Medical Journal of Australia最新文献

Objective: To assess the impact of strategies to improve public hospital emergency access using a detailed ward-level simulation modelling approach.

Design and setting: Discrete event simulation was used to simulate patient flow at three principal referral Australian hospitals from 1 September 2021 to 31 August 2022. Models were developed and validated using every emergency department (ED) presentation, inpatient episode of care and patient ward movement at the study hospitals.

Main outcome measures: Mean and total ED length of stay, mean waiting time, access block rate, 4-h rule compliance and bed utilisation for patients admitted from the ED.

Results: Reducing ED demand via arrangements that accommodate the same proportion and types of admissions from the ED as the existing ED presenting population reduces access block, with larger impacts in winter than in summer. However, reducing 'general practitioner-type patients' in EDs has negligible impact on access block. Tangible impacts on improving patient flow can be achieved by removing maintenance care patients from hospitals (reducing the percentage of access block by up to a third) and reducing elective admissions. Strategies that emphasised morning, midday and early afternoon discharges led to large flow improvements. The strategy already practised by most hospitals of sharing patients among wards greatly improves emergency access, and gains are the same order of magnitude as reducing overall ED demand.

Conclusions: The study provides support to policymakers looking for evidence regarding strategies to improve emergency access to public hospital care.

Objectives: To evaluate the effect of hospital occupancy levels on inpatient and emergency department (ED) flow rates, ED length of stay (ED) and access block, and identify critical occupancy thresholds above which patient flow deteriorates.

Design: Retrospective cohort study using routinely collected administrative data.

Setting: Twenty-five public hospitals in Queensland, Australia, over a 5.5-year period (1 April 2017 to 31 August 2022).

Main outcome measures: ED presentation and discharge rates, inpatient admission and discharge rates, hospital occupancy levels, length of stay, access block and 4-h rule compliance.

Results: The analysis reveals a significant performance shift as hospital occupancy levels increase and identifies site-specific critical 'choke points' where patient flow deteriorates. Notably, as occupancy rises, we observed a growing divergence between ED presentations and discharge rates, and between inpatient admissions and discharges, indicating system congestion. Additionally, when assessing flow across the 25 hospitals, the data demonstrates that a 10% increase in bed occupancy rate correlates with a 0.32-h (19-min) extension in ED length of stay (or 33 min for patients admitted from the ED). Also, significant disparities in hospital operations were observed between weekends and weekdays, with weekday admissions and discharges up to three times higher than weekends, highlighting the increased operational pressure during the work week.

Conclusions: The investigation challenges the traditional 85% occupancy target, demonstrating that optimal occupancy levels vary by hospital. The study also underscores the strong correlation between hospital bed occupancy and ED access performance, with higher hospital occupancy correlating with longer ED stays and decreased adherence to performance indicators. As hospitals approach full capacity, the pressure on ED resources intensifies, resulting in longer wait times and delays in care.

This editorial highlights three studies that collectively offer a roadmap towards system-level improvement in access, flow and quality of care. These studies used linked data from several Queensland hospitals and explored emergency department (ED)-hospital capacity associations with ambulance, ED and hospital dysfunction. One study found ED occupancy was strongly associated with ambulance dysfunction (ramping, response times). The second study associated hospital occupancy with ED dysfunction. Larger hospitals with occupancies above 85%-90% became dysregulated with rapid overcrowding. The modelling study in three tertiary hospitals reported that reduced admissions (ED or elective procedures), improved discharges (earlier, quicker community discharge, home care) and flexible bed use (any ward, over-census) improved flow. Diverting general practice-type attendances and weekend surgery seemed ineffective. Rapid, adequate flexible admitting capacity seems important for safe, efficient hospital-ED care and ambulance function.