ACCESS BLOCK IN TASMANIAN EDs Findings from the 2019 Access Block Snapshot Surveys
Overcrowding and Wait Times in Tasmanian EDs
1. Introduction
Two snapshot surveys of Australian hospital EDs accredited for specialist training by the Australasian College for Emergency Medicine (ACEM) were undertaken in 2019. The first was undertaken on Monday 3 June 2019 at 10:00am local time (the early 2019 survey), and the second undertaken at 10:00 local time on 2 September 2019 (the late 2019 survey). Of the 129 eligible Australian hospital EDs asked to participate, 124 provided data in the June survey and 114 provided data in the September survey.
The purpose of this report is to highlight the pressures on Tasmanian EDs by presenting the most recent data from the Access Block Snapshot Surveys, backed up by ACEM’s Annual Site Census for 2017-18. In response to the deteriorating performance of the Tasmania health system, Tasmanian Directors of Emergency Medicine have given permission for the separate release of the data collected for the study over the last four years. This report presents the findings from these data, both in isolation and in comparison, with national averages to show the unique situation faced by hospitals in Tasmania.
The summary and analysis of results from across Australia will be released in a separate report.
2. Summary of findings
Survey data by the Australasian College for Emergency Medicine (ACEM) demonstrates that demand pressures on Tasmania’s emergency departments (EDs) are continuing to increase, that patients in Tasmania’s EDs face the longest waits for inpatient care of anywhere in the country, and that the situation at Royal Hobart Hospital (RHH) continues to deteriorate.
Our June and September 2019 snapshot surveys show that, based on the performance measures of access block and 24-hour wait times, the two largest EDs in Tasmania were the worst performing hospitals in Australia.
The findings from the June 2019 snapshot survey show that: • Launceston General Hospital, with 17 (57%) access blocked patients out of 30 awaiting treatment and 11 patients staying more than 24 hours, was the worst performing hospital in the country. • The Royal Hobart Hospital, with 13 (50%) access blocked patients out of 26 being treated and 6 waiting for over 24 hours, was the second worst after Launceston General Hospital.
The findings from the September 2019 snapshot survey show that: • Launceston General Hospital had 13 (46%) access blocked patients out of 28 awaiting treatment, with 7 patients staying more than 24 hours. • The situation at Royal Hobart Hospital had deteriorated markedly from June, with 20 (57%) access blocked patients out of 35 awaiting treatment, and 7 patients staying more than 24 hours.
Collectively, across 2019 our surveys show that Tasmania’s two major public hospitals accounted for 29% of all access block within the Australian hospitals that responded to this survey.
ACEM defines access block as the situation where patients who have been admitted and need a hospital bed are delayed from leaving the Emergency Department (ED) because of lack of inpatient bed capacity. A patient is considered access blocked when an admitted patient spends longer than eight hours in the ED from their time of arrival. These outcomes are the result of blockages to patient flow that originate in the management of inpatient capacity and are therefore beyond the ED to control.
Page 1 of 2 The deteriorating performance of Tasmania’s two largest emergency departments in 2019 follows from the results from ACEM’s Annual Site Census for the 2017-18 financial year (unpublished). This survey found that 1,288 patients, or 2% of all presentations to Royal Hobart Hospital ED experienced dangerously long wait times in excess of 24 hours. This compares with a national average of 0.6% of all patients. Note that figures for Launceston General Hospital were not collected in this census.
3. Background
Emergency departments provide expert medical care for undifferentiated, unscheduled patients with illnesses or injuries 24 hours a day. As emergency departments (EDs) are available 24/7 and are often the entrance point into the broader hospital and healthcare system, the ability of ED teams to ensure timely access to necessary care is undermined by delays in access to inpatient or community-based services. These pressures are most visible in EDs through access block, ED overcrowding and ambulance ramping.
Access block, ED overcrowding, and ambulance ramping are too common occurrences in Tasmania’s four public hospitals, putting at risk the health and safety of patients and staff. Our members’ report that access block and overcrowding are the major causes of workplace stress, burn out and workplace conflict with their colleagues in other parts of the hospital.
