ED Capacity Management

Admissions Flow through ED

Tim Parke

ED Consultant

through ED

Improved Outcomes• Trauma• Sepsis• STEMI• GDFU

Early senior input

Overcrowding prevention

Checklists and protocols

Effective Emergency Care

Guidance to Eliminate Crowding

The purpose of the document is to develop guidance to eliminate crowding.

1. Capacity Planning

2. Early Notification

3. Decision to Admit Rights

4. Standardised Process and Escalation

Emergency Department Overcrowding

• Increases 10 day mortality for admitted patients by >30% (Aus)

• Increases mortality for discharged patients by >70% (Canada)

Capacity Planning: Site Data

• source (postcode zone/sector), mode of arrival and destination by time of day

• weekend discharge rates• average length of stay, occupancy / turnover

interval,.• daily boarding / redirections• full breach analysis

Early Notification

• With improved communication of capacity and demand, early notification has been seen to be effective in early escalation steps.

• A mutually agreed pathway of care will be implemented for the “to be admitted” patients (including those referred by a GP) aiming to minimise unnecessary waits and delays

Decision to Admit Rights

• Patient journeys cannot be delayed in the ED by the wait for specialist review that are not going to influence the decision to admit.

• Tests or investigation in the ED should be prioritised to reduce the delay to disposition decisions.

• Once the decision to admit is taken, the patient should be moved to the ward bed without further delays for secondary review.

Crowding Escalation

• Locally agree Crowding Threshold

• Capacity stress is identified, and the clinically appropriate beds are not available from senior clinicians decision that the patient is ready to move.

Crowding Escalation Step 1 of locally agreed threshold

• After 2 hours of patients ready to move the senior operation manager:– alert senior Clinicians AND Managers across affected

teams and convene in the ED or the assessment area affected by crowding

– initiate proactive discharges across all wards & departments

– open additional acute staffed beds– review non-urgent elective care such as operation,

infusions or investigations and consider deferral

Crowding EscalationStep 2 of locally agreed threshold

• After 4 hours of patients ready to move the Senior operation manager continues step 1

• The Medical Director and Senior Management Team should immediately consider:– cancel all non-critical surgery across all specialties – boarding patients from specialties under maximum

pressure. – diverting GP referrals or stable emergency patients

waiting for beds to neighbouring hospitals

Crowding EscalationStep 3 of locally agreed threshold

After 8 hours of patients ready to move – immediate notification of CEO– emergency incident group convened including senior clinicians

from acute and in-patient specialties, emergency medicine and Social Work

The emergency incident group should consider the following responses to rapidly protect patients from further harm:

– activation of a locally agreed Full Capacity Protocol 1 to safely transfer fully assessed patients who require admission, to in-patient areas in order to avoid critical overload of the ED or assessment areas

– closure of the ED to new patients with diversion to neighbouring hospitals (including discussion with neighbouring boards)

1FCP – see note 1

Delegates

You are invited to:• Review the steps of the guidance

• Consider barriers and opportunities to implementation

• Discuss and feedback today!