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Objective: Many factors influence patient flow through an ED, including streaming, treatment spaces and staff resources. This pilot study explored and compared real time patient flow using a single‐stream system versus varying configurations of possible two‐stream systems using computer simulation. Methods: Simulation modelling was used to assess the delay in treatment of a rapid‐antigen‐tested‐based, two‐stream model for patient flow through ED during the peak phase of the COVID pandemic. Results: Modelling two‐stream configuration for all patients (minimum time to be seen for both COVID‐positive and COVID‐negative patients) showed that in the case study ED, a two‐stream system and linked changes in bed configuration for managing the risks of infection can impact delays in treatment. Conclusions: Data‐driven modelling within specific clinical settings can inform the (in)efficiency of patient flow processes and help clinicians and managers make evidence‐based decisions about patient transition through EDs. This can assist with reconfiguration of ED patient streaming particularly during periods of unique need, such as the recent COVID‐19 pandemic. [ABSTRACT FROM AUTHOR]

The provision of waiting time information in emergency departments (ED) has become an increasingly popular practice due to its positive impact on patient experience and ED demand management. However, little scientific attention has been given to the quality and quantity of waiting time information presented to patients. To improve both aspects, we propose a set of state space models with flexible error structures to forecast ED waiting time for low acuity patients. Our approach utilizes a Bayesian framework to generate uncertainties associated with the forecasts. We find that the state‐space models with flexible error structures significantly improve forecast accuracy of ED waiting time compared to the benchmark, which is the rolling average model. Specifically, incorporating time‐varying and correlated error terms reduces the root mean squared errors of the benchmark by 10%. Furthermore, treating zero‐recorded waiting times as unobserved values improves forecast performance. Our proposed model has the ability to provide patient‐centric waiting time information. By offering more accurate and informative waiting time information, our model can help patients make better informed decisions and ultimately enhance their ED experience. [ABSTRACT FROM AUTHOR]

Objective: To investigate the impact of QScript implementation on pregabalin‐related poisoning presentations to the ED. Methods: This is a retrospective review of pregabalin‐related poisoning presentations to a tertiary Australian ED in the 4 years prior to, and 1 year following the introduction of QScript real‐time prescription monitoring system. Results: Pregabalin‐related poisoning presentations fell by 28% from an average of 98 presentations annually over the 4 years prior to QScript implementation to 71 in 2022. The severity of poisonings was similar over the periods. Conclusions: The introduction of QScript was associated with a reduction in pregabalin‐related poisoning presentations. [ABSTRACT FROM AUTHOR]

Objectives: To compare time metrics associated with a temporary disruption to ED computed tomography (CT) scanner location from adjacent to the ED with direct access from resuscitation rooms, to a location remote to the ED. Methods: A retrospective before and after study was conducted in a public metropolitan ED with over 66 000 presentations annually. Time‐to‐CT metrics, operational time metrics and ED length of stay were extracted and analysed from presentations between October 2020 and January 2021. Results: There were 3031 CT scans during the study period. Overall, the disruption was associated with a significant 27–36 min delay (P < 0.01) in time‐to‐CT start; these delays were also observed in a subset of trauma patients. In a subset of presumed stroke patients, time‐to‐brain perfusion was significantly delayed by up to 10 min (P < 0.01). There was a 14% (P < 0.01) greater demand for operational services and a time imposition of up to 8 min (P < 0.01) to transport patients to or from CT scanning when the CT scanner was located away from the ED. ED length of stay was consistent at all time points. Conclusion: Although rapid, proximate access to CT scanning is often considered desirable in terms of the management of trauma and other time‐critical emergencies, the wider time and resource implications demonstrated in this study suggest a potential broader benefit to co‐located CT scanning in ED. Our experience could be considered in future re‐design of EDs. [ABSTRACT FROM AUTHOR]

The article presents the discussion on telemedicine and digital technologies supporting the provision of emergency care for more than 20 years. Topics include enabling ubiquitous, high quality, secure video conferencing, remote monitoring and digital ordering and review of investigations; and implications for the emergency and primary care workforces, particularly in rural and regional centres.

