Asplin, B and Knopp, R (2001). "A room with a view: On-call specialist panels and other health policy challenges in the emergency department." Annals of Emergency Medicine 37(5): 500-3.

Paramedics respond to a 911 call for a patient with a head injury. They initiate appropriate treatment and begin transport; however, they soon learn that the destination hospital's ED is "on divert," forcing them to transport the patient to the city's only remaining open ED. This requires an additional 15-minute transport, and the ambulance is out of its service area for an extra 45 minutes.
In the ED, paramedics note the long row of gurneys in the hallway, signaling that this ED may soon need to divert ambulances. Some patients have been waiting 4 to 5 hours to be seen. Others have been admitted but must wait in the ED because there are no beds available in the hospital. The nurse who greets the patient and paramedics is a per diem nurse on his third ED shift, and he is still unfamiliar with the department's operating procedures. The ongoing nursing shortage has forced the hospital to use at least one per diem nurse for each ED shift.
An emergency physician evaluates the patient, initiates treatment, and asks the clerk to page the neurosurgeon on call. Repeated efforts to page the on-call physician are unsuccessful. Despite the Emergency Medical Treatment and Active Labor Act (EMTALA), problems with on-call physician response have continued to worsen. It is, however, hard to criticize this physician; he is one of the few remaining neurosurgeons who agrees to be on call for the ED. After 2 hours, he responds and agrees to admit the patient to the ICU. Unfortunately, there are no ICU beds available. The closure of a hospital in the area 2 years ago reduced the ICU bed capacity for the city, and since that time, patients require increasingly long stays in the ED waiting for a bed. After several telephone calls with the nursing supervisor, a bed becomes available, and the patient is admitted 7 hours after arriving in the ED.

Audit Office of New South Wales (1998). Performance Audit Report. Hospital Emergency Departments. Planning Statewide Services. Sydney, Audit Office of New South Wales: 1-66.

This audit reviews the NSW Department of Health's (the Department's) approach to planning for the provision of emergency department services, the coordination of services and the impact of initiatives to address system wide problems. Future performance audits will examine the management of
emergency department services, the efficiency and effectiveness of service delivery and relationships between emergency departments and other health service providers. Specifically, the focus of the audit was on determining whether:
1. The Department's plan for the provision of emergency department services is effective and able to respond to changes in demand
2. In planning for the provision of emergency department services, the Department would consider:
*strategic plans prepared by the NSW Ambulance Service
*the impact of private emergency departments
3. The Department produces guidelines to assist Area Health Services to determine the appropriate level of emergency department services to match community needs
4. Initiatives introduced by the Department to improve the performance of emergency departments are effective.

Audit Office of New South Wales (2000). Performance Audit Report. Hospital Emergency Departments. Delivering Services to Patients. Sydney, Audit Office of New South Wales: 1-85.

This audit is the second performance audit report of emergency department services in NSW public hospitals. The first report, Hospital Emergency Departments Planning Statewide Services tabled in October 1998, examined the approaches to planning for the provision of services, the coordination of services and the impact of initiatives to address system wide problems.
This performance audit examines factors that impact on patient flow through the emergency department from arrival to discharge or admission to hospital. This audit examined the operations of nine emergency departments in principal referral, metropolitan and rural hospitals.
The audit focused on determining whether:
1. Emergency departments manage patient flow efficiently and meet benchmarks for waiting times
2. An efficient and effective relationship exists between staffing levels, mix of staff and workload
3. Systems are in place to ensure the provision of high quality services to patients
4. Management of the emergency department facilitates the effective and efficient treatment of patients.

Audit Office of New South Wales (2001). Performance Audit Report. Ambulance Service of New South Wales. Readiness to Respond. Sydney, Audit Office of New South Wales: 1-115.

This performance audit examines the efficiency and effectiveness of staff deployment practices and systems within the NSW Ambulance Service (the Service). The audit considers, inter alia, the extent to which resources are managed to meet variations in demand for services. It also examines resource modelling, rostering, aspects of leave and work practices, training, structural matters and alternate resource options. Governance and ethics issues are canvassed, as is the key issue of how effectively ambulance operations are integrated within the NSW health system.

