Should ED be another ward?

I recently attended the Strategies for Improving Patient Flow conference in Auckland NZ. As always I came away with many valuable insights from the passionate and knowledgeable presenters and attendees.

Unexpectedly I also now have this challenging thought that won’t go away so I felt the need to share it and hopefully create a discussion around it.

The conference started off with a presentation by David Meates, Chief Executive, Canterbury DHB and West Coast DHB. Many interesting points were raised, and one in particular was a key element that formed my thinking. David challenged us all to stop using the past in our thinking around improvement. In fact, he suggested discarding the past to think differently as the future is a different world that needs new thinking if we are going to truly innovate.

 

Over the first day, there was a big focus on ED and the associated flow into and out of ED. We’ve worked with many customers on the associated flow for ED patients who require admission and explored how to maximise processes for admission from ED. I did hear many ideas on how to reduce the demand on ED. A lot of these ideas focus on external influences on ED capacity which are largely out of the control of the ED and any patient flow improvements. Some of the themes discussed, which all agreed were not new themes, centred around improving patient flow by patients avoiding ED for minor issues and the ambulance service directing patients to GP’s and other non ED services.

 

We heard the 6-hour rule is potentially flawed as it includes those patients discharged from ED without admission. As I understand the 6-hour rule, it is designed to minimise ED crowding and ensure patients clinical outcomes are not negatively impacted through a long stay in ED. However, is one target sufficient for ED? Should we separate the target across admitted and non-admitted patients?

 

Once a patient is admitted, they move much more freely between wards and even to ICU during their visit than they do from ED to an inpatient bed. Now I understand there are many reasons for the detailed admission process along with the clinically required checks and balances. These are what we’ve always done so we should continue – shouldn’t we? Or should we forget the past and look for new, innovative improvements? Specifically, is the 6-hour rule something we should advocate to change?

 

Another recurring theme through the conference was the patient experience and who cares for the patient. So put yourself in the patients’ shoes. They present to ED, are assessed and a decision is made to admit them. Admit them to what? The hospital? Are they not already in the hospital? Why isn’t this just a transfer? Isn’t ED a potential entry point for a patient’s journey through the hospital? From a patient perspective this just seems confusing

 

As the conference progressed, I started to ask myself why is it so complex to admit a patient to an inpatient bed? As I started to share my thoughts with those more knowledgeable in ED processes than me, there was an acknowledgment of the seemingly overly complex admission process. Reasons for the existing process largely centred on the clinical handover from ED doctors to inpatient doctors. This is a process that mostly sees a senior experienced doctor handing a patient’s care over to a more junior registrar. It was suggested there is potentially a lack of trust in the detail being handed over in that what the inpatient doctor was told they’d receive is not what they get. The desire for a patient to be left in ED is often to have the perfectly packaged patient when the care transfers.  Inpatient nurses and doctors want every I dotted every T crossed, all work up complete with a definite diagnosis BEFORE they move out of ED.  Potentially this can’t happen anymore as there isn’t enough time.  Therefore, trust is let down when what they thought they were getting turns out after all as something else. A problem, but not an insurmountable challenge.

 

So to my thought –  why is ED not just another ward of the hospital that can more simply transfers their patients? Is this what’s needed to change the culture? If we were to truly consider the patient first, we’d accept them into the hospital, provide the best care possible in the right location with the right team at the right time. One of the talks demonstrated how their ED had redesigned processes and reduced the time to admit from 4 hours to 1.5 hours. How is this sort of time and associated delay good for the patient? They arrive at ED, get the care needed and then get “transferred” to another hospital bed. Is it just me or does that sound ridiculous?

 

I’m keen to hear your thoughts on the above. Am I just dreaming or could there be a better way to treat our patients that move through ED, and make life easier for staff? If we could forget the way we currently flow through ED, how would we design it to provide the best possible care and centred around the patient?

Dave Piggott

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