Pull out the plug in emergency departments

Delays in emergency departments lead to longer hospital stays according to research published in the current issue of the Medical Journal of Australia.

The research, co authored by Dr Don Liew, emergency physician at the Angliss Hospital in Upper Ferntree Gully in Melbourne's outer urban area, and colleagues from Monash University and Royal Melbourne Hospital, investigates the association between emergency department length of stay (EDLOS) and inpatient length of stay (IPLOS) among patients admitted to inpatient units of a metropolitan Melbourne health service during one year.

Dr Liew said strategies to reduce emergency department length of stay (EDLOS) should target elderly patients and may significantly reduce healthcare costs and improve the health outcomes for patients.

Dr Liew said access block is a direct cause of prolonged emergency department length of stay, and is specified by an EDLOS of eight hours or more. But he says EDLOS is commonly prolonged by other factors, and may affect patient outcomes even in stays of less than eight hours.

"This study is the first to show that prolonged EDLOS is associated with excess IPLOS, even after adjusting for major confounding factors such as being elderly (more complex illness, or awaiting discharge to an aged care facility)," Dr Liew said.

"Compared with patients who stay in the ED for four to eight hours, those who remain for eight to 12 hours are about 20 per cent more likely to stay in hospital longer than the state average for the relevant admission problem.

"This rises to 50 per cent if the EDLOS is greater than 12 hours.

"Conversely, there is about 30 per cent less likelihood of IPLOS exceeding the state average inpatient length of stay if EDLOS is four hours or less," Dr Liew said.

Dr Liew said funding of public hospitals for inpatient care is based on the state average, not the actual inpatient length of stay. But it's the inpatient length of stay that drives hospital costs. The difference between the two is met by the hospital and is not reimbursed by the state.

In the same issue of the Journal, editorial comment by Associate Professor Drew Richardson, from the Australian National University, said queuing has long been used to ration elective services, but queuing is fundamentally an inefficient means of rationing care for time-critical illness.

"Emergency departments are specialist multidisciplinary units with expertise in managing acutely unwell patients for the first few hours in hospital. Neither the facilities (generally poor privacy, small trolleys, 24 hour lighting) nor the staff are appropriate for providing longer-term inpatient care," Associate Professor Richardson said.

He said much can be done to improve our hospital systems but clinicians must be willing to trial different methods of management such as treatment in the home and accelerated discharge.

But he said the bottom line is the lack of acutely available beds.

"The daily variation in emergency medical activity has for too long allowed both emergency staff and others to assume the ED has 'rubber walls' and that the marginal cost of the ED absorbing additional care to inpatients is low," Associate Professor Richardson said.

"Emergency departments are expert at triage to achieve 'the greatest good for the greatest number', but, when prioritising, even emergency physicians are reluctant to consider denying care to patients with whom they have begun a therapeutic relationship.

"EDs are faced with the ridiculous situation of providing many hours of care to patients whose conditions were urgent on arrival but stable after treatment, while potentially unstable patients of similar initial urgency languish in the waiting room or in an ambulance for want of an ED trolley and nurse."

Associate Professor Richardson said restricting the access and quality of initial care because of inability to provide timely later care is ethically dubious and is likely to lead to adverse outcomes and medicolegal exposure.

"Hospitals, communities and government must debate and decide the allocation of resources to EDs and wards and agree on a sensible approach to providing appropriate care in both environments.

"The debate is no longer about the level of resources our EDs deserve, but rather about how to ensure that ED resources are directed to those who need them - the patients in the waiting room," Associate Professor Richardson said.

The Medical Journal of Australia is a publication of the Australian Medical Association.

CONTACT:     Research   Dr Don Liew 03 8922 8006 (W) / 0419 357 639
                   Editorial     Associate Professor Drew Richardson 02 6244 2418 (W) / 0413 316 057
                   AMA          Judith Tokley 02 6270 5471 (W) / 0408 824 3906