Build it and they will come

We now no longer accept boundless ED lengths of stay as an intractable condition of our practices. We have developed tools for communication, education, advocacy and research to improve the efficiency with which we deliver care, while simultaneously facing rising patient volumes and resource limitations. In this issue of Emergency Medicine Australasia, three investigations provide us with data and analyses of methods to improve patient flow and to minimize obstacles to efficient patient care in the ED. Chan et al. surveyed ED medical and non-medical staff about their perceptions of delay points in ED care, and compared staff opinions to actual data from a hospital-sponsored patient flow study. The authors characterized seven reasons for patient delay and asked the survey responders to rank order each reason according to perceived importance, stratifying responses into three time frames: 2.6 h (160 min), 5.3 h (320 min) and 8 h (480 min) after ED presentation. While there are some unanswered questions about their methodology, the real question being asked was ‘Why do you think this patient is still here in the ED’? The provocative result: staff perceptions about delay generally do not match the actual data collected. The implication? Objective data gathering and analyses are generally superior to perception when crafting system improvements to improve patient flow. This conclusion did not surprise me, but does serve to remind us all that ‘best guesses’ are not always best. Chan leads us then, into the next two studies, those of Ieraci et al. and of Kinsman et al. They and their colleagues assessed the effectiveness of a fast track streaming system (FTSS) through data collection and analyses in two different EDs. Both studies used similar outcome measures. Ieraci et al. assessed the impact of the FTSS on patient waiting time and compliance with the New South Wales Department of Health Australasian Triage Scale corresponding benchmarks, treatment time, patients leaving the ED before treatment completed and ED return visits within 48 h. The study compared patients seen in 6 months in 2005 without FTSS (total ED census/year = 32 316), with patients seen in the same 6 months in 2006 (total ED census/ year = 37 008) when about 32% of patients were directed to FTSS with the new system in place. In 2006, patients were assigned to FTSS according to two subjective criteria determined by the triage nurse: (i) lowcomplexity patient; and (ii) the patient did not require nursing in a bed. Space was taken from the ED in order to accommodate FTSS, and reconfigured to meet its needs. Dedicated staff were assigned that included one career medical officer and two nurse practitioners. Two nurses were reassigned, or rotated from the ED pool to fast track, so it appears that additional nursing staff were not provided to specifically accommodate FTSS. The study demonstrated a decrease in mean waiting time, improved waiting time benchmark compliance and reduced mean treatment time. Kinsman et al. compared the length of stay on admitted patients, length of stay on non-admitted patients and the proportion of patients who left without treatment, before and after the institution of a FTSS. Their