Baggoley, C, Phillips, D, et al. (1994). "A study of emergency admissions at the Flinders Medical Centre using the Appropriateness Evaluation Protocol." Emergency Medicine 6: 29-36.

Analysis of 3046 consecutive admissions through the Emergency Department at Flinders Medical Centre was performed to determine whether they were valid acute admissions. The study period was 15th December 1992 to 28th February 1993. There was an average of 40.1 admissions from just over 140 presentations per day during this period.
The admissions were reviewed against a modification of the Appropriateness Evaluation Protocol (AEP). This Protocol has been evaluated in a study for the Clinical Advisory Committee of the South Australian Health Commission. The modifications involved adding to the survey form criteria which had been accepted as overriding clinical reasons for admission in the Evaluation of the AEP report and conducting the survey prospectively as patients were admitted, rather than in a retrospective manner.
Analyses were made of the day and time of the day of admission. A separate analysis was conducted of patients referred by general practitioners (GPs). The busiest days were Sunday, Tuesday and Thursday, the busiest time for admission was 1600 to 2000 hours. For GP referred patients the quietist day was Sunday.
Particular analyses were conducted on those criteria which had been added to the original AEP and on those patients who met none of the criteria, by definition, non acute admissions.
There were very few non acute admissions through the emergency department. Only 83 patients (2.72%) met none of the 24 criteria, although many of these admissions could be justified on the basis that there were no viable alternatives to admission.
If the AEP is to be used, the method chosen consumed fewer resources and provided the opportunity for more immediate analysis and feedback than the previous study.

Baren, J, Shofer, F, et al. (2001). "A randomized, controlled trial of a simple emergency department intervention to improve the rate of primary care follow-up for patients with acute asthma exacerbations." Annals of Emergency Medicine 38: 115-22.

Study Objective: We determined whether a simple emergency department intervention improves the likelihood of primary care provider (PCP) follow-up after ED discharge for an acute asthma exacerbation.
Methods: This randomized, controlled clinical trial was conducted in an urban university-based ED. Participants were patients with asthma between the ages of 16 and 45 years who were treated and discharged from the ED. The study intervention was usual care or an intervention that consisted of a free 5-day course of prednisone, vouchers for transportation to and from their PCP, and a 48-hour telephone reminder to make an appointment with their PCP. The main outcome was whether the patient received follow-up care as determined by PCP contact at 4 weeks.
Results: One hundred ninety-two patients with asthma were enrolled over 8 months; 178 (93%) had complete follow-up. The intervention and control groups were similar with regard to age, sex, ethnicity, or years of education. The 2 groups were also comparable with respect to multiple measures of baseline access/barriers to care and severity of ED exacerbation. Patients receiving the intervention were significantly more likely to follow up with their PCP than control patients (relative risk 1.6; 95% confidence interval [CI] 1.1, 2.4). When adjusted for other factors influencing PCP follow-up care (ethnicity, prior PCP relationship, insurance status, regular car access), intervention patients were more likely to follow up with their PCP (odds ratio 3.1; 95% CI 1.5, 6.3).
Conclusion: Providing medication, transportation vouchers, and a telephone reminder to make an appointment increased the likelihood that discharged patients with asthma obtained PCP follow-up.

Bensberg, M (2000). Health Promotion in Emergency Departments Project. Melbourne, Department of Human Services.

This report outlines the findings of the project development phase of the Health Promotion in Emergency Departments Project.

Bensberg, M (2001). Health Promotion in Emergency Departments Program. Progress Report. Melbourne, Department of Human Services: 1-27.

This report outlines the progress to date of the Health Promotion in Emergency Departments Project. The aim of this report is to describe the progress of the program. It is about the achievements that the program and the seven participating emergency departments have made in the first six months of implementation, from December 2000 to May 2001. While the program is in its infancy, it is proceeding well.

Bolton, P, Mira, M, et al. (1997). "The Balmain Hospital General Practice Casualty: An alternative model of primary health care provision." Australian Health Review 20(1): 100-7.

The Balmain Hospital General Practice Casualty is a unique casualty style service, staffed and run by local general practitioners. It is a joint initiative of the Central Sydney Area Health Service and the Division of General Practice, Central Sydney Area, and is jointly funded by the Area Health Service and the Commonwealth. The casemix seen and type of services provided suggest that the service is intermediate
between that provided by general practitioners and that provided by emergency departments. The service is well accepted by patients and local general practitioners. A number of benefits are seen by both service providers and users in terms of continuity of care and increased general practitioner skills.

