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Digital health technologies are a proposed solution to improve healthcare delivery and reduce pressures on the healthcare system, but these technologies are new to much of the health workforce. This perspective paper highlights lessons learned from the global experience of rapid digital transformation of health workforces, including fostering a culture of learning, ensuring accreditation and recognition, and adopting a transdisciplinary approach. Evidence-based actions are proposed to address recommendations to (1) ensure foundational workforce digital health capability and (2) build specialist digital health career pathways. Australia must take a national approach and strategically leverage strong collaborations across sectors including healthcare, education and government to ensure a consistent, regulated and sustainable digital workforce capability.

Digital disruption and transformation of health care is occurring rapidly. Concurrently, a global syndemic of preventable chronic disease is crippling healthcare systems and accelerating the effect of the COVID-19 pandemic. Healthcare investment is paradoxical; it prioritises disease treatment over prevention. This is an inefficient break-fix model versus a person-centred predict-prevent model. It is easy to reward and invest in acute health systems because activity is easily measured and therefore funded. Social, environmental and behavioural health determinants explain ~70% of health variance; yet, we cannot measure these community data contemporaneously or at population scale. The dawn of digital health and the digital citizen can initiate a precision prevention era, where consumer-centred, real-time data enables a new ability to count and fund population health, making disease prevention 'matter'. Then, precision decision making, intervention and policy to target preventable chronic disease (e.g. obesity) can be realised. We argue for, identify barriers to, and propose three horizons for digital health transformation of population health towards precision prevention of chronic disease, demonstrating childhood obesity as a use case. Clinicians, researchers and policymakers can commence strategic planning and investment for precision prevention of chronic disease to advance a mature, value-based model that will ensure healthcare sustainability in Australia and globally.

Objectives The aim of this study was to examine patient perceptions regarding vascular access quality measurement. Methods A web-based, cross-sectional survey was performed using a convenience sample of healthcare consumers with vascular access experience, recruited from September 2019 to June 2020. Survey respondents were asked to rate the perceived importance of 50 vascular access data items, including patient demographics, clinical and device characteristics, and insertion, management and complication data. Data were ranked using a five-point Likert scale (1, least important; 5, most important), and are reported as median values. Respondents proposed additional items and explored broader perspectives using free-text responses, which were analysed using inductive thematic analysis. Results In all, 68 consumers completed the survey. Participants were primarily female (82%), aged 40-49 years (29%) and living in Australia or New Zealand (84%). All respondents indicated that measuring the quality of vascular access care was important. Of the 50 items, 37 (74%) were perceived as 'most important' (median score 5), with measures of quality (i.e. outcomes and complications) rated highly (e.g. thrombosis and primary blood stream infection). Participants proposed 16 additional items. 'Gender' received the lowest perceived importance score (median score 3). Two themes emerged from the qualitative analysis of broader perspectives: (1) measurement of vascular access device complication severity and associated factors; and (2) patient experience. Conclusion Measuring vascular access quality and safety is important to consumers. Outcome and complication measures were rated 'most important', with respondents identifying a need for increased monitoring of their overall vascular access journey through the health system. What is known about the topic? The use of vascular access devices is common among hospitalised patients. Quality surveillance is not standardised, with no incorporation of patient preference. What does this paper add? We identify the data items consumers perceive as valuable to measure related to their vascular access journey; most importantly, consumers perceived the collecting of vascular access data as important. What are the implications for practitioners? Health services can use these data to develop platforms to monitor the quality and safety of vascular access care.

Successful implementation of digital health programs is imperative as it is becoming increasingly clear that digital solutions will underpin modern health care. These projects are often supported by large budgets and if not implemented successfully, the quality, safety, and efficiency of patient care may be compromised. Failure rates for the implementation of large, complex healthcare software platforms in digital health programs have been persistently high. Although several factors may contribute to the failure of such projects, the majority have been reported to fail largely due to poor project management. Nevertheless, little is known about the optimal project management approaches for digital health projects, with many health services reliant on external advisory companies and contractors for advice. Although publication bias makes it difficult to reliably study and understand global trends for the failure of digital health projects, examination of media reports and published literature indicates that this is a global phenomenon affecting digital health projects in North America, Europe and Australasia. In this article, our aim is to examine the literature for evidence underpinning current project management approaches used when implementing commercial, off-the-shelf healthcare information technology solutions, including complex healthcare software in large digital health programs in hospitals or across health systems, and evaluate the suitability of current project management approaches to deliver these projects. This starts to build an important evidence base for hospitals and health services considering digital transformation projects.

