Whole-of-hospital response to admission access block: the need for a clinical revolution.

Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia. .
The Medical journal of Australia (Impact Factor: 4.09). 03/2010; 192(6):354.
Source: PubMed
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Available from: Biswadev Mitra, Sep 30, 2015
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    ABSTRACT: To assess the effectiveness of acute medical units (AMUs) in hospitals. (i) Controlled and observational studies in peer-reviewed journals retrieved from PubMed, EPOC, CINAHL and ERIC databases published between January 1990 and July 2008; and (ii) reports from non-peer-reviewed websites combined with Google search. Articles reporting effects of the introduction of an AMU on mortality, length of stay, discharge disposition, readmissions, resource use and patient and/or staff satisfaction. Data extraction Data on unit operations and outcome measures were extracted by a single author and confirmed by a second author, with disagreement settled by consensus. Nine peer-reviewed reports of before-after analyses of seven units introduced into the UK and Ireland were analysed. Two studies, one prospective, reported significant reductions in in-patient mortality between 0.6 and 5.6% points following commencement of AMU. Four studies reported significant reductions in the length of stay between 1.5 and 2.5 days. Waiting times for patient transfer from emergency departments to medical beds decreased by 30% in one study. In three studies, the proportion of medical patients discharged directly home from the AMU increased by 8-25% points. Three studies noted no increase in 30-day readmission rates following unit commencement. Two studies described significant improvements in patient and staff satisfaction with care. Eight non-peer-reviewed reports relating to 48 units confirmed reductions in the length of stay. Limited observational data suggest AMUs reduce in-patient mortality, length of stay and emergency department access block without increasing readmission rates, and improve patient and staff satisfaction.
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    ABSTRACT: Overcrowding occurs when emergency department (ED) function is impeded, primarily by overwhelming of ED staff resources and physical capacity by excessive numbers of patients needing or receiving care. Access block occurs when there is excessive delay in access to appropriate inpatient beds (> 8 hours total time in the ED). Access block for admitted patients is the principal cause of overcrowding, and is mainly the result of a systemic lack of capacity throughout health systems, and not of inappropriate presentations by patients who should have attended a general practitioner. Overcrowding is most strongly associated with excessive numbers of admitted patients being kept in the ED. Excessive numbers of admitted patients in the ED are associated with diminished quality of care and poor patient outcomes. These include (but are not limited to) adverse events, errors, delayed time-critical care, increased morbidity and excess deaths (estimated as at least 1500 per annum in Australia). There is no evidence that telephone advice lines or collocated after-hours GP services assist in reducing ED workloads. Changes to ED structure and function do not address the underlying causes or major adverse effects of overcrowding. They are also rapidly overwhelmed by increasing access block. The causes of overcrowding, and hence the solutions, lie outside the ED. Solutions will mainly be found in managing hospital bedstock and systemic capacity (including the use of step-down and community resources) so that appropriate inpatient beds remain available for acutely sick patients.
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