Bolton, P, Mira, M, et al. (2000). "Oranges are not the only fruit: The role of emergency departments in providing care to primary care patients." Australian Health Review 23(3): 132-6.

Effective and integrated primary health care services are seen world wide as the lynch pin of an equitable, efficient and high quality health care. Health services dominated by specialist care suffer either from uncontainable costs (USA with 14% of GDP) or poor quality care (Russia and other former members of the
Soviet bloc). Ierachi et al. (2000) argue that Australia should take the retrograde step of endorsing a service which aims to "provide rapid, high quality and continuously accessible unscheduled care, for conditions covering the full spectrum of acute illness and injury" (emphasis added). They aim to provide care "for conditions", not for people. General practice provides care for people, not just diseases or injuries.

British Association for Accident and Emergency Medicine (1989). Accident and emergency ward. BAEM website: 1-2.

This facility is an essential part of every Accident and Emergency (A & E) Department. The advantage of such a ward is that it provides expertise in the management of its typical patients. They stay in hospital for shorter periods than in other wards and are often better and more economically managed because of the use of Social and other liaison Services for crisis intervention. Such a ward provides a safety net for some patients who might otherwise be discharged injudiciously. Flexibility of use is also an important feature.

Bullard, M, Holroyd, B, et al. (2001). "Patients who leave without being seen in the emergency department." Academic Emergency Medicine 8(5): 576-7.

Objectives: Patients who leave without being seen (LWBS) constitute a problem for EDs due to their potential for increased morbidity and dissatisfaction. Few jurisdictions can accurately evaluate the pattern of LWBS for a large population; this study examines this ED subgroup using a provincial database.
Methods: All patients presenting to Alberta EDs were eligible for inclusion. Data were derived from a sample of ED patients treated in 17 health regions over 1 year (98/99) with a disposition code of LWBS. Data were extracted from the Ambulatory Care Classification System (ACCS) database, computerized abstracts coded similarly across all regions. Diagnostic categories were recorded using ICD-9 coding by medical nosologists and represented the primary physician discharge diagnostic code. Descriptive statistics and crude presentation rates are reported.
Results: Overall, 1.49 million ED visits were recorded; 18,672 (1.3%) LWBS cases occurred during that period. Young children (ages <5; 14%) and adults (ages 20-29; 23%) represent the largest percentage of cases. Elders (>64 years) represent <5% of the overall LWBS sample. Males (9,332; 50%) and females are similarly represented. Wide seasonal variation (34%) was observed and December rates were highest (9.7%). LWBS occur most frequently on Mondays (18%) and hourly trends demonstrate a bimodal pattern (peaks in the late morning and early evening hours). Most (16,460 {95%}) LWBS patients do not repeat this behavior, but 0.5% of individuals in the province have up to 4 LWBS events per year. The crude rates provincially are 5.7/1,000 ED visits; higher-than-average rates occurred in one of the two largest urban areas (population >500,000).
Conclusions: This study characterizes annual LWBS cases across a large population. These data suggest further detailed evaluation of LWBS may be fruitful, especially using linkages to other databases to determine eventual outcomes and subsequent health services utilization.

Clark, M, Purdie, J, et al. (1998). Emergency Pre-Hospital Ambulance Services. An Evaluation of Unmet Need. Queensland, Queensland Ambulance Service: 1-85.

This study is concerned with unmet need for ambulance services. In essence, the study is concerned with examining the extent to which people with urgent medical needs do not use an ambulance service and the reasons for their chosen method of arrival at hospital.

Clinical Advisory Committee (1991). Evaluation of the Appropriateness Evaluation Protocol (AEP). South Australia, South Australian Health Commission.

The evaluation of the adult Appropriateness Evaluation Protocol (AEP) is presented in this report. The SAHC Clinical Advisory Committee initiated the study to assess this form of utilisation review as a management instrument in clinical medicine.

Dale, J, Lang, H, et al. (1996). "Cost effectiveness of treating primary care patients in accident and emergency: A comparison between general practitioners, senior house officers, and registrars." British Medical Journal 312(7042): 1340-4.

