Access Block (or Emergency Access Performance – EAP) can result in emergency department (ED) delays, poor patient outcomes and prolonged inpatient length of stay (Kelly et al 2007, Bauman et al 2004, Richardson 2002, Cameron et al 2002, Derlet et al 2000).

In approaching Winter 2007, Maitland Hospital, a 152 bed acute facility was experiencing problems with EAP sustaining levels below 65% with a benchmark of 80%.

Using a collaborative approach between the Lower Hunter Cluster and Maitland Hospital, cost efficient strategies were implemented to enhance patient flow.

Outcomes include enhanced cross sector communication mechanisms, an improvement in Maitland Hospital's EAP by 19% to 84% in two months despite increased ED presentations and a reduction in the average length of stay at Kurri Kurri Transitional Care Unit (TCU) from 149 days to 24 days.

To improve patient access within the Lower Hunter during Winter 2007 cost efficiently while:

• improving EAP to 80% benchmark at Maitland Hospital
• reducing LOS at Kurri Kurri TCU X 50 days

Approaching Winter 2007, Maitland Hospital was experiencing problems with EAP (transfer of patient from ED to ward within eight hours) sustaining 64% in July 2007 - 15% below the benchmark of 80%.

As the regional referral centre in the Lower Hunter region, it was important that patient access to Maitland Hospital was maintained particularly in anticipation of the expected seasonal winter increase in ED attendances and hospital admissions.

Recently established communication meetings between Maitland Hospital and the Lower Hunter Cluster (Cessnock, Kurri Kurri, Singleton and Dungog Health Services and Lower Hunter Community Health) identified the need for enhanced support from the cluster particularly during the busy winter period.

1. EAP Maitland Hospital
   • EAP had been trending poorly at Maitland Hospital in comparison with other Acute Hospitals – see Graph 1.
     
     

     Graph 1. EAP Southern HNE Acute Hospitals Aug 2006 – July 2007
     

2. Post Acute Community Care Service (PACC)
   • Maitland Hospital’s PACC Team provides a home based acute care community service to patients who may have otherwise required hospital admission and also to promote early hospital discharge. Admissions to service had steadily increased since establishment, however in the previous two years there had been a levelling in numbers due to fixed staffing. (11 per cent of patients were not accepted to the service due to limited capacity.)
3. Length of Stay for Placement Patients
   • A survey of hospital patients awaiting residential placement (nursing home/hostel) in the Lower Hunter in June 2007 identified two patients awaiting placement at Maitland Hospital compared to 29 patients in the cluster.
   • In the 10 bed Transitional Care Unit at Kurri Kurri Hospital some patients were waiting for placement >6 months with an average length of stay of 149 days.
     
     
     Graph 2. Length of Stay Transitional Care Unit Kurri Kurri Hospital Aug '06 – June ‘07
      

This project is aligned with a number of plans:

• NSW State Health Plan. Strategic Direction Number 5: 'Make smart choices about the costs and benefits of healthcare'. Our goal was to sustain ED access for patients during a busy winter period as cost efficiently as possible, making the most effective use of finite resources available to meet healthcare needs.
• HNE Strategic Plan - Improved equity of access
• HNE Balanced Scorecard - Emergency Access Performance indicator
• HNE Annual Operations Plan 2007-2008
• NSW Health Sustainable Access Plan

