The following section outlines commentary and observations about emergency department demand from 1999-2000 to 2005-06 for 38 metropolitan and rural hospitals using data sourced through the VEMD.43 The data is intended to provide a snapshot of emergency department use on a statewide basis and does not reflect differing patient demographics and numbers of presentations at emergency departments at different hospitals.

1. Emergency department presentations by age Growth in emergency presentations from 1999-2000 to 2005-06 differed across age cohorts with the highest growth seen in people over 85 years of age. The number of emergency department presentations increased by 22 per cent for those under 15 years, by 34 per cent for those aged 15-64 years, 37 per cent for those aged 65-84 years and by 56 per cent for those aged 85 years and over. This is represented in Figure 1.

Figure 1: Emergency department presentations by age cohort, 1999-2000 to 2005-06

43 Only 29 hospitals reported to the VEMD in 1999-2000; one small metropolitan hospital began reporting presentations in 2000-01 and six rural hospitals and one small metropolitan hospital began reporting in 2003-04. Rural urgent care centres and primary injury services do not report to the VEMD. The activity for the hospitals that did not report to VEMD from 1999-2000 has been estimated for earlier years based on their actual VEMD data submission for the most recent years. Casey Hospital opened and began reporting data in 2004-05. 84 Better faster emergency care

2. Emergency department presentations by age and gender In 2005-06, there were similar presentation patterns by gender across each age cohort although the presentation rate for males was higher than females in 14 years and under age cohort. Fifty per cent of presentations were male. Presentations for males under 14 years made up 13 per cent of all presentations compared with females under 14 years who made up 10 per cent of all presentations. Males aged between 15 and 64 years made up 29 per cent of all presentations, slightly less than the 31 per cent of presentations that females of this age group represented. Presentations for males females between 65 and 84 years each made up seven per cent of all presentations. Presentations for females aged over 85 years made up two per cent of all presentations compared to one per cent for presentations for males. Figure 2 presents presentations by age and gender in 2005-06.

Figure 2: Percentage of presentations by age and gender, 2005-06

3. Emergency department presentations by triage category In 2005-06, almost half of all presentations were ACEM triage category four (semi urgent). Triage category three (urgent) and category four presentations made up 75 per cent of all presentations, and triage category five (non urgent) presentations made up 17 per cent of all presentations. Emergency department presentations in 2005-06 for each ACEM triage category is presented in Figure 3.

Figure 3: Percentage of emergency department presentations by ACEM triage category in 2005-06 Better faster emergency care 85

There was significant variation in the growth of presentations for each ACEM triage category from 1999-2000 to 2005-06. Triage category two (emergency) presentations experienced the highest percentage growth – 78 per cent or an average annual growth of 13 per cent. There was negative growth in the number of triage category one (resuscitation) and triage category five (non-urgent) presentations. Figure 4 presents the percentage growth of each triage category for the period.

Figure 4: Emergency department presentation growth by ACEM triage category using 1999-2000 as the base year

4. Arrival time by triage category In 2005-06, category five presentations (non-urgent) showed a significant peak arrival time - between 9am and 11am with almost 20 per cent of these presentations arriving at this time. The remaining triage categories had arrival time patterns that were similar to each other. Figure 5 presents arrival time for each triage category over a 24-hour period.

Figure 5: Arrival time by triage category, 2005-06 86 Better faster emergency care

5. Arrival time by age In 2005-06, peak arrival times varied according to age group during the 24-hour period. The peak presentation time for people aged 0–14 was between 6pm and 10pm. People aged between 65 and 84, and 85 years and over had a peak arrival time between 10am and 1pm. Presentation times for people aged between 15 and 64 years of age showed a consistent pattern between 9am and 9 pm. Figure 6 shows arrival times for age groupings 0-14 years, 15-64 years, 65-84 years and 85 years and over.