Objective This study investigated evidence for the approach known as 'benefits management' (BM) used in many digital hospital initiatives. Methods A qualitative narrative overview was conducted on the BM literature and compared with a qualitative systematic overview of electronic medical record (EMR) implementation literature. Results Twenty-five articles on BM and 12 literature reviews on EMR implementation were examined. The BM approach does not have strong support in the literature and does not support all the needs of large EMR implementations. Conclusion The current BM approach provides an inadequate basis for managing and reporting on the outcomes that ensue from a digital hospital initiative. A shift is needed from benefits idealisation to value optimisation. What is known about the topic? Health services are under increasing pressure to demonstrate that the benefits anticipated from digital health investments have been realised. What does this paper add? This paper informs the practice of benefits governance in EMR implementations. The results reveal inadequacies in current BM models and practice that are currently enshrined in policy despite a lack of evidence. What are the implications for practitioners? Health service leaders must be willing to question the governance of benefits from health service transformations using more evidence-based approaches to increase the value obtained from investments in digital transformation.

Objective This study aims to assist hospitals contemplating digital transformation by assessing the reported qualitative effects of rapidly implementing an integrated eHealth system in a large Australian hospital and determining whether existing literature offers a reliable framework to assess the effects of digitisation. Methods A qualitative, single-site case study was performed using semistructured interviews supplemented by focus groups, observations and documentation. In all, 92 individuals across medical, nursing, allied health, administrative and executive roles provided insights into the eHealth system, which consisted of an electronic medical record, computerised decision support, computerised physician order entry, ePrescribing systems and wireless device integration. These results were compared against a known framework of the effects of hospital digitisation. Results Diverse, mostly positive, effects were reported, largely consistent with existing literature. Several new effects not reported in literature were reported, namely: (1) improvements in accountability for care, individual career development and time management; (2) mixed findings for the availability of real-time data; and (3) positive findings for the secondary use of data. Conclusions The overall positive perceptions of the effects of digitisation should give confidence to health services contemplating rapid digital transformation. Although existing literature provides a reliable framework for impact assessment, new effects are still emerging, and research and practice need to shift towards understanding how clinicians and hospitals can maximise the benefits of digital transformation. What is known about the topic? Hospitals outside the US are increasingly becoming engaged in eHealth transformations. Yet, the reported effects of these technologies are diverse and mixed with qualitative effects rarely reported. What does this paper add? This study provides a qualitative assessment of the effects of an eHealth transformation at a large Australian tertiary hospital. The results provide renewed confidence in the literature because the findings are largely consistent with expectations from prior systematic reviews of impacts. The qualitative approach followed also resulted in the identification of new effects, which included improvements in accountability, time management and individual development, as well as mixed results for real-time data. In addition, substantial improvements in patient outcomes and clinician productivity were reported from the secondary use of data within the eHealth systems. What are the implications for practitioners? The overall positive findings in this large case study should give confidence to other health services contemplating rapid digital transformation. To achieve substantial benefits, hospitals need to understand how they can best leverage the data within these systems to improve the quality and efficiency of patient care. As such, both research and practice need to shift towards understanding how these systems can be used more effectively.