4. Detailed Survey Findings
National and state level findings When examining the degree of access block in Tasmania compared to different hospital classifications nationally, the state remains the worst performing jurisdiction in Australia for extended waits, particularly for access blocked patients (patients with a length of stay greater than eight hours). As shown in Figure 1 (below), Tasmania as a state has significantly higher rates of access block compared to hospitals nationally.
Figure 1: Number of ED patients (broken down by patient admission status) in Australia vs. Tasmania
Another major concern is that, overall, the proportion of 24 hour waits in Tasmania has been markedly elevated since early 2015. As shown in Figure 2 (below), in 2019 alone an mean of 46% of access blocked patients were waiting 24 hours or longer; the proportion of access blocked patients waiting 24 hours or longer in Tasmania ranged from 520% (early 2019) to 300% (late 2019) of national levels (late 2019).
This 2019 finding confirms a long-term pattern of access block problems in Tasmania. Indeed, except for the September 2016 survey, the proportion of access blocked patients waiting longer than 24 hours in Tasmania has ranged from 130% to 520% higher than national levels between 2015-2019 (see Figure 2).
These findings clearly demonstrate an overall trend where the proportion of ED patients waiting 24 hours or longer has been consistently higher than the national mean and highlights the continued strain in the Tasmanian health system.
Access Block in Tasmanian EDs: findings from the June 2019 Access Block Survey [DRAFT] Page 2 of 9 Figure 2: Percentage of access block patients waiting >24hr in Australia vs. Tasmania
Unpublished results from ACEM’s Annual Site Census provide a national perspective on these findings. While the national rate of 24-hour stays was just 0.6% of patients in the 2017-18 financial year, Tasmania’s Royal Hobart Hospital reported that 2% of all patient presentations in in the same period waited 24 hours or longer. This rate was equalled only by the NT, which also recorded a 2% result. Comparable smaller jurisdictions including South Australia and the ACT both reported less than 1% of patients waiting 24 hours or longer in the ED. Local level findings At a local level, Tasmania’s two major EDs – Royal Hobart Hospital and Launceston General Hospital - consistently have high incidences of access block and 24-hour waits compared to other hospitals in the state and the national mean.
Figures 3 and 4 (below) show the 5-year trend in ED access block levels in Royal Hobart Hospital and Launceston General Hospital EDs, compared to national rates across Australia. In the early 2019 survey, the mean number of patients in Tasmania’s two major EDs that were experiencing access block (wait times in excess of 8 hours) was much higher than both the national mean (all Australian hospitals) and mean for all major referral hospitals in Australia. This comparison with the national mean held true in the late 2019 survey; Royal Hobart Hospital had a 10% increase in access block numbers.
Figure 3: RHH access block relative to All Australian Hospitals and All Major Referral Hospitals
Access Block in Tasmanian EDs: findings from the June 2019 Access Block Survey [DRAFT] Page 3 of 9 Figure 4: LGH access block relative to All Australian Hospitals and All Major Referral Hospitals
Although the total figures of access block patients in these hospitals fluctuate each year (likely due to limitations arising from such survey designs), the contrast in Tasmanian ED performance compared to the national mean indicates a long-standing issue of access block in Tasmania’s two major hospitals. In the first survey of 2019, Royal Hobart Hospital and Launceston General Hospital had 13 and 17 access- blocked patients respectively, compared to the national hospital mean of 5. In late 2019, Royal Hobart Hospital and Launceston General Hospital had 20 and 13 access-blocked patients respectively, compared to the national hospital mean of 9.
The proportion of access blocked patients that are facing dangerously long wait times (in excess of 24 hours) has seen a marked increase over the past two years in Tasmania. Figure 5 (below) demonstrates the proportion of access block at different levels (8, 16 and 24 hours) in 2019. At Royal Hobart Hospital and Launceston General Hospital, the proportion of patients with waits in excess of 24 hours in June (46% and 65%, respectively) is several orders of magnitude higher than that of the all Australian hospitals (10%) and all major referral hospitals (12%). This trend continued in September, with 35% of patients at Royal Hobart Hospital and 54% of patients at Launceston General Hospital having waits in excess of 24 hours, compared to 13% across all Australian hospitals and 12% across all major referral hospitals.