Objectives: To compare outcome and costs of general practitioners, senior house officers, and registrars treating patients who attended accident and emergency department with problems assessed at triage as being of primary care type.
Design: Prospective intervention study which was later costed.
Setting: Inner city accident and emergency department in south east London.
Subjects: 4641 patients presenting with primary care problems: 1702 were seen by general practitioners, 2382 by senior house officers, and 557 by registrars.
Main outcome measures: Satisfaction and outcome assessed in subsample of 565 patients 7-10 days after hospital attendance and aggregate costs of hospital care provided.
Results: Most patients expressed high levels of satisfaction with clinical assessment (430/562 (77%)), treatment (418/557 (75%)), and consulting doctor's manner (434/492 (88%)). Patients' reported outcome and use of general practice in 7-10 days after attendance were similar: 206/241 (85%), 224/263 (85%), and 52/59 (88%) of those seen by general practitioners, senior house officers, and registrars respectively were fully recovered or improving (2=0.35, P=0.840), while 48/240 (20%), 48/268 (18%), and 12/57 (21%) respectively consulted a general practitioner or practice nurse (2=0.51, P=0.774). Excluding costs of admissions, the average costs per case were £19.30, £17.97, and £11.70 for senior house officers, registrars, and general practitioners respectively. With cost of admissions included, these costs were £58.25, £44.68, and £32.30 respectively.
Conclusion: Management of patients with primary care needs in accident and emergency department by general practitioners reduced costs with no apparent detrimental effect on outcome. These results support new role for general practitioners.

Department of Health (1999). Accident and Emergency Modernisation Programme: Interim Report to Ministers October 1999. United Kingdom, NHS Executive: 1-19.

In March 1999 the Government announced an investment of between £70 and £80 million in A&E departments, in addition to the previously announced £30 million. The total commitment in 1999/2000 is £115 million. As well as the investment in physical resources, the programme aims to identify and disseminate good practice and new ways of working to ensure that the organisation of A&E services, and the physical environment in which they are provided, give the maximum benefit to patients and staff.
Terms of Reference:
* Oversee the national A&E modernisation programme
* Identify best practice, and develop quality standards and performance indicators for A&E.
* Work with key professionals and advanced sites to develop new and better ways of organising Accident and Emergency services
* Provide leadership to the A&E beacons programme
* Report regularly to ministers on the team's progress
* To deliver the A&E modernisation programme according to the Terms of Reference
* Lead major innovative projects
* Sponsor and support regional work

Drummond-Fowler, S (1996). "A fresh approach to emergency care." Nursing Standard 10(35): 22-4.

The development of an improved service for patients attending A&E was not without its problems. But, as Sue Drummond-Fowler reports, the nurses met the challenge.

Hospital Demand Management Group (2001). Comparison of Emergency Services Performance in NSW. An Overview of Restricted Access. Melbourne, Department of Human Services: 1-18.

Following reports that NSW has made significant improvements in relation to hospital emergency services performance and in particular, Restricted Access (or Ambulance Bypass) a visit was arranged to discuss the operation and management of Ambulance Bypass in NSW. This paper is based on short discussions with senior personnel in NSW Health and Ambulance Service of NSW.

Hospital Demand Management Group (2001). Emergency Demand Management. A New Approach. Victoria, Department of Human Services: 1-18.

In the 2000-2001 budget, the Government invested an additional $176M in hospitals including a range of
strategies to manage demand for elective and emergency services.
Unprecedented emergency demand pressures continue and require new management approaches. Increasing waiting times in emergency departments and delays in admission to inpatient wards are not an emergency department problem and involve the management of patient care in all areas of the hospital. Accordingly, a hospital wide approach is needed, in fact, an approach which involves the full continuum of care in the health system.
The purpose of this document is to inform the sector about the new approach to demand management and the wide range of activities that have been put in place.

Fielden, N (1999). "Treatment of community-acquired pneumonia in the emergency department." Journal of Emergency Nursing 25(6): 461.