Figure 6: Arrival time by age cohort, 2005-06

6. Length of stay for admitted patients by arrival time A total of 77 per cent of admitted patients who arrived in the emergency department between 12 noon and 6pm were admitted within eight hours, compared to 61 per cent for admitted patients arriving between midnight and 6am. A total of nine per cent of admitted patients who arrived between 12 noon and 6pm had an emergency department length of stay of more than 16 hours, compared to four per cent of patients who arrived between midnight and 6am. Figure 7 presents length of stay for admitted patients according to arrival time.

Figure 7: Length of stay by arrival time for admitted patients, 2005-06 Better faster emergency care 87

7. Length of stay for non-admitted patients by arrival time A total of 82 per cent of non-admitted patients arriving between 6am and midday, midday and 6pm, and 6pm and midnight had an emergency department length of stay of four hours or less compared to 74 per cent of non-admitted patients who arrived during midnight to 6am. Only 0.5 per cent of all non-admitted patients had a length of stay of greater than sixteen hours. Figure 8 presents length of stay by arrival time for non-admitted patients.

Figure 8: Length of stay group by arrival time for non-admitted patients, 2005-06

8. Emergency departments representations In 2005-06, 20,982 people presented to the same hospital emergency department four or more times during the year. This represents 3.5 per cent of all presenters during the year, and 13.6 per cent of all presentations. The percentage of people who presented to the same hospital emergency department four or more times was 3.0 per cent for people aged 0-14 years, 3.2 per cent for people aged between 15 and 64 year olds, 5.2 per cent for people aged 65-84 years and 5.3 per cent for people aged 85 years and over.

9. Emergency department inpatient admissions Only some presentations to the emergency department become an admission to the hospital. Between 1999-2000 and 2005-06 the number of admissions from the emergency department increased from approximately 195,000 to 286,275 - an average annual increase of 7.8 per cent. The rate of admissions has remained consistent during this period - between 20 per cent and 23 per cent. 88 Better faster emergency care

10. Emergency department inpatient admissions by triage category In 2005-06, admission rate varied significantly across triage categories. A total of 72 per cent of category one presentations, 55 per cent of category two presentations, 39 per cent of category three presentations, 15 per cent of category four presentations, and four per cent category five presentations were admitted to a hospital inpatient bed. However the high numbers of triage category three and category four presentations means that these two categories account for 78 per cent of emergency department admissions, while category one admissions account for only two per cent of all emergency department admissions. This is presented in Figure 9.

Figure 9: Emergency department admissions by triage category, 2005-06.

11. Emergency department admissions by age cohort The largest growth in emergency department inpatient admissions from 1999-2000 to 2005-06 was seen in people aged 85 years and over. Figure 10 outlines emergency department admission rates by age cohort from 1999-2000 to 2005-06.

Figure 10: Percentage of admissions by age cohort, 1999-2000 and 2005-06

0-14 15-64 65-84 85+ 1999-2000 15 per cent 17 per cent 43 per cent 52 per cent 2005-2006 13 per cent 19 per cent 46 per cent 58 per cent Better faster emergency care 89

12. Destination following discharge Following an emergency department presentation, people may be discharged to their place of residence, transferred to another hospital, or depart before their treatment has been completed. Between 1999-2000 and 2005-06 departure destination rates were consistent, with about 70 per cent of patients going home, and about 25 per cent of presentations being admitted to either the same hospital or transferred to another hospital. Departure destination rates between 1999-2000 and 2005-06 are presented in Figure 11.

Figure 11: Percentage of emergency presentation departure destination, 1999-2000 and 2005-06

Departure destination 1999-2000 2005-06 Home or residential facility 70 per cent 69 per cent Admitted to same hospital 22 per cent 23 per cent Left before the completion of treatment 5.6 per cent 5.6 per cent Transferred to another hospital 2.5 per cent 2.3 per cent Died 0.1 per cent 0.1 per cent 90 Better faster emergency care Better faster emergency care 91

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