Figure 5: Breakdown of 2019 access block (as a % of total access block levels) in RHH and LGH
Figures 6 and 7 (below) show the proportion of access blocked patients waiting longer than 24 hours in Royal Hobart and Launceston General Hospitals, respectively, compared to the national means across all hospitals and hospitals in their peer group (major referral). The number of patients waiting 24 hours or longer has seen large increases far in excess of the mean for all hospitals nationally. At Royal Hobart Hospital, 16 out of 29 (55%) patients being treated were waiting for a bed in the early 2019 survey; in the late 2019 survey, this proportion had increased to 25 out of 37 patients (67%). At Launceston General
Access Block in Tasmanian EDs: findings from the June 2019 Access Block Survey [DRAFT] Page 4 of 9 Hospital, 18 out of 38 (47%) patients being treated were waiting for a bed in the early 2019 survey; in the late 2019 survey, this proportion remained steady at 15 out of 34 patients (44%).
Figure 6: Proportion of access blocked patients waiting >24 hours in RHH vs. Australia and Major Referral
Figure 7: Proportion of access blocked patients waiting >24 hours in LGH vs. Australia and Major Referral
5. Discussion
Access block and ED overcrowding have implications for patient safety, as they are both associated with poor health outcomes and preventable mortality and morbidity. Risks to patient safety and quality of care are heightened the longer patients wait; for this reason, the survey results in relation to 24-hour waits are extremely concerning. Across Australia, it is increasingly common for EDs and hospitals to operate at 100% capacity every day. Operating at this level places unbearable pressure on ED clinicians, which is reflected in increased risks of sick leave and burnout.
When examining the Tasmanian data against averages at a national level, Tasmania fares poorly, even when factoring in the positive performances of North Western General Hospital and Mersey Hospital. Launceston General Hospital, with 17 access blocked patients out of a total of 30 being treated and 11 staying more than 24 hours, was the worst performing hospital in the country. The Royal Hobart Hospital, with 13 (50%) access block out of 26 being treated and 6 over 24 hours, was the second worst.
The most recent survey results confirms a long term pattern of access block problems in Tasmania that requires a state-wide strategy that supports measurable improvements including zero tolerance for 24 hour length of stay in emergency departments waiting for admission for inpatient care.
Access Block in Tasmanian EDs: findings from the June 2019 Access Block Survey [DRAFT] Page 5 of 9 5.1 May 2019 Tasmanian Auditor General’s Report on Emergency Care In May 2019, the Tasmanian Audit Office (TAO) released findings from its audit of the performance of Tasmania’s four major hospitals regarding the delivery of ED services. It found that ED patients were not receiving timely care.
The report attributed these delays to long-standing practices and behaviours within hospitals contributing to dysfunctional silos, poor coordination between inpatient areas and EDs, and the lack of a whole-of-hospital approach to improving patient flow. The TAO highlighted findings from a 2017 study that found significant scope across Tasmanian hospitals to free up existing bed capacity by improving bed management, including admission, patient management and discharge practices.
5.2 Royal Hobart Hospital Access Block Solutions Meeting In June 2019, following publication of the TAO report, the then Tasmanian Health Minister invited stakeholders, including ACEM representatives, to participate in a round-table discussion in Hobart to identify and implement solutions to improve patient flow at Royal Hobart Hospital (RHH). ACEM hoped that the Royal Hobart Hospital Access Solutions meeting would begin resolving the chronic problems crippling the Royal Hobart Hospital, and its flow-on effects through the broader Tasmanian health system, and would result in the implementation of effective strategies to resolve them.
At the meeting participants identified the underlying issues and key decisionmakers committed to a range of actions following from agreed principles for timely access to quality care that were necessary to improve patient flow through the ED into inpatient areas, as well as whole of hospital reforms to strengthen the culture of cooperation and accountability. For these reasons, ACEM supported the Royal Hobart Hospital Access Solutions Action Plan as essential to resolving the culture and practices that result in siloed departments and dangerous levels of overcrowding and 24 hour waits in the ED.