Clinical topic: The prevalence of community-acquired pneumonia (CAP) among adults with respiratory symptoms is estimated to be 28% in an ED setting, with approximately 20% of these patients requiring hospitalization. Mortality ranges from 2% to 30% among hospitalized patients. Investigations showed that early specific interventions, such as the ordering of cultures and the initiation of IV antibiotics in the emergency department, could reduce mortality, length of stay, and cost of care.
Implementation: The Pneumonia Project from the Ohio Peer Review System recommended the early administration of antibiotic therapy for CAP, within 4 hours of presentation to the emergency department. Other quality improvement initiatives included the development of a critical care path. This poster describes the process of managing the patient population of CAP in the emergency department using a clinical pathway and antibiotic algorithm. Guidelines from the American Thoracic Society for interventions in patients with CAP are described, including triage assessment for risk factors and signs and symptoms, and time to treatment in the emergency department for administration of antibiotics. Charts were reviewed from the first 2 quarters of 1997. Specific interventions, such as ordering of cultures and antibiotics in the emergency department, were compared. The results were shared with the physicians and nurses during the third quarter. Charts were reviewed from the last quarter of 1997 to note any improvement in ED interventions.
Outcomes: Fifty-two percent of the time, antibiotics were ordered in the emergency department in the first half of the year, with an improvement to 85% by the end of the year. However, administration of antibiotics in the emergency department within 4 hours of the patient's presentation to the emergency department decreased from 79% to 67% by the end of the year. Cultures were ordered 73% of the time in the first half of the year and 72% of the time in the last quarter of the year.
Recommendations: Further education of the nursing staff was needed to emphasize the importance of early initiation of antibiotics ordered in the emergency department prior to the patient's admission to the hospital. Use of the clinical pathway was also re-emphasized.

Gerbeaux, P, Ledoray, V, et al. (2001). "Medical student effect on emergency department length of stay." Annals of Emergency Medicine 37(3): 275-8.

Study Objective: Taking advantage of a medical student strike, the authors evaluated the effect of medical students on emergency department length of stay (LOS).
Methods: ED LOS and patient characteristics were compared for the 4-day strike period and the same days the week before. Proportions were compared by using the Mann-Whitney U test and the chi(2) test (P <.05).
Results: Eight hundred thirty-one patients were studied. There was no significant difference between the study and control periods for the general patient characteristics or laboratory or radiologic investigations. Median LOS decreased by 24% (31 minutes, 95% confidence interval [CI] 24 to 38) during the strike (110 minutes [95% CI 65 to 178] to 79 minutes [95% CI 40 to 135], P <10(-4)).
Conclusion: Medical students lengthen ED LOS. This should be explained to patients and should be considered as one justification for increasing medical staff in the teaching ED.

Gomez, M, Anderson, J, et al. (1996). "An emergency department based protocol for rapidly ruling out myocardial ischaemia reduces hospital time and expense: Results of a randomised study (ROMIO)." Journal of the American College of Cardiology 28: 25-33.

Objectives: We tested the hypothesis that an emergency department-based protocol for rapidly ruling out myocardial ischemia would reduce hospital time and expense but maintain diagnostic accuracy.
Background: Patients with a missed diagnosis of myocardial infarction have a high mortality rate; however, providing routine hospital care to low risk patients may not be time- or cost-effective.
Methods: One hundred low risk patients were entered into the study and randomized either to an emergency department-based rapid rule-out protocol (n = 50) or to routine hospital care (n = 50). Patients receiving routine care were managed by their attending physicians. The rapid protocol included serum enzyme testing at 0, 3, 6 and 9h, serial electrocardiograms with continuous ST segment monitoring and, if results were negative, a predischarge graded exercise test. Study patients were also compared with 160 historical control subjects.
Results: Myocardial infarction or unstable angina occurred in 6% of patients within 30 days; no diagnoses were missed. By intention to treat analysis (n = 50 in each group), the hospital stay was shorter and charges were lower with the rapid protocol than with routine care (p = 0.001). Among patients in whom ischemia was ruled out, those assigned to the rapid protocol had a shorter hospital stay (median 11.9 vs. 22.8 h, p = 0.0001) and lower initial ($893 vs $1,349, p = 0.0001) and 30-day ($898 vs. $1,522, p = 0.0001) hospital charges than did patients given routine care. In historical control subjects, the hospital stay was longer (median 34.5 h, p = 0.001 vs. either group) and charges greater (median $2,063, p = 0.001, vs rapid protocol, p = 0.02, vs. routine care group).
Conclusions: In low risk patients who present to the emergency department with chest pain, the rapid protocol ruled out myocardial infarction and unstable angina more quickly and cost-effectively than did routine hospital care.