Objective This study provides insights into the reported early impacts of the digital transformation of a large Australian hospital and healthcare service (HHS) by surveying staff perceptions of an integrated electronic medical record (ieMR). Methods The information systems success model was used as a tool to evaluate perceptions of system quality, information quality, individual benefits and expected organisational benefits of the ieMR soon after its introduction at the HHS. A questionnaire was distributed to staff in all five hospitals in the HHS immediately after implementation. Overall staff perceptions were examined, in addition to how perceptions differed by site and profession. Results Overall, staff held mildly positive early perceptions of system quality, information quality, individual benefits and expected organisational benefits. These views were largely consistent across sites. In terms of professions, allied health held more positive perceptions, followed by administrative and nursing professionals. Medical professionals held negative perceptions, but were neutral regarding their future expectations. Conclusion On average, staff viewed the ieMR mildly positively immediately after implementation (despite significant changes to work practices), but differences exist across professional groups. What is known about the topic? Hospitals globally are in the midst of a digital transformation. Yet, reported impacts are mixed and there have been few studies of the effects of comprehensive electronic medical record (EMR) implementations. What does this paper add? This paper evaluates a comprehensive EMR immediately after go-live. We found positive early perceptions of system quality, information quality, individual benefits and expected organisational benefits. We also found that perceptions of medical professionals were largely negative, but they were neutral in terms of their future expectations. What are the implications for practitioners? Health services may be unsure of the effect of implementing a comprehensive EMR because of conflicting reports in the literature, some touting major benefits, others stressing major costs. Our results paint a middle-ground picture immediately after implementation. Staff perceptions are mildly positive on average, which is reassuring given the results were obtained during the early disruptive period after implementation.

As the focus of clinicians and government shifts from speciality-based care to system-based key performance indicators such as the National Emergency Access Target (NEAT) or the 4-h rule, integration between emergency department (ED) and inpatient clinical workflows and information systems is becoming increasingly necessary. Such system measures drive the implementation of integrated electronic medical records (ieMR) to digitally integrate these workflows. The objective of this case study was to describe the impact of digital transformation of the ED-in-patient interface (EDii) of a large tertiary hospital on process measures and clinical outcomes for patients requiring emergency admission to hospital. Data were collected from routine clinical and administrative information systems to measure process and clinical outcome measures, including ED length of stay, compliance with the 4-h rule and in-patient mortality between 28 November 2014 and 28 February 2017. The 4-h rule compliance for all patients, as well as for the EDii group (admitted to hospital excluding short stay ward), declined after digitisation. There were 55 fewer deaths in the postintervention group (15% relative reduction; P = 0.02) and a 10% relative reduction in adjusted mortality as measured by the Hospital Standardised Mortality Ratio for emergency patients (eHSMR), which did not reach statistical significance. Digital deceleration in ED performance did occur with an ieMR rollout, but worsening of key patient outcomes was not observed.

Digital transformation of Australian hospitals is occurring rapidly. Although the clinical community has had limited ability to influence high-level decision making and investments into digital health technologies, as these technologies increasingly transform the way patients are cared for, the clinical community must influence the digital health agenda and be an integral part of the decision-making process. This case study details the process and lessons learnt during the development of the state-wide consensus statement detailing the clinical requirements for digital health initiatives to form the Queensland Digital Health Clinical Charter. To the best of our knowledge, Queensland is the first Australian jurisdiction to create a Digital Clinical Charter to be specifically referenced in the investment in and governance of digital health in hospitals. By developing this clinical charter for digital health, and in articulating the needs of clinicians, a clinical framework will be added to both the decision-making process around the investments in digital health and the definition and realisation of the expected benefits from these sizable investments.

