Wednesday, 16 April 2014

The Doctor Won't See You Now

  1. Are low socioeconomic groups causing long wait times in Australia's public hospital emergency departments by presenting with matters that should be dealt with elsewhere?
  2. Are there any (business) opportunities to reduce this?
People who claim metropolises and bazaars are the world's 'melting pots' have never waited in a hospital emergency department.


There you will see the rich, poor, bleeding, incapacitated, lively, quiet, obnoxious, with varying skill levels in English. And that's just the staff. (Drum roll.)

Anecdotal waiting times for treatment are long. 3 hour 3am horror stories seem standard. And when people experience more than 30 minutes of glacial queues - punctuated with scrambling out to move the car - their minds will drift from problem, to solution, and when none is found, to blame.

Triage is where your wandering mind will realise that you never knew so many 'x' people existed. It is there that a desire to be of public service will meet and romance xenophobia. 'They' should be seeing a GP rather than clog up emergency.

Source: AIHW 2013. Australian hospital statistics 2012-13: emergency department care. Health services series 52. Cat. no. HSE 142. Canberra: AIHW.

Caught between a Doc and a Hard Place

In depth studies of  'Potentially avoidable GP-type presentations' - having triage category of Semi-urgent (4) and Urgent (5) - are yet to be conducted. That said, GP type presentations in 2013 (2,176,612) accounted for 33% of admissions 6,573,893. While this is a large proportion, it is not safe to base an assumption that any one person's matter is inappropriate for the hospital.

Triage CategoryTarget Waiting MinutesEmergency Department Admissions 2012-2013% Seen on TimeMedian Waiting Time90th Percentile waiting time
1. Resuscitation045,12510000
2. Emergency 10711,92482517
3. Urgent 302,297,619681983
4. Semi-urgent602,924,5817229124
5. Non-urgent120591,4279125117
Total6,573,8937319101

Furthermore, hospitals are accommodating all triage categories with a level of success that would not suggest a crisis.

The proportion of Non-urgent admissions is a fraction of the next higher: Semi-Urgent. Were people recklessly appearing at emergency, it would be as high, or higher. It appears that Australians then generally avoid squandering the public medical purse. If anything, it indicates difficulty distinguishing between urgent and semi-urgent. Perhaps diagnostic education would empower individuals, or perhaps this assessment should remain the domain of health professionals. Another possible cause for the relatively overloaded Urgent and Semi-urgent categories is resourcing for treatment. Presumably, people in lower categories have less need to wait for machines, and can be dealt with faster.

That said, waiting a median of 30 minutes or even 2 hours for a semi-urgent matter is hardly a blow out. My compassion makes me sympathetic, but the numbers say, "Toughen up, Princess."

But surely wait times could be improved if the poor and uneducated were removed by some modest Swiftian proposal from the system. After all, people from the lowest socioeconomic areas accounted for 24% of GP-Type matters where the wealthiest accounted for just 15%.

It ain't me, I ain't no Fortunate One

Indigenous StatusPotentially Avoidable GP-type Presentations
Indigenous95,561
Other Australians(c)2,081,051

Lest we prematurely scorn unfortunates, there are no published tables on the total admissions by socioeconomic area. But perhaps we could extrapolate from data on emergency department visits by Australian Aborigines, arguably the most disadvantaged 3% of the Australian population. Indigenous people accounted for 5.3% of all hospital admissions, but 4.6% of GP-type admissions. The poor then, could make more unnecessary visits simply because they also make more necessary ones.

Simply targeting patients from low socioeconomic areas will not work (and is ethically dubious) as emergency wait times are caused by rich as well as poor, making any assumption that ignorance causes the long wait even less likely. Surely everyone by now must believe that going to emergency means hours of waiting. If we assume - as we do in many other areas - that market conditions are efficiently communicated, then the decision to attend emergency and withstand if not exacerbate the waiting times may be rational because alternatives are less palatable. Perceptions of exorbitant car park fees and tortuous waits may still compare favourably to making an appointment days later with your own GP. Rest and fluids may be the perfect cure, but only a doctor's cert will enable you to claim sick leave or compensation.

Alternative medicine

The data can quash socioeconomic opportunities but raise others. 11% of all admissions are for patients between 0 to 4 years of age. Double most other 5-year age brackets.
Emergency department presentations, by age group and sex, public hospital emergency departments, 2012–13
Weekends and mornings are particularly busy for emergency departments. Note too the spike in the proportion of Semi/Non-Urgent presentations between 9 and 5 am. Though too inconclusive to diagnose Monday-itis, investigating relations between spikes in hospital admissions to business times could yield results.
Proportion of presentations, by hour of presentation for each triage category, public hospital emergency departments, Australia, 2012–13
Proportion of presentations by day of the week and time of presentation , public hospital emergency departments, 2012–13 (per cent)

Proportion of presentations by day of the week and time of presentation , public hospital emergency departments, 2012–13 (per cent)

Can I get a second opinion?

Some bad news first: treatment times are longer than waiting times. This supports the notion that bottlenecks lie further along the process and thus increases the difficulty of finding solutions that lie outside the hospital system. Any attempts to reach the National Emergency Access Target (NEAT) - 90% patient discharge or referral within 4 hours - by attacking waiting times is wasted focus.
Emergency Department Presentation Length of Stay 2012-2013 (minutes)

The good news: the perceived problem is diminishing. Emergency waiting times are in fact shrinking across Australia.
Emergency presentation waiting time statistics, public hospital emergency departments, 2008–09 to 2012–132008–092009–102010–112011–122012–13
Proportion seen on time (%)7070707273
Median waiting time to service delivery (minutes)2323232119
90th percentile waiting time to service delivery (minutes)119115114108101

But if you can't sit by and, well, wait, then I have three broad suggestions from my time on a service desk.

Education

Examples: Advertisements, Websites, Apps. As there is no identifiable group responsible for the long wait times, the target must be broad. However, the subject can be focussed - for example, how to distinguish between urgent and non-urgent. Education must not be wholly passive. No one will visit a website or download an app without external stimuli. Education can be an excellent diversion.

Diversion

HealthDirect, the Freecall number manned by nurses is an example. Diversion or streaming should occur before the patient has invested in waiting in emergency. The best diversion occurs at the point the decision is made to attend hospital. The alternative must also meet the patient's needs in a similar or better way. Referral to a GP who is closed, or further away will not suffice, nor will a suggestion to simply rest when a doctor's cert is required for work the next day. Otherwise, patients would simply remain in triage frustrating themselves and staff.

Transparency

Example: wallboards, statistics, queue ticket machines. If people are already frugal about visiting hospital this will not impact waiting times, but it will improve the waiting experience. If you knew you would be spinning your wheels for an hour you could bring some work while accompanying your wife or child. Knowing how many hundreds were being cared for as you wait might bring patience. Finally, having a numbered place in the queue makes it easier to tolerate the queue.

How long have you waited in emergency? In the minute you take to comment, 12 people will have passed through Australia's emergency departments.

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