Grantham, H (1994). "A general practitioner's guide to emergency services." Australian Family Physician 23(2): 129-33.

Emergency services are a diverse group of agencies that have evolved in response to local needs. Dealing with emergency services at an accident site can be difficult for medical officers who are unfamiliar with the services. The best way of improving this situation is to meet with the emergency services first and prepare by joint training with them.

Grouse, A and Bishop, R (2001). "Non-medical technicians reduce emergency department waiting times." Emergency Medicine 13(1): 66-9.

Objective: To observe the impact of trained non-medical technicians on emergency department waiting times. The technicians were to perform minor procedures that had previously been performed by medical staff.
Methods: A prospective cohort study with two matched groups of patients. One group comprised patients who presented to the emergency department on days when the technicians worked (working group) and the other comprised patients who presented when the technicians did not work (control group). The waiting times for patients in each group were compared.
Results: The median waiting time was 10 min shorter in the working group than the control group (P < 0.0001). This reduction was confined to triage categories 3 and 4. The number of patients who left without being seen was reduced from 8.2% in the control group to 5.3% in the working group (P < 0.00001).
Conclusion: When added to the normal staff complement, non-medical technicians reduce patient waiting times in the emergency department.

Herren, K, Mackway-Jones, K, et al. (2001). "Is it possible to exclude a diagnosis of myocardial damage within six hours of admission to an emergency department? Diagnostic cohort study." British Medical Journal 323(7309): 372-.

Objective: To assess the clinical efficacy and accuracy of an emergency department based six hour rule-out protocol for myocardial damage.
Design: Diagnostic cohort study.
Setting: Emergency department of an inner city university hospital.
Participants: 383 consecutive patients aged over 25 years with chest pain of less than 12 hours' duration who were at low to moderate risk of acute myocardial infarction.
Intervention: Serial measurements of creatine kinase MB mass and continuous ST segment monitoring for six hours with 12 leads.
Main outcome measure: Performance of the diagnostic test against a gold standard consisting of either a 48 hour measurement of troponin T concentration or screening for myocardial infarction according to the World Health Organization's criteria.
Results: Outcome of the gold standard test was available for 292 patients. On the diagnostic test for the protocol, 53 patients had positive results and 239 patients had negative results. There were 18 false positive results and one false negative result. Sensitivity was 97.2% (95% confidence interval 95.0% to 99.0%), specificity 93.0% (90.0% to 96.0%), the negative predictive value 99.6%, and the positive predictive value 66.0%. The positive likelihood ratio was 13.9 and the negative likelihood ratio 0.03.
Conclusions: The six hour rule-out protocol for myocardial infarction is accurate and efficacious. It can be used in patients presenting to emergency departments with chest pain indicating a low to moderate risk of myocardial infarction.

Heslop, L (1995). A poststructural analysis of contemporary understandings of emergency care. Nursing, Ethical and Social Processes. T Barnett. Churchill, Distance Education Centre, Monash University: 3-17.

This paper is a political and social analysis that explores the forms of knowledge at work in health care institutions and the way in which that knowledge constitutes the nurse as a subject and the patient as an object of that knowledge.

Hoffenberg, S, Hill, M, et al. (2001). "Does sharing process differences reduce patient length of stay in the emergency department?" Academic Emergency Medicine 8(5): 578.