These commitments are captured in the Communique from the meeting and the Royal Hobart Hospital Access Solutions Access Plan (the Access Plan). The Royal Hobart Hospital Access Solutions Action Plan commits Tasmanian Health Services to system and process changes under short term actions (July 2019), along with a cultural improvement program to support departments and staff to work collaboratively to prioritise patient quality and safety. The Department of Health’s progress reports on implementation of the RHH Access Solutions Action Plan is also available from the Department of Health’s website.
5.3 Outcomes from the Access Solutions Action Plan Improvements in patient flow through RHH ED and inpatient departments are integral to supporting the performance of all of Tasmania’s EDs. Unfortunately, as ACEM data clearly shows, there has been no improvement in patient flow at RHH since June, meaning ED staff must care for patients in an ED that is regularly and dangerously overcrowded.
ACEM’s snapshot survey results for September are in contrast to a statement from the Health Minister on 30 September stating that improvements at the Royal Hobart Hospital are driving better patient flow. While the performance of Royal Hobart Hospital has been the focus of attention, Launceston General Hospital is also experiencing significant stress due to access block.
Reports that the Tasmanian Government intends on implementing cuts to the state’s health budget represent additional risk to the health system, threatening to further strain a system currently in crisis. Given this situation, health expenditure and existing resourcing levels are clearly not enough to support Tasmanian EDs to maintain a standard of care equitable to that of other states. Any reduction from existing resourcing levels therefore puts the health system under further strain, threatening to put more people at greater risk of access block and 24-hour wait times. In this context, the potential for budget cuts to Tasmania’s major hospitals is of great concern.
Sustained action is required to address the systemic causes of access block and 24 hour waits within Launceston and Royal Hobart Hospital EDs, as recurring blockages in patient flow at these tertiary hospitals undermine the performance of the health system across the State.
Access Block in Tasmanian EDs: findings from the June 2019 Access Block Survey [DRAFT] Page 6 of 9 Looking around Australia, high performing hospitals have a range of policies and procedures that empower ED clinicians and build cultures of cooperation and accountability across emergency, medical and surgical departments. In these hospitals, the rapid transfer of patients out of the ED is facilitated by adequate bed and staffing numbers, with efficient resource use enabled by compliance with protocols for decision–to-admit, interim management plans, discharge planning and authority and accountability frameworks for each step of the patient journey. Agreed protocols empower ED clinicians to refer patients for admission and for staff on the wards to discharge patients, supported by robust escalation processes with time-based targets and performance actively monitored and measured. These patient-centred practices are reinforced by Executive and medical leadership support to eliminate silos, including through investing in change management to support sustained whole of hospital performance improvement.
6. Recommendations
6.1 That the Tasmanian Government develop a state-wide strategy for safe emergency departments
All Tasmanians have the right to expect that regardless of where they live, they will receive timely emergency care from emergency departments. The regular incidence of overcrowding, access block and ambulance ramping are proxy measures for unsafe delays in access to necessary inpatient care that is putting lives in danger at both the Royal Hobart and Launceston General Hospitals’ emergency departments. This strategy should include measurable improvements in these three key indicators that can be publicly reported against to track actual progress against key performance measures.
The strategy needs to prioritise the introduction of criteria led discharge processes from inpatient areas to allow for improved patient flow and increase the number of inpatient registrars rostered on to afterhours shifts, to improve admissions to wards outside of business hours. KPIs for admission improvements, including compliance with the Decision to Admit Authority, will strengthen accountability for reducing the incidence of access block and improving the culture of cooperation and collegiality at Royal Hobart Hospital and Launceston General Hospital.
Compliance with the principles for timely, quality care that were agreed to in the Access Solutions Action Plan need to be evident in a reduced rate of access block and 24-hour waits at both Royal Hobart Hospital and Launceston General Hospital
6.2 That the Tasmanian Government introduce mandatory reporting of 12 and 24-hour LOS In support of zero tolerance for 24-hour length of stay in emergency departments waiting for admission for inpatient care, ACEM recommends that the Tasmanian Department of Health introduce a mandatory reporting regime for all public hospital CEOs in the state, whereby (1) any incident of a 12-hour length of stay in the ED is escalated to the hospital CEO, and (2) any incidents of 24-hour waits are reported to the Health Minister.