Objective In an era of rapid digitisation of Australian hospitals, practical guidance is needed in how to successfully implement electronic medical records (EMRs) as both a technical innovation and a major transformative change in clinical care. The aim of the present study was to develop a checklist that clearly and comprehensively defines the steps that best prepare hospitals for EMR implementation and digital transformation. Methods The checklist was developed using a formal methodological framework comprised of: literature reviews of relevant issues; an interactive workshop involving a multidisciplinary group of digital leads from Queensland hospitals; a draft document based on literature and workshop proceedings; and a review and feedback from senior clinical leads. Results The final checklist comprised 19 questions, 13 related to EMR implementation and six to digital transformation. Questions related to the former included organisational considerations (leadership, governance, change leaders, implementation plan), technical considerations (vendor choice, information technology and project management teams, system and hardware alignment with clinician workflows, interoperability with legacy systems) and training (user training, post-go-live contingency plans, roll-out sequence, staff support at point of care). Questions related to digital transformation included cultural considerations (clinically focused vision statement and communication strategy, readiness for change surveys), management of digital disruption syndromes and plans for further improvement in patient care (post-go-live optimisation of digital system, quality and benefit evaluation, ongoing digital innovation). Conclusion This evidence-based, field-tested checklist provides guidance to hospitals planning EMR implementation and separates readiness for EMR from readiness for digital transformation. What is known about the topic? Many hospitals throughout Australia have implemented, or are planning to implement, hospital wide electronic medical records (EMRs) with varying degrees of functionality. Few hospitals have implemented a complete end-to-end digital system with the ability to bring about major transformation in clinical care. Although the many challenges in implementing EMRs have been well documented, they have not been incorporated into an evidence-based, field-tested checklist that can practically assist hospitals in preparing for EMR implementation as both a technical innovation and a vehicle for major digital transformation of care. What does this paper add? This paper outlines a 19-question checklist that was developed using a formal methodological framework comprising literature review of relevant issues, proceedings from an interactive workshop involving a multidisciplinary group of digital leads from hospitals throughout Queensland, including three hospitals undertaking EMR implementation and one hospital with complete end-to-end EMR, and review of a draft checklist by senior clinical leads within a statewide digital healthcare improvement network. The checklist distinguishes between issues pertaining to EMR as a technical innovation and EMR as a vehicle for digital transformation of patient care. What are the implications for practitioners? Successful implementation of a hospital-wide EMR requires senior managers, clinical leads, information technology teams and project management teams to fully address key operational and strategic issues. Using an issues checklist may help prevent any one issue being inadvertently overlooked or underemphasised in the planning and implementation stages, and ensure the EMR is fully adopted and optimally used by clinician users in an ongoing digital transformation of care.

The Australian Commission for Safety and Quality in Health Care has created the National Safety and Quality Health Service standards that all hospitals must address in order to remain accredited. This case study details the first known digitisation of the 10 national quality and safety standards mandated in a quaternary integrated digital hospital. A team of clinical informaticians, information technology experts and clinicians was assembled. Data were chosen and the data were then extracted and validated and presented (often in near real time) in an easily consumable dashboard format with appropriate governance to allow clinicians and executives to monitor the quality and safety standards across the hospital. All 10 standards were defined and extracted contemporaneously from the digital hospital for every patient, every time. This is in stark contrast with traditional retrospective point prevalence surveys. This case study details the first known fully digital accreditation in a sophisticated integrated digital hospital. Digitisation of hospital quality and safety to produce real-time data is the future of clinical redesign to improve patient care.

Evidence suggests improved outcomes for patients requiring emergency admission to hospital are associated with improved emergency department (ED) efficiency and lower transit times. Factors preventing timely transfers of emergency patients to in-patient beds across the ED-in-patient interface are major causes for ED crowding, for which several remedial strategies are possible, including parallel processing of probable admissions, direct-to-ward admissions and single-point medical registrars for receiving and processing all referrals directed at specific speciality units. Dynamic measures of ED overcrowding that focus on boarding time are more indicative of EDs with exit block involving the ED-in-patient interface than static proxy measures such as hospital bed occupancy and numbers of ED presentations. The ideal 4-h compliance rate for all ED presentations is around 80%, based on a large retrospective study of more than 18million presentations to EDs of 59 Australian hospitals over 4 years, which demonstrated a highly significant linear reduction in risk-adjusted in-patient mortality for admitted patients as the compliance rate for all patients rose to 83%, but was not confirmed beyond this rate. Closely monitoring patient outcomes for emergency admissions in addition to compliance with time-based access targets is strongly recommended in ensuring reforms aimed at decongesting EDs do not compromise the quality and safety of patient care.