Objective: To assess the ability of the best demonstrated processes (BDP) methodology to decrease emergency department (ED) patient length of stay (LOS) in the slowest EDs in a large multi-hospital system.
Methods: Two hundred ninety-one EDs were ranked by LOS and the fastest and slowest EDs were observed to identify the BDP. The resulting "meaningful differences" were shared with all EDs throughout the hospital system. LOS studies were repeated after the BDP intervention. Five separate LOS measures were performed over a 19-month period with 223 to 273 EDs participating in each measure. Three interval times were calculated: arrival to exam room, exam room to physician evaluation, and physician evaluation to discharge.
Results: Two hundred ninety-one EDs participated and 386,837 patient visits were evaluated. Prior to intervention, the average LOS was 147 minutes for all EDs and 186 minutes in the slowest third. Between the initial and final measurement period there was an 8-minute (5.4%) improvement in LOS on a system-wide basis and the slowest third of EDs improved LOS by 29 minutes (15.6%). Prior to intervention, arrival to exam room time was 27 minutes, exam room to physician evaluation was 20 minutes, and evaluation to discharge was 100 minutes. After intervention, these times decreased to 22 (p < 0.001), 18 (p < 0.001), and 99 (p = 0.33) minutes, respectively. The slowest one-third of EDs went from 37 to 24 minutes for arrival to exam room time (p <0.001), from 25 to 20 minutes room to evaluation (p < 0.001), and from 124 to 113 minutes for evaluation to discharge (p < 0.001).
Conclusions: Implementing observed best demonstrated processes meaningful differences resulted in decreased patient LOS in EDs, particularly in the slowest one-third of EDs in the hospital system.

Johnson, L, Taylor, T, et al. (2001). "The emergency department on-call backup crisis: Finding remedies for a serious public health problem." Annals of Emergency Medicine 37(5): 495-9.

In recent years, growing reports indicate that many emergency departments are losing the support of their hospital's medical staff for the provision of on-call backup services. Anecdotal evidence suggests that this is a national problem that has become an epidemic in states with high managed care penetration, such as California and Arizona. As the on-call problem continues to grow, it threatens the integrity of the entire emergency care system and must be addressed as a serious public policy issue.

Kilpatrick, E and Holding, S (2001). "Use of computer terminals on wards to access emergency test results: A retrospective audit." British Medical Journal 322: 1101-3.

Objective: To assess delay in clinicians obtaining emergency biochemistry test results when the telephoning of results by laboratory staff is supplanted by installation of computer ward terminals.
Design: Retrospective observational study.
Setting: Accident and emergency department and acute medical admissions ward of a teaching hospital.
Sample: 3228 emergency requests for biochemistry tests sent from the accident and emergency department and 1836 from the medical admissions ward during August 1999 to January 2000 when there was no recorded telephone contact for results.
Main outcome measures: Proportion of emergency biochemistry results accessed via a ward terminal within 1 or 3 hours of becoming available and the proportion never seen by this means.
Results: The results from 1443/3228 (45%) of urgent requests from accident and emergency and 529/1836 (29%) from the admissions ward were never accessed via the ward terminal. Results from 794/3228 (25%) of accident and emergency requests and 413/1836 (22%) of admissions ward requests were seen within 1 hour of becoming available while a further 491/3228 (15%) and 341/1836 (19%) respectively were accessed between 1 and 3 hours. In up to 43/1443 (3%) of the accident and emergency test results that were never looked at the findings might have led to an immediate change in patient management.
Conclusions: When used as the sole substitute for telephoning results, the provision of terminal access to laboratory results on wards can hinder rather than promote the communication of emergency blood results to healthcare staff.

Lane, D, Monefeldt, C, et al. (2000). "Looking in the wrong place for healthcare improvements: A system dynamics study of an accident and emergency department." Journal of the Operational Research Society 51: 518-31.

Accident and Emergency (A&E) units provide a route for patients requiring urgent admission to acute hospitals. Public concern over long waiting times for admissions motivated this study, whose aim is to explore the factors which contribute to such delays. The paper discussed the formulation and calibration of a system dynamics model of the interaction of demand pattern. A&E resource deployment, other hospital processes and bed numbers; and the outputs of policy analysis runs of the model which vary a number of the key parameters. Two significant findings have policy implications. One is that while some delays to patients are unavoidable, reductions can be achieved by selective augmentation of resources within, and relating to, the A&E unit. The second is that reductions in bed numbers do not increase waiting times for emergency admissions, their effect instead being to increase sharply the number of cancellations of admissions for elective surgery. This suggests that basing A&E policy solely on any single criterion will merely succeed in transferring the effects of a resource deficit to a different patient group.

Lee, A, Lau, F, et al. (1999). "Measuring the inappropriate utilization of accident and emergency services?" International Journal of Health Care Quality Assurance 12(7): 287-92.

