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Emergency departments need treatment

As resources get stretched to breaking point, nurse practitioners could help solve ED workflow problems. By Louis White

Australian hospital emergency departments are under pressure as patient numbers increase, while workforce and workflow issues between hospital departments remain constant.

Funding is always an issue in any health system, but emergency departments are in need of an overhaul to address the growing demand.

“We need to understand the complexity,” says Professor Gerry Fitzgerald of the School of Public Health and Social Work at Queensland University of Technology. “Then we need to simplify it so that we can manage it.

“There has been a 20 per cent increase in the number of patients attending emergency departments over the past five years, and the numbers continue to grow. Australian emergency departments now manage over six million attendances each year. Reform isn’t just desirable, it’s a necessity.”

Professor Fitzgerald believes that a change in the public’s perception of emergency departments is needed, along with new professions such as emergency medicine and emergency nursing, combined with improved staffing levels and more senior medical and nursing staff.

He also says that congestion in the system has clinical impacts, which leads to a knock-on in morale.

“We need the federal government to support private hospital emergency departments with Medicare rebates,” he says. “We need to create 24-hour primary care and minor emergency centres, as well as establish hospital avoidance strategies, addressing the whole process of patient admission from initial sickness to treatment.”

Statistics reveal that care in categories 1 and 2 (all patients are ranked 1-5 on arrival in emergency care, with 1 being the most serious) has risen in the last decade. There has been a 3.7 per cent annual growth in demand per capita for ambulances between 1999-2000 and 2009-10.

Sunday, Monday and Saturday continue to be the busiest times for hospital emergency department care.

“There are four main issues that we need to address in emergency departments,” says Associate Professor Ramon Shaban of the Faculty of Health at Griffith University. “They are demand management; workforce levels and positions; quality and safety of patients and staff; as well as the design of emergency departments.

“Design really needs to be addressed. We need to look at other industries, such as airports, that deal with large numbers of people in a short period of time. We really need to improve the workflow.”

Shaban’s concerns are illustrated by a single survey across all 94 emergency departments conducted by the Australasian College of Emergency Medicine (ACEM) in Australia in 2009. On June 1 of that year at 10am, the average Australian emergency department had 21.6 patients under treatment, with a further 5.5 waiting to be seen.

Of those under treatment, 7.1 were waiting for beds, representing 33 per cent of the patient workload. Of these, 70 per cent were experiencing “access block”; that is, they had already been in the emergency department for more than eight hours.

“We need to extend the role of nurses in emergency departments,” Shaban says. “They are the ones spending the most time with the patient, and if they could help ease the pain by administering a broader scope of medication, it could help. Paramedics, too, could play a bigger role and lessen the need for people to be admitted to an emergency department.”

In 2009, the Western Australian government brought in a four-hour target for waiting times in hospital emergency departments, as part the federal government health reforms. This means that patients in emergency departments should be either seen to and admitted or discharged within four hours.

A survey in late 2011 by ACEM revealed that since the 10 emergency departments in Western Australia brought in the target, waiting times for patients wanting beds in emergency departments had fallen 30 per cent.

“What we need to look at is how we deliver care in emergency departments now and what we need in four to five years’ time,” says Associate Professor Julie Considine. She holds a joint appointment between Northern Health in Melbourne and Deakin University, where she provides academic, clinical and professional leadership, builds research capacity and integrates evidence into clinical practice.

“There are many issues to be addressed, such as the lack of beds in general hospitals, which leaves patients in emergency departments who should be moved, thereby creating a delay in attending to new patients,” says Considine. “The whole health system needs to take some responsibility regarding the situation of the emergency departments.

“Nurses are the largest and most constant workforce in hospitals and I believe that the role of nurse practitioner is a key position going forward – but it also creates the issue of who will pick up the slack of the work that they were doing.”

A nurse practitioner is a registered nurse educated to a master’s degree level and authorised to function autonomously and collaboratively in an advanced and extended clinical role.

The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills; it may include the direct referral of patients to other healthcare professionals, prescribing medications and ordering diagnostic investigations.

“Australian nurses are amongst the best educated in the world and we want to keep it that way,” Considine says, who herself has a clinical background in emergency nursing over two decades.

“Nurses in emergency departments spend more time with patients than anyone else and will know if the symptoms are progressively getting worse. We need to widen their scope of work to help. We also need more hospital staff in emergency departments, such as orderlies and people in administration.

“There is a high burnout with nurses in emergency departments due to the physical, emotional and mental stress.”

Dianne Crellin, executive director of the College of Emergency Nursing Australasia and an emergency nurse practitioner, says: “There are always areas to improve. You can have up to 200 patients a day in an emergency department and that really affects the capacity to care when issues such as workflow and staff capacity need to be addressed.

“Nurses do a great job under intense pressure, and I believe if we extended the scope of their role it would help everyone – from the patients to the doctors.

“If more nurses, with the proper training, were able to prescribe medication, it could result in more timely access to medical care.”

The debate over improvements will continue for some time, but the emergency department is only one department of a hospital, and part of a bigger health system with multiple issues needing to be addressed.

Federal funding fight
• Emergency departments throughout New South Wales will be at risk of bed closures if the federal government fails to renew funding agreements set to expire in June next year, says NSW Premier Barry O’Farrell. “Without these funds, beds will close,” he said. “That means people will wait longer for elective surgery, people will wait for longer in emergency departments and wards will close – it’s as simple as that.”

Child-friendly triage

Canberra Hospital’s emergency department may be made child-friendly, with the federal government’s recent announcement of a $5 million commitment to build a waiting, triage and treatment area specifically for children. The commitment, which is tied to Labor being re-elected, would see children treated and moved through the department more quickly.

Award for regional ED work
• An emergency department clinical nurse specialist has been selected as a category winner in the 2012 WA Nursing and Midwifery Excellence Awards. Kelly-Ann Hahn from the Royal Perth Hospital was recognised for her work implementing a triage program in regional EDs. Hahn has also been involved in the Nursing and Midwifery Nursing Rotational Program, which offers unique travel and lifestyle opportunities with clinical development experience.

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