Objective The transition to digital hospitals is fast-moving. Although US hospitals are further ahead than some others in implementing eHealth technologies, their early experiences are not necessarily generalisable to contemporary healthcare because both the systems and technologies have been rapidly evolving. It is important to provide up-to-date assessments of the evidence available. The aim of this paper is to provide an assessment of the current literature on the effects to be expected from hospital implementations of eHealth technologies. Methods A narrative review was conducted of systematic reviews investigating the effects of eHealth technologies (clinical decision support systems (CDSS), computerised provider order entry (CPOE), ePrescribing, electronic medical records (EMRs)) published between November 2015 and August 2017 and compared the findings with those of a previous narrative review that examined studies published between January 2010 and October 2015. The same search strategy and selection criteria were used in both studies. Results Of the seven relevant articles, three (42.9%) examined the effects of more than one eHealth system: only two (28.6%) studies were high quality, three (42.9%) were of intermediate quality and two (28.6%) were of low quality. We identified that EMRs are largely associated with conflicting findings. Previous reviews suggested that CPOE are associated with significant positive results of cost savings, organisational efficiency gains, less resource utilisation and improved individual performance. However, these effects were not investigated in the more recent reviews, and only mixed findings for communication between clinicians were reported. Similarly, for ePrescribing, later reviews reported limited evidence of benefits, although when coupled with CDSS, more consistent positive findings were reported. Conclusion This overview can help inform other hospitals in Australia and elsewhere of the likely effects resulting from eHealth technologies. The findings suggest that the effects of these systems are largely mixed, but there are positive findings, which encourage ongoing digital transformation of hospital practice. What is known about the topic? Governments are increasingly devoting substantial resources towards implementing eHealth technologies in hospital practice with the goals of improving clinical and financial outcomes. Yet, these outcomes are yet to be fully realised in practice and conflicting findings are often reported in the literature. What does this paper add? This paper extends a previous narrative review of systematic reviews and categorises the effects of eHealth technologies into a typology of outcomes to enable overall findings to be reported and comparisons to be made. In doings so, we synthesise 7 years of eHealth effects. Mixed results are largely reported for EMRs, with many benefits being compromised by practices stemming from resistance to EMRs. Limited evidence of effectiveness exists for CPOE and ePrescribing. CDSS are associated with the most consistent positive findings for clinician- and hospital-level effects. We observed renewed interest in the literature for the effect of eHealth technologies on communication both between clinicians and with patients. Other new insights have emerged relating to effects on clinical judgement, changing practice and staff retention. What are the implications for practitioners? eHealth technologies have the potential to positively affect clinical and financial outcomes. However, these benefits are not guaranteed, and mixed results are often reported. This highlights the need for hospitals and decision makers to clearly identify and act on the drivers of successful implementations if eHealth technologies are to facilitate the creation of new, more effective models of patient care in an increasingly complex healthcare environment.

The digital transformation of hospitals in Australia is occurring rapidly in order to facilitate innovation and improve efficiency. Rapid transformation can cause temporary disruption of hospital workflows and staff as processes are adapted to the new digital workflows. The aim of this paper is to outline various types of digital disruption and some strategies for effective management. A large tertiary university hospital recently underwent a rapid, successful roll-out of an integrated electronic medical record (EMR). We observed this transformation and propose several digital disruption "syndromes" to assist with understanding and management during digital transformation: digital deceleration, digital transparency, digital hypervigilance, data discordance, digital churn and post-digital 'depression'. These 'syndromes' are defined and discussed in detail. Successful management of this temporary digital disruption is important to ensure a successful transition to a digital platform.

