Patients treated in a security room, staff acting as sitters for mental health patients, and waits of more than 70 hours are just some of the findings of new research, based on Launceston General Hospital.
Published this week in the International Emergency Nursing journal, "Delayed flow is a risk to patient safety: A mixed method analysis of emergency department patient flow" identifies the factors contributing to patient flow bottlenecks and extended emergency departments stays.
Mapping the journey through the ED, with attendance data of more then 89,000 patients and observations from a focus group, the study highlights a system under pressure where patient safety is routinely compromised though triage delays and the use of makeshift spaces.
How it was done
The study used analysis of attendance data routinely collected between 2016 and 2017, including total presentations, arrival mode, triage category, ED length of stay, discharge destination and hospital admission rate.
Observational data was also collected from research assistants - third year nursing students based in the ED for 24 hours a day, for 96 hours. Here, they mapped the journey of patients starting from the time of arrival and ending when a person left the department or was treated in a fast track area.
A group of 12 RAs also met once week to focus on three main areas, based on their observational data: processes perceived to be done well; the most problematic aspects; and recommendations for what could be done better. Their observations were recorded, transcribed and included in the study.
What it found
There were 89,013 ED presentations to the hospital between between 2016 and 2017. Of these, 69.9 per cent were discharged, 24.6 per cent were admitted, 4.6 per cent left without being seen and 0.6 per cent were transferred to another hospital.
The report found arrival numbers increased in daytime hours, peaking between 10am and 4pm, with the age of patients presenting to the ED ranging from zero to 105 years of age. The ED length of stays ranged from less than one hour, to 121 hours, with an average of three hours.
Data was collected on 511 individuals, 504 triage presentations and seven patients in an ED cubicle. All up, 282 patient journeys through the ED were tracked. It found the time spent waiting for triage was extended during periods with higher presentation numbers, and sometimes exceeded recommended wait-times. Almost half the patients (180) spent time in the waiting room post triage.
The longest ED journey tracked was 71 hours for a patient awaiting an inpatient bed.
The RAs described an ED environment of extreme crowding and organised chaos, but also acknowledged the professionalism, teamwork, and efficiency of the ED staff who were identified as coping under pressure.
"The RAs observed compromising care and safety, highlighting waiting room and triage area design, ramping, crowding, staff and patient safety, access block, and limitations in mental healthcare as the most problematic issues," the report reads.
Concerns over the use of makeshift spaces included a lack of privacy and the inappropriate use of space. Areas utilised for patient assessment included a security room, ambulance air-lock area and the ramping of multiple patients in the triage and triage assist area.
"Staff were also observed performing makeshift roles, such as support [security] staff acting as 'sitters' for involuntary mental health or confused patients, limiting their ability to perform other aspects of their role."
The group recommended the redesign of the hospital's triage area and queuing process, a separate ambulance ramping area, and a separate waiting area for mental health and low-acuity patients.
Risks to patient safety
The study noted crowding affected all aspects of the patient journey, with three key findings emerging.
An unexpected finding was the hidden time patients spent queuing for triage. It found the time spent in queue, from arrival to triage assessment, was higher than previously reported, varied considerably, peaked during the middle of the day and at times exceeded recommended triage scale parameters.
"The poor design of the queueing system to reach the triage nurse affected triage flow, which was also interrupted by visitors and ambulance triage workload," the report reads. "The design of the triage desk was prohibitive for assessment, and created blind spots impeding observation of patients in the queue and waiting area."
The report found many of the makeshift spaces used to assess and treat patients did not have associated staffing allocations, call bells, duress alarms, examination equipment, or monitoring capability - all potentially compromising patient safety.
The biggest area of concern was the triage assessment area - an area designed for brief assessment with one bed-space. However, during the study period 30 per cent of tracked patients spent time in the TAA, which was used to accommodate multiple patients at a time, including ramped patients.
A key factor delaying ED discharge was the availability of an inpatient bed, with the report tracking patients who spent up to 71 hours in the ED waiting to be admitted.
"Patients were transferred quickly once a bed was available, suggesting it is access block, not the ED transfer process, contributing to the increased EDLOS," it reads.
The report also acknowledged vulnerable groups including Tasmania's ageing population, with elderly patients associated with increased ED stays and higher rates of admission. Similarly, it found psychiatric patients had a 33 per cent increase in EDLOS.
Responding to the study, Health Minister Sarah Courtney said the government had done a lot to support the LGH, including funds in the latest state budget for capital improvements to the ED airlock.
"Emergency department and Ambulance Tasmania staff will be consulted in the development of the design," she said.
"Further work is underway, including looking at how we can ensure we are using our district hospitals in the most effective way.
"Emergency Department performance is measured in accordance with national reporting standards, and we will continue to report consistently with other hospitals in Australia."
Ms Courtney said the government, the department and local hospital management would continue to look at what else they can do to support staff and patients.
The report was written by Alex Pryce, Maria Unwin, Leigh Kinsman and Damhnat McCann, and funded by the Clifford Craig Foundation.
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