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).