Objective The aim of the present study was to determine the effects of hospital-based eHealth technologies on quality, safety and efficiency of care and clinical outcomes. Methods Systematic reviews and reviews of systematic reviews of eHealth technologies published in PubMed/Medline/Cochrane Library between January 2010 and October 2015 were evaluated. Reviews of implementation issues, non-hospital settings or remote care or patient-focused technologies were excluded from analysis. Methodological quality was assessed using a validated appraisal tool. Outcome measures were benefits and harms relating to electronic medical records (EMRs), computerised physician order entry (CPOE), electronic prescribing (ePrescribing) and computerised decision support systems (CDSS). Results are presented as a narrative overview given marked study heterogeneity. Results Nineteen systematic reviews and two reviews of systematic reviews were included from 1197 abstracts, nine rated as high quality. For EMR functions, there was moderate-quality evidence of reduced hospitalisations and length of stay and low-quality evidence of improved organisational efficiency, greater accuracy of information and reduced documentation and process turnaround times. For CPOE functions, there was moderate-quality evidence of reductions in turnaround times and resource utilisation. For ePrescribing, there was moderate-quality evidence of substantially fewer medications errors and adverse drug events, greater guideline adherence, improved disease control and decreased dispensing turnaround times. For CDSS, there was moderate-quality evidence of increased use of preventive care and drug interaction reminders and alerts, increased use of diagnostic aids, more appropriate test ordering with fewer tests per patient, greater guideline adherence, improved processes of care and less disease morbidity. There was conflicting evidence regarding effects on in-patient mortality and overall costs. Reported harms were alert fatigue, increased technology interaction time, creation of disruptive workarounds and new prescribing errors. Conclusion eHealth technologies in hospital settings appear to improve efficiency and appropriateness of care, prescribing safety and disease control. Effects on mortality, readmissions, total costs and patient and provider experience remain uncertain. What is known about the topic? Healthcare systems internationally are undertaking large-scale digitisation programs with hospitals being a major focus. Although predictive analyses suggest that eHealth technologies have the potential to markedly transform health care delivery, contemporary peer-reviewed research evidence detailing their benefits and harms is limited. What does this paper add? This narrative overview of 19 systematic reviews and two reviews of systematic reviews published over the past 5 years provides a summary of cumulative evidence of clinical and organisational effects of contemporary eHealth technologies in hospital practice. EMRs have the potential to increase accuracy and completeness of clinical information, reduce documentation time and enhance information transfer and organisational efficiency. CPOE appears to improve laboratory turnaround times and decrease resource utilisation. ePrescribing significantly reduces medication errors and adverse drug events. CDSS, especially those used at the point of care and integrated into workflows, attract the strongest evidence for substantially increasing clinician adherence to guidelines, appropriateness of disease and treatment monitoring and optimal medication use. Evidence of effects of eHealth technologies on discrete clinical outcomes, such as morbid events, mortality and readmissions, is currently limited and conflicting. What are the implications for practitioners? eHealth technologies confer benefits in improving quality and safety of care with little evidence of major hazards. Whether EMRs and CPOE can affect clinical outcomes or overall costs in the absence of auxiliary support systems, such as ePrescribing and CDSS, remains unclear. eHealth technologies are evolving rapidly and the evidence base used to inform clinician and managerial decisions to invest in these technologies must be updated continually. More rigorous field research using appropriate evaluation methods is needed to better define real-world benefits and harms. Customisation of eHealth applications to the context of patient-centred care and management of highly complex patients with multimorbidity will be an ongoing challenge.

Objective The aim of the present study was to provide a summary of a systematic review of literature reporting benefits and limitations of implementing National Emergency Access Target (NEAT), a target stipulating that a certain proportion of patients presenting to hospital emergency departments are admitted or discharged within 4h of presentation. Methods A systematic review of published literature using specific search terms, snowballing techniques applied to retrieved references and Google searches was performed. Results are presented as a narrative synthesis given the heterogeneity of included studies. Results Benefits of a time-based target for emergency care are improved timeliness of emergency care and reduced in-hospital mortality for emergency admissions to hospital. Limitations centre on using a process measure (time) alone devoid of any monitoring of patient outcomes, the threshold nature of a time target and the fact that currently NEAT combines the measurement of clinical management of two very different patient cohorts seeking emergency care: less acute patients discharged home and more acute patients admitted to hospital. Conclusions Time-based access targets for emergency presentations are associated with significant improvements in in-hospital mortality for emergency admissions. However, other patient-important outcomes are deserving of attention, choice of targets needs to be validated by empirical evidence of patient benefit and single targets need to be partitioned into separate targets pertaining to admitted and discharged patients. What is known about the topic? Time targets for emergency care originated in the UK. The introduction of NEAT in Australia has been controversial. NEAT directs that a certain proportion of patients will be admitted or discharged from an emergency department (ED) within 4h. Recent dissolution of the Australian National Partnership Agreement (which provided hospitals with financial incentives for achieving NEAT compliance) has prompted a re-examination of the 4-h rule, the evidence underpinning its introduction and its benefits and risks to patients What does this paper add? This paper is executive summary of key findings from a systematic literature review on the benefits and limitations of NEAT (the 4-h rule) commissioned by the Queensland Clinical Senate to inform future policy and targets. What are the implications for practitioners? There is evidence that a time-based target has been associated with a reduction in in-hospital mortality for emergency admissions to Australian hospitals. Concerns remain regarding a time-based target alone being used to drive redesign efforts at improving access to emergency care. A time-based target should be coupled with close monitoring of patient outcomes of emergency care. Target thresholds need to be evidence based and separate targets should be reported for admitted, discharged and all patients presenting to the ED.