The purpose of this paper is to demonstrate through practical application how a system dynamics (SD) patient flow model of an emergency department (ED) can show which levers effectively reduce backlogs to improve access to care. Overcrowded EDs are struggling to meet demand and access targets. In 2016 and 2017, in the UK and Australia, respectively, 15% and 28% of arrivals waited longer than the targeted 4‐hr treatment time. Historically, simulation models that have informed access to emergency care have ignored the wider systems impacts. There is a growing awareness of the value of systems analysis tools for informing interventions and policy. In this study, we constructed a pilot system dynamics patient flow model, where the scope was the ambulatory and ambulance patient arrivals, the ED processes for acute and fast‐track pathways, pathology and radiology services, the ED short‐stay unit, and the Medical Assessment Planning Inpatient Unit. Patients queued to access constrained ED resources (doctors and beds) and diagnostic services (pathology and X‐ray). The model was tested on actual data from five separate historical periods spanning 3 years. The resultant daily pattern of peaks and troughs in patient flow and system delays accurately replicated patterns in actual patient flows, resource use, and the location of delays. "What if" scenario analysis (b) simulated how access would have looked in the sample weeks with different intervention strategies, (b) simulated system limits on the basis of current resources, (c) accurately identified levers that historically have been most effective at minimizing ambulance ramping, and (d) identified when additional staffing would fail to improve flow. [ABSTRACT FROM AUTHOR]

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. What is known about this topic?: Much has been written about the introduction of electronic medical records (EMRs) in emergency departments. This work sits alongside a substantial body of evidence outlining the relationship between process measures of ED performance and important patient outcomes. However, much less is known about the impact of digital transformation on the complex adaptive system that is the EDii and the impact of digitisation on the vulnerable group of patients who require emergency admission to hospital. What does this paper add?: The objective of this case study was to describe the effect of a rapid rollout of an integrated EMR. This EMR simultaneously transformed care delivery both in the ED and the inpatient space and impacted on the politically and clinically sensitive performance and outcome measures of the EDii in a large tertiary hospital. The present study is the first that specifically examined the effect of digitisation at the EDii. What are the implications for practitioners?: The understanding that digital deceleration will occur, but that with good patient outcome monitoring worsening of key patient outcomes is not likely to occur, now holds a key place in digital transformation planning. The measures of the EDii examined in this case study provide a foundation for this montoring. [ABSTRACT FROM AUTHOR]

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 18 million 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. [ABSTRACT FROM AUTHOR]

After successfully avoiding the situations experienced by some countries, Australasian EDs now face a future in which the ongoing threat of COVID‐19 is added to the traditional challenges in providing quality emergency care. The contribution of emergency medicine to the national containment strategy adds a new dimension to the demands placed on emergency medicine in Australia and similarly, to the elimination strategy employed in New Zealand. These demands will best be met by a considered, planned and resourced approach that will challenge traditional measures of 'ED efficiency'. [ABSTRACT FROM AUTHOR]

Objectives. The aim of this study was to assess the relationship between compliance with time-based Emergency Department (ED) targets (known as NEAT) and the time taken to collect an electrocardiogram (TTE) in patients presenting with chest pain. Methods. This was a pilot descriptive retrospective cohort study completed in a large inner city tertiary ED. Patients who presented with active or recent chest pain between July 2014 and June 2015 were eligible for inclusion. Pregnant patients, inter-hospital transfers, and traumatic chest pain were excluded. A random selection of 300 patients from the eligible cohort comprised the final sample. The differences of TTE between categories of NEAT compliance were compared using Kruskal-Wallis test. Also, the factors affecting with the acquisition of ECG within ten minutes of arrival were explored using proportional hazards regression. Results. There was a significant inverse association between the percentage of admitted patients leaving the ED within four hours (admitted NEAT) and TTE. As admitted NEAT compliance increased TTE decreased (p = 0.004). A number of variables including triage score, arrival time, total NEAT, first location, doctor wait time and cardiac diagnosis were all significant predictors of TTE. After adjusting for other variables Admitted NEAT remained as an independent predictor of TTE. Conclusion. There is likely to be a relationship between NEAT and TTE that is reflective of overall hospital and not just ED functioning; however the exact relationship remains uncertain. Further study in a multisite study is warranted to further explore the relationship between NEAT, TTE and other important clinical metrics of ED performance. [ABSTRACT FROM AUTHOR]