1. Formal Communication Mechanisms
   • Regular cross-sector communication meetings between Maitland Hospital and the Lower Hunter Cluster were established allowing access and patient flow issues to be identified and solutions sought.
2. Escalation Strategies
   • High level escalation of bed block issues from Maitland Hospital to the cluster and visa versa was implemented.
   • The cluster GM was notified daily of Maitland Hospital’s EAP and bed status.
   • Bed management escalation plans were activated as appropriate.
3. Care Placement Coordinator Position
   • Winter Strategy funding was approved to commence a Care Placement Coordinator position focusing on placement of Nursing Home and Hostel patients covering Cessnock and Kurri Kurri Hospitals.
   • Established care placement processes from the Short Term Resident Accommodation Service at Newcastle were utilised to expedite placement and documentation modified to align with the Lower Hunter Cluster.
   • In consultation with the NUMs, a flowchart was developed for the placement process and information folders established in each unit.
4. PACC Team Management Re-Alignment and Winter Enhancements
   • Line management of the PACC Team was transferred to Community Health to enable capacity building and support at times of increased activity. (Lower Hunter Community Services also had the ability to readily increase clinical positions of the PACC Team for short durations such as winter - at the time not possible at Maitland Hospital.)
   • Additional positions to the Team approved as Winter Enhancements included:
     • 0.5 FTE Physiotherapist
     • 0.5 FTE Occupational Therapist
     • 3.0 FTE Registered Nurses (The additional nursing positions were activated with the support of the Lower Hunter Community Health)
5. Additional Beds at Kurri Kurri Hospital - the capacity to flex up beds as required was approved as a winter strategy but utilised infrequently.

1. Improved EAP - Maitland Hospital
   • EAP at Maitland Hospital increased from 64.9% in July ‘07 to 84% in September ‘07. (See Graph 3.)
     
     
     Graph 3. Maitland Hospital EAP August 2006 – May 2008
2. Increased PACC Referrals
   • PACC Team referrals increased from 41 in July 2007 to 78 in August and 84 in September 2007 and have sustained increased referrals since Winter 2007.
     
     
     Graph 4. PACC Referrals January 2006 – June 2008
3. Decreased Length of Stay TCU Kurri Kurri Hospital
   • 26 patients were placed in the first month of implementation of the Care Placement Coordinator position indicating issues related to process as opposed to lack of available hostel or nursing home beds.
   • Average length of stay in the Transitional Care Unit at Kurri Kurri Hospital decreased from 149 days (June 07) to 24.67 days (Jan 08) – better outcome for patients and increasing bed capacity.
     
     
     Graph 5. Average LOS Transitional Care Unit KKDH August 2006 - April 2008
4. Cost Analysis
   • The average operational costs of a 10-bed unit over a three-month winter period would equate to approximately $695,000 (SAP Funding Model).
   • Lower Hunter Cluster winter strategies operational costs following establishment were $215,000 as below with potential savings of $480,000.

Without these strategies, the significant growth in ED presentations to Maitland Hospital during 07/08 could not have been accommodated. The traditional approach to winter strategy in the acute sector has included the opening of additional hospital beds at a significant cost. What this project has demonstrated is that a cross-sector collaborative approach to patient flow and access can achieve desired outcomes at a significantly reduced cost.

• Resultant from the significant success of these strategies, the Care Placement Co-ordinator and enhanced PACC positions have been sustained with HNE Health executive approval with a view to permanent implementation.
• The PACC Team has also commenced a Transitional Aged Care Program in the community with 15 funded places to further assist with early discharge strategies.
• The cross-sector communication meetings remain in place.
• The cluster continues to monitor Maitland Hospital’s EAP on a daily basis and early bed escalation strategies continue.
• Maitland Hospital has sustained good EAP performance despite increases in ED presentations.

Minimisation of access block is a focus for many NSW Health Acute Hospitals. The flow-on effects of access block can result in increased inpatient length of stay, increased ED waiting times and decreased efficiency and quality of care (Kelly et al 2007, Bauman et al 2004, Richardson 2002, Cameron et al 2002, Derlet et al 2000). The traditional approach to winter strategy in the acute sector has included the opening of additional hospital beds at a significant cost. What this project has demonstrated is that a cross-sector collaborative approach to patient flow and access can achieve desired outcomes at a significantly reduced cost and would be transferable to other sectors in health.

General Manager, Lower Hunter Cluster
Hunter New England Local Health District
Phone: 02 4991 0411