Objective The aim of the present study was to identify patient and non-patient factors associated with reduced mortality among patients admitted from the emergency department (ED) to in-patient wards in a major tertiary hospital that had previously reported a near halving in mortality in association with a doubling in National Emergency Access Target (NEAT) compliance over a 2-year period from 2012 to 2014. Methods We retrospectively analysed routinely collected data from the Emergency Department Information System (EDIS) and hospital discharge abstracts on all emergency admissions during calendar years 2011 (pre-NEAT interventions) and 2013 (post-NEAT interventions). Patients admitted to short-stay wards and then discharged home, as well as patients dying in the ED, were excluded. Patients included in the study were categorised according to age, time and day of arrival to the ED, mode of transport to the ED, emergency triage category, type of clinical presentation and major diagnostic codes. Results The in-patient mortality rate for emergency admissions decreased from 1.9% (320/17022) in 2011 to 1.2% (202/17162) in 2013 (P<0.001). There was no change from 2011 to 2013 in the percentage of deaths in the ED (0.19% vs 0.17%) or those coded as in-patient palliative care (17.9% vs 22.2%). Although deaths were not associated with age by itself, the mortality rate of older patients admitted to medical wards decreased significantly from 3.5% to 1.7% (P=0.011). A higher mortality rate was seen among patients presenting to ED triage between midnight and 12 noon than at other times in 2011 (2.5% vs 1.5%; P<0.001), but this difference disappeared by 2013 (1.3% vs 1.1%; P=0.150). A similar pattern was seen among patients presenting on weekends versus weekdays: 2.2% versus 1.7% (P=0.038) in 2011 and 1.3% versus 1.1% (P=0.150) in 2013. Fewer deaths were noted among patients with acute cardiovascular or respiratory disease in 2013 than in 2011 (1.7% vs 3.6% and 1.5% vs 3.4%, respectively; P<0.001 for both comparisons). Mode of transport to the ED or triage category was not associated with changes in mortality. These analyses took account of any possible confounding resulting from differences over time in emergency admission rates. Conclusions Improved NEAT compliance as a result of clinical redesign is associated with improved in-patient mortality among particular subgroups of emergency admissions, namely older patients with complex medical conditions, those presenting after hours and on weekends and those presenting with time-sensitive acute cardiorespiratory conditions. What is known about the topic? Clinical redesign aimed at improving compliance with NEAT and reducing time spent within the ED of acutely admitted patients has been associated with reduced mortality. To date, no study has attempted to identify subgroups of patients who potentially derive the greatest benefit from improved NEAT compliance in terms of reduced risk of in-patient death. It also remains unclear as to what extent non-patient factors (e.g. admission practices and differences in coding of palliative care patients) affect or confound this reduced risk. What does this paper add? The present study is the first to reveal that enhanced NEAT compliance is associated with lower mortality among particular subgroups of emergency patients admitted to in-patient wards. These include older patients with complex medical conditions, those presenting after hours or on weekends or those with time-sensitive acute cardiorespiratory conditions. These results took account of any possible confounding resulting from differences over time in emergency admission rates, deaths in the ED, numbers of short-stay ward admissions and coding of palliative care deaths. What are the implications for practitioners? Efforts aimed at improving NEAT compliance and efficiencies at the ED-in-patient interface appear to be worthwhile in reducing in-patient mortality among particular subgroups of emergency admissions at high risk. More research is urgently needed in identifying patient- and system-level factors that predispose to higher mortality rates in such populations, but are potentially amenable to focused interventions aimed at optimising transitions of care at the ED-in-patient interface and increasing NEAT compliance for patients admitted to in-patient wards from the ED.