Notification at the 12-hour mark alerts the CEO to an internal system failure within the whole hospital to deliver timely and safe care, therefore requiring CEO intervention to identify and address the underlying cause and authorise immediate interventions at an all-of-hospital level. Note that this threshold for access to inpatient care is well in excess of the four-hour NEAT and the eight-hour measure of access block.
The requirement for notification at 24 hours is an accountability measure for the CEO, whereby the Health Minister is advised of issues in bed and workforce capacity in the health system that the hospital was unable to resolve and that therefore needs intervention from the Minister.
Addressing access block and improving patient flow requires Medical and Executive leadership that recognises access block as an indication of over-occupancy, bed block in inpatient areas and other whole of system problems effecting the performance of the ED. More importantly, these problems are not the responsibility of the ED to resolve. Clearly defined responsibilities for executive staff are also necessary to improve governance and accountability outcomes. Strengthened reporting will support improved clinical governance and accountability for performance in inpatient departments.
Access Block in Tasmanian EDs: findings from the June 2019 Access Block Survey [DRAFT] Page 7 of 9 6.3 That the Tasmanian Government resource cultural change and leadership programs at RHH The Tasmanian Audit Office’s report on emergency care found that long-standing practices and behaviours within hospitals were contributing to dysfunctional silos, poor coordination between inpatient areas and EDs, and the lack of a whole-of-hospital approach to improving patient flow. The TAO highlighted findings from a 2017 study that found significant scope across Tasmanian hospitals to free up existing bed capacity by improving bed management, including admission, patient management and discharge practices.
These reports show that cultural issues are long-standing and difficult to resolve however it is in the interests of all Tasmanians that the Government takes the necessary action to resolve these issues. Starting with Royal Hobart Hospital, the CEO needs a project team that is expert in change management and leadership development, that reports directly to the CEO on progress and barriers to change and is authorised and resourced to lead improvements and strengthen accountability.
Investing in cultural change should be complemented by funding IT systems in Royal Hobart Hospital and Launceston General Hospital that are necessary to support timely and robust data collection, analysis and reporting to drive improved quality of care, communication and service efficiency. Note that the rollout of Medtasker to streamline referral and communication and automate notification of delays and patient flow impediments was an immediate priority (within two weeks) of the RHH Access Solutions Plan. 6.4 That the Tasmanian Government commission an independent audit of outcomes from the Access Solutions Action Plan ACEM recommends that in the face of conflicting reports on the implementation of actions set out in the Royal Hobart Hospital Access Solutions Action Plan, that the Tasmanian Government commission an independent audit of actions and outcomes.
ACEM notes the correspondence from the Health Minister dated 9 August, advising that all short-term actions identified in the Plan had been met, and that this is driving better care for patients. Unfortunately, ED staff report that, as of 30 August, directives from Royal Hobart Hospital Executive about policies, including the decision to admit authorisation for ED Consultants and ‘no right of refusal policies’, have been issued but are not being followed and do not seem to be enforced. Royal Hobart Hospital ED reports that as a result, there is still no improvement in patient flow out of the ED, so the incidence of 24-hour length of stay continues to rise.
7. Conclusion
ACEM’s snapshot surveys show that there is systemic failures in Tasmanian health services to ensure that patients have timely access to emergency care. These failures are outside of the control of emergency departments. Following the Tasmanian Audit Office’s findings, the Royal Hobart Hospital Access Solutions Meeting agreed on the issues undermining the safety of Tasmanian EDs and committed to actions to resolve them.
While ministerial and departmental reports state that implementation of these actions is now complete, the data shows deteriorating outcomes at RHH. Furthermore, while the focus has been on Hobart, the data shows that Launceston General Hospital needs urgent attention.
Tasmanian EDs urgently require a state-wide strategy that addresses culture and accountability for whole of hospital performance, with objective measures of impact reported via feedback from stakeholders and verifiable data sources.
8. Contact for further information
Nicola Ballenden Executive Director, Policy and Strategic Partnerships Australasian College for Emergency Medicine 34 Jeffcott Street, West Melbourne VIC 3003, Australia Telephone +61 3 9320 0444, Email [email protected]
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