Unwell patients in the ED requiring inpatient admission must negotiate the interface between the ED and inpatient wards. Despite its importance and scale, this ED-inpatient interface (EDii) is poorly characterised. The aim of this paper is to clearly define the EDii and to describe its importance to (i) the patient: delays to admission and errors in communication across the EDii can increase adverse outcomes; (ii) the hospital: poor EDii function reduces hospital efficiency and effectiveness; and (iii) the healthcare system: half of all hospital inpatient admissions occur via the EDii and so EDii affects system-wide performance. The EDii can be defined as the dynamic, transitional phase of patient care in which responsibility for, and delivery of care, is shared between ED and inpatient hospital services. The EDii is characterised by a complex interplay of patient, hospital and system factors. A clear definition of the EDii and an understanding of its importance will assist future research and interventions to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Objectives. The aim of the present study was to assess the relationship between and the effect of the 4-h target or National Emergency Access Target (NEAT) on the time-to-analgesia (TTA), as well as the provision of analgesia in an adult emergency department (ED). Methods. The present study was a pilot descriptive explorative retrospective cohort study conducted in a public metropolitan ED. Eligible presentations for analysis were adults presenting with a documented pain score of ≥4 out of 10 between 1 and 14 September 2014. Triage Category 1, pregnant, chest pain and major trauma cases were excluded from the study. As a result, data for 260 patients were analysed. Results. Of 260 patients, 176 had analgesia with a median TTA of 49 min. Increased NEAT compliance did not significantly decrease TTA. However, when the factors that affected the provision of analgesia were analysed, an association was demonstrated between Admitted and Short Stay NEAT performance and the provision of analgesia. The likelihood of receiving analgesia at all increased as Admitted and Short Stay NEAT compliance improved. Conclusion. NEAT is a significant health policy initiative with little clinical evidence supporting its implementation. However, as the Admitted NEAT compliance increases, the probability of receiving analgesia increases, demonstrating a possible link between hospital function and clinical care provision that needs to be explored further. [ABSTRACT FROM AUTHOR]

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 4 h 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 currentlyNEATcombines 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: We explored the relationship between the National Emergency Access Target (NEAT) compliance rate, defined as the proportion of patients admitted or discharged from emergency departments (EDs) within 4 hours of presentation, and the risk-adjusted in-hospital mortality of patients admitted to hospital acutely from EDs.Design, Setting and Participants: Retrospective observational study of all de-identified episodes of care involving patients who presented acutely to the EDs of 59 Australian hospitals between 1 July 2010 and 30 June 2014.Main Outcome Measure: The relationship between the risk-adjusted mortality of inpatients admitted acutely from EDs (the emergency hospital standardised mortality ratio [eHSMR]: the ratio of the numbers of observed to expected deaths) and NEAT compliance rates for all presenting patients (total NEAT) and admitted patients (admitted NEAT).Results: ED and inpatient data were aggregated for 12.5 million ED episodes of care and 11.6 million inpatient episodes of care. A highly significant (P < 0.001) linear, inverse relationship between eHSMR and each of total and admitted NEAT compliance rates was found; eHSMR declined to a nadir of 73 as total and admitted NEAT compliance rates rose to about 83% and 65% respectively. Sensitivity analyses found no confounding by the inclusion of palliative care and/or short-stay patients.Conclusion: As NEAT compliance rates increased, in-hospital mortality of emergency admissions declined, although this direct inverse relationship is lost once total and admitted NEAT compliance rates exceed certain levels. This inverse association between NEAT compliance rates and in-hospital mortality should be considered when formulating targets for access to emergency care. [ABSTRACT FROM AUTHOR]