Background: Movement of emergency patients across the emergency department (ED)-inpatient ward interface influences compliance with National Emergency Access Targets (NEAT). Uncertainty exists as to how best measure patient flow, NEAT compliance and patient mortality across this interface., Objective: To compare the association of NEAT with new and traditional markers of patient flow across the ED-inpatient interface and to investigate new markers of mortality and NEAT compliance across this interface., Methods: Retrospective study of consecutive emergency admissions to a tertiary hospital (January 2012 to June 2014) using routinely collected hospital data. The practical access number for emergency (PANE) and inpatient cubicles in emergency (ICE) are new measures reflecting boarding of inpatients in ED; traditional markers were hospital bed occupancy and ED attendance numbers. The Hospital Standardised Mortality Ratio (HSMR) for patients admitted via ED (eHSMR) was correlated with inpatientNEAT compliance rates. Linear regression analyses assessed for statistically significant associations (expressed as Pearson R coefficient) between all measures and inpatient NEAT compliance rates., Results: PANE and ICE were inversely related to inpatient NEAT compliance rates (r = 0.698 and 0.734 respectively, P < 0.003 for both); no significant relation was seen with traditional patient flow markers. Inpatient NEAT compliance rates were inversely related to both eHSMR (r = 0.914, P = 0.0006) and all-patient HSMR (r = 0.943, P = 0.0001)., Conclusions: Traditional markers of patient flow do not correlate with inpatient NEAT compliance in contrast to two new markers of inpatient boarding in ED (PANE and ICE). Standardised mortality rates for both emergency and all patients show a strong inverse relation with inpatient NEAT compliance.

Objective: To implement and evaluate strategies for improving access to emergency department (ED) care in a tertiary hospital., Methods: A retrospective pre-post intervention study using routinely collected data involving all patients presenting acutely to the ED of a major tertiary hospital over a 2-year period. Main outcome measures were changes in: the percentage of patients exiting the ED (all patients, patients discharged directly from the ED, patients admitted to inpatient wards); mean patient transit times in the ED; inpatient mortality rates; rates of ED 'did not wait' and re-presentations within 48 h of ED discharge; and selected safety indicators. Qualitative data on staff perceptions of interventions were also gathered., Results: Working groups focused on ED internal processes, ED-inpatient unit interface, hospital-wide discharge processes and performance monitoring and feedback. Twenty-five different reforms were enacted over a 9-month period from April to December 2012. Comparing the baseline period (January-March 2012) with the post-reform period (January-March 2013), the percentage of patients exiting the ED within 4 h rose for all patients presenting to the ED (from 32% to 62%), for patients discharged directly from the ED (from 41% to 75%) and for admitted patients (from 12% to 32%; P<0.001 for all comparisons). The mean (±s.d.) time all patients spent in the ED was reduced from 7.2±5.8 to 4.4±3.5 h (P<0.001) and, for admitted patients, was associated with reduced in-hospital mortality (from 2.3% to 1.7%; P=0.045). The 'did not wait' rates in ED fell from 6.9% to 1.9% (P<0.001), whereas ED re-presentations within 48 h among patients discharged from the ED rose slightly (from 3.1% to 3.8%; P=0.023). Improvements in outcome measures were maintained over the subsequent 12 months., Conclusions: Multiple reforms targeting processes both within the ED and its interface with inpatient units greatly improved access to ED care over 12 months and were associated with decreased in-hospital mortality. WHAT IS KNOWN ABOUT THIS TOPIC?: Prolonged stays in the ED result in overcrowding, delayed ambulance access to ED care and increased adverse outcomes for admitted patients. The introduction in Australia of National Emergency Access Targets (NEAT), which stipulate at least 70% of patients in the ED must exit the department within 4h, have spurred hospitals into implementing a wide range of reforms with varying levels of success in achieving such targets. WHAT DOES THIS PAPER ADD?: This study demonstrates how multiple reforms implemented in a poor performing tertiary hospital caused the proportion of patients exiting the ED within 4h to double within 9 months to reach levels comparable with best performing peer hospitals. This was associated with a 26% reduction in in-hospital mortality for admitted patients and no clinically significant adverse effects. It demonstrates the importance of robust governance structures, executive sponsorship, cross-disciplinary collaboration, regular feedback of NEAT performance data and major redesign of existing clinical processes, work practices and bed management operations. WHAT ARE THE IMPLICATIONS FOR CLINICIANS AND MANAGERS?: Improving access to emergency care should be regarded as a problem located and resolved both within and without the ED. It requires a whole-of-hospital solution involving interdisciplinary collaboration and significant change in culture and practice relating to inpatient units and their interface with the ED.