ED = Damage Containment Zone

1. ED = Damage Containment Zone Presentation by Duncan Stuart Frank Daly, Amanda Ling 27 July 2006

2. USA overcrowding Similar problem and strategies to down-under • Standardise metrics for benchmarking workloads • Improve operational management • Tougher funder/accreditation standards & penalties

3. Operational management • No single magic bullet – need package • Redesign, lean thinking etc etc • ED benchmarking data • Prediction, queuing theory, smooth scheduled admissions • Schedule discharges • Hospitalist role • Reduce demand for ICU • Rapid response teams(MET)

4. ED internationally accepted politically as “damage containment zone”for whole-of-system poor planning & under-funding

5. Model of care planning wrong = ED LOS pays the price • Chest pain • 6-10 hour troponins routine practice • Acute abdomen • Routine CT before surgeon will see • O&G • similar increased reliance ultrasound • Observation Units • 5 beds per 10,000 presentations • Increase ED imaging and path support

6. On current bed utilisation(without factoring in the new tech/defensive medicine shifts in practice • Not enough beds available at all stages of the care continuum • Major acute bed shortages • SE Qld 1000 acute beds (Pagan, QH) • Australia 4,000 acute beds (Dean, HRT)

7. How to Solve ED Over-crowding • “Burning platform” (crisis) makes change happen faster ….. but • Only ED has a burning platform • Only wards can fix ED crowding • “Over-crowding is a hospital-wide problem” – rhetoric needs some teeth … • Wards and ED need equal burning platform !

8. Consequences of ED over-crowding • Emergency medicine dying as attractive specialty • Increased LOS in ED and wards • Increased staff dissatisfaction and loss at a time of national workforce crisis • Increasing ED over-crowding

9. Enough is enough !!!! Its time to “speak softly and carry a big stick”

10. Al Capone solves ED over-crowding … • “you can get a lot further with a kind word and a gun than a kind word alone” (IHI teleconference 27/7/06) • All cities with recurrent ED over-crowding to now adopt Perth’s “No diversion, no ramping” ED-led over-crowding management strategy for three months trial (winter)

11. Perth constant ED overcrowding • Nothing being done …. • In severe crisis, RPH’s ED patients sent to wards “over-census” • Ambulance pressure ED Directors to avoid ramping • Longer ED stays and outliers increase inpatient LOS increases ED overcrowding

12. “no diversions, no ramping”(Full Capacity Protocols – Sunnybrook USA studies) • DG implements “no diversions, no ramping” 3 month trial on recommendation of ED Directors of RPH and SCGH • Share the load/urgency across hospital and all hospitals simultaneously: • Ambulance diversions “let hospitals off the hook” for good bed management !! • Buy time to implement 17 other programs and strategies in parallel e.g. HITH, etc

13. National ED overcrowding strategy • Wards must take over-census patients (Perth) • Three stage implementation • Policy alone led to improves ward discharges! • Discharge team on weekends (SCGH) • Snr Med Reg, Pharmacist & Disch Co-ord • Pull system across continuum • Starts residential care, Discharge lounge • Ambulances “load share” cases

14. Operate hospitals to specifications • Outliers the exception (rare) • Dangerous and inefficient • Fix maximum occupancy (85-93%?) • Standardise metrics and jargon • Access Block –which admitted patients not counted? • Immediate comparative study of various “ED sort – admit?” • Front end Transitional - “SSU”, “Obs Ward”, EMU, etc