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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.

Digital transformation in healthcare improves the safety of health systems. Within our health service, a new digital hospital has been established and two wards from a neighbouring paper-based hospital transitioned into the new digital hospital. This created an opportunity to evaluate the impact of complete digital transformation on medication safety. Here we discuss the impact of transition from a paper-based to digital hospital on voluntarily reported medication incidents and prescribing errors. This study utilises an interrupted time-series design and takes place across two wards as they transition from a paper to a digital hospital. Two data sources are used to assess impacts on medication incidents and prescribing errors: (1) voluntarily reported medication incidents and 2) a chart audit of medications prescribed on the study wards. The chart audit collects data on procedural, dosing and therapeutic prescribing errors. There are 588 errors extracted from incident reporting software during the study period. The average monthly number of errors reduces from 12.5 pre- to 7.5 post-transition (p < 0.001). In the chart audit, 5072 medication orders are reviewed pre-transition and 3699 reviewed post-transition. The rates of orders with one or more error reduces significantly after transition (52.8% pre- vs. 15.7% post-, p < 0.001). There are significant reductions in procedural (32.1% pre- vs. 1.3% post-, p < 0.001), and dosing errors (32.3% pre- vs. 14% post-, p < 0.001), but not therapeutic errors (0.6% pre- vs. 0.7% post-, p = 0.478). Transition to a digital hospital is associated with reductions in voluntarily reported medication incidents and prescribing errors. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. What is known about the topic?: Healthcare delivery is complex and the ability of healthcare providers to maintain consistent standards of quality and safety is variable. Traditionally, these standards have been assessed by intermittent retrospective point-prevalence survey activity. Sophisticated digital hospitals provide the opportunity to develop data and analytics that monitor quality and safety standards across every patient, every time in near real time. What does this paper add?: This paper describes a digital hospital which has created streaming analytics to monitor live performance of quality and safety standards. The necessary skills, leadership and governance for this process are outlined and the products described. What are the implications for practitioners?: Shifting from retrospective paper-based point prevalence surveys to a digital platform has several implications. Firstly, it is an imperative to drive digital transformation of Australian hospitals. Secondly, it provides data for intervention to the hospital staff, so that issues can be addressed and improved in real-time, rather than waiting for survey results. Lastly, this new model of maintaining quality and safety also requires the development of new skills in the hospital setting including data literacy, digital clinical governance and clinical informatics. [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]

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.Alarge 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. [ABSTRACT FROM AUTHOR]

Objective We sought to obtain a deeper understanding of the differing needs and expectations of inpatient and ED medical staff regarding the admission process for medical patients. Design Online questionnaire regarding their attitudes to and perceptions of various aspects of the admission process was used. Setting The setting is a tertiary 640-bed adult hospital with over 60 000 ED presentations per year and an inpatient admission rate of 30%. Results A total of 42 out of 56 (75%) internal medical trainees (IMT) felt that the ED admission workup standard was lower or much lower than the inpatient standard; however, 10 of 16 (62.5%) ED trainees (EDT) thought it was similar ( P = 0.009). Regarding why IMT order additional tests in the ED, the major reason supported by IMT was to 'identify or exclude urgent pathology' (53/56, 96.4%); however, this reason ranked only fifth for EDT (2/16, 12.5%) who ranked 'to ensure nothing was missed' (12/15, 80%) first. A total of 24 out of 56 (42.8%) IMT felt that if ED admissions were enacted without IMT review, inappropriate admissions to hospital would occur regularly although only one of 16 EDT (6.3%) agreed ( P = 0.025). A total of 14 out of 16 (87.5%) EDT but only 16 of 56 (23.2%) IMT were comfortable with admissions occurring without inpatient review in the ED ( P < 0.001). The top two perceived barriers to a smooth and timely admission process for IMT were patient instability (34/43, 79.1%) and inadequate ED workup (37/49, 75.5%); for EDT, they were excessive IMT workload (11/14, 78.6%) and referral close to the end of an IMT shift (7/11, 63.6%). Conclusion Substantial barriers to more harmonious admission processes exist. A 'paradigm shift' where roles and responsibilities are clear might be required. Defusing tension across the ED-inpatient interface should improve efficiency and ensure that patient outcomes remain the focus. [ABSTRACT FROM AUTHOR]

Background: Engaging patients in the delivery of health care has the potential to improve health outcomes and patient satisfaction. Patient portals may enhance patient engagement by enabling patients to access their electronic medical records (EMRs) and facilitating secure patient-provider communication.Objective: The aim of this study was to review literature describing patient portals tethered to an EMR in inpatient settings, their role in patient engagement, and their impact on health care delivery in order to identify factors and best practices for successful implementation of this technology and areas that require further research.Methods: A systematic search for articles in the PubMed, CINAHL, and Embase databases was conducted using keywords associated with patient engagement, electronic health records, and patient portals and their respective subject headings in each database. Articles for inclusion were evaluated for quality using A Measurement Tool to Assess Systematic Reviews (AMSTAR) for systematic review articles and the Quality Assessment Tool for Studies with Diverse Designs for empirical studies. Included studies were categorized by their focus on input factors (eg, portal design), process factors (eg, portal use), and output factors (eg, benefits) and by the valence of their findings regarding patient portals (ie, positive, negative, or mixed).Results: The systematic search identified 58 articles for inclusion. The inputs category was addressed by 40 articles, while the processes and outputs categories were addressed by 36 and 46 articles, respectively: 47 articles addressed multiple themes across the three categories, and 11 addressed only a single theme. Nineteen articles had high- to very high-quality, 21 had medium quality, and 18 had low- to very low-quality. Findings in the inputs category showed wide-ranging portal designs; patients' privacy concerns and lack of encouragement from providers were among portal adoption barriers while information access and patient-provider communication were among facilitators. Several methods were used to train portal users with varying success. In the processes category, sociodemographic characteristics and medical conditions of patients were predictors of portal use; some patients wanted unlimited access to their EMRs, personalized health education, and nonclinical information; and patients were keen to use portals for communicating with their health care teams. In the outputs category, some but not all studies found patient portals improved patient engagement; patients perceived some portal functions as inadequate but others as useful; patients and staff thought portals may improve patient care but could cause anxiety in some patients; and portals improved patient safety, adherence to medications, and patient-provider communication but had no impact on objective health outcomes.Conclusions: While the evidence is currently immature, patient portals have demonstrated benefit by enabling the discovery of medical errors, improving adherence to medications, and providing patient-provider communication, etc. High-quality studies are needed to fully understand, improve, and evaluate their impact. [ABSTRACT FROM AUTHOR]

Patients who require emergency admission to hospital require complex care that can be fragmented, occurring in the ED, across the ED-inpatient interface (EDii) and subsequently, in their destination inpatient ward. Our hospital had poor process efficiency with slow transit times for patients requiring emergency care. ED clinicians alone were able to improve the processes and length of stay for the patients discharged directly from the ED. However, improving the efficiency of care for patients requiring emergency admission to true inpatient wards required collaboration with reluctant inpatient clinicians. The inpatient teams were uninterested in improving time-based measures of care in isolation, but they were motivated by improving patient outcomes. We developed a dashboard showing process measures such as 4 h rule compliance rate coupled with clinically important outcome measures such as inpatient mortality. The EDii dashboard helped unite both ED and inpatient teams in clinical redesign to improve both efficiencies of care and patient outcomes. [ABSTRACT FROM AUTHOR]