Accident and Emergency (A&E) departments are increasingly popular venues for primary care, causing a serious threat to healthcare quality. This paper reports the development of a comprehensive research method for identifying primary care patients attending A&E. Patients were randomly selected from the four A&E departments across different time periods and different regions in Hong Kong. The definition of GP cases was based on a retrospective record review conducted by a panel of emergency physicians using the standard laid down by the Hong Kong College of Family Physicians. The patients sampled were similar in sex and age distribution to A&E attendees for the whole territory. The level of GP cases was found to be 57 per cent, with a significantly higher proportion of patients in the younger age group. The high level of use reflects the lack of a well co-ordinated development of primary care services and interfacing with secondary care.

McDermott, M, Grant, E, et al. (1999). "Asthma care practices in Chicago-area emergency departments." Chest 116(4 - suppl 1): 167S-173S.

Introduction: Emergency departments (EDs) represent an important source of asthma care, yet there are few studies detailing how ED asthma practices vary and to what extent EDs meet expectations of national asthma guidelines. The purpose of this study is to characterize ED care for persons with asthma in a single large community.
Methods: During 1996 and 1997, a cross-sectional, self-administered survey to characterize asthma care practices was conducted among medical directors of the 89 EDs serving the Chicago metropolitan area (six counties). The survey topic areas included asthma-specific demographics and selected utilization statistics; assessment practices; treatment practices; discharge and follow-up activities; and familiarity with, attitudes toward, and utilization of guidelines/protocols.
Results: Sixty-four EDs completed surveys, for a response rate of 71.9%. Ninety-four percent of the respondents were ED medical directors. As part of assessment, peak flow measurements, while common, were used less frequently than pulse oximetry. The average (+/- SE) estimated length of stay for asthma care was 3.0 +/- 0.1 h, and average disposition time (ie, the decision to admit) was 2.5 +/- 0.2 h. Systemic steroids (either IV or po) were estimated to be given to 73.2 +/- 3.9% of patients during their ED visits. Systemic steroids were prescribed for 55.9 +/- 3.5% of patients at time of discharge. Only 57.0 +/- 5.4% of patients were estimated to have received any type of written asthma educational materials. Approximately 25% of patients were reported to have been given a detailed follow-up appointment at the time of discharge.
Conclusion: The results reveal that the medical directors reported many of the Chicago-area EDs as providing asthma care that is consistent with key aspects of national guidelines. However, in certain critical areas of care, the EDs demonstrate a high degree of variation, often with the community falling short of guideline recommendations. By identifying these variations in asthma care, it is now possible to target specific goals for community-wide asthma quality improvement among the EDs in the Chicago metropolitan area.

Miller, D, Lewis, L, et al. (1996). "Controlled trial of a geriatric case-finding and liaison service in an emergency department." Journal of the American Geriatrics Society 44(5): 513-20.

Objective: To evaluate the effects of a program of case-finding and liaison service for older patients visiting the emergency department.
Design: Nonrandomized controlled trial with systematically assembled intervention cohort and matched control group.
Setting: An urban teaching hospital.
Participants: There were 385 intervention subjects aged 65 years and older and 385 control subjects matched by day of visit, gender, and age within 5 years.
Interventions: Geriatric medical, dental and social problems were identified in intervention subjects by a geriatric nurse clinician using well validated assessment instruments during a 30-minute evaluation. Recommendations were made to the patient, family, and attending emergency department physician, and attempts were made to arrange appropriate follow-up services.
Measurements: Frequency with which geriatric problems were identified in intervention subjects; physician, patient, and family compliance with recommendations; and mortality, institutionalization, health status, use of medical and social services, presence of an advanced directive, and quality of life at 3-month follow-up.
Results: Sixty-seven percent of patients were dependent in at least one activity of daily living, 82% had at least one geriatric problem identified, and 77% reported at least one unmet dental or social support need. The cost of identifying geriatric and dental/social issues was $5 and $1, respectively, for each problem. Physicians compiled with 61.6% of suggestions, and patients and families complied with 36.6% of recommendations. Mortality and nursing home residence proportions at 3 months were not significantly different (9.3% vs 9.7% and 5.0% vs 2.5% in intervention and control groups, respectively). Intervention subjects reported more difficulty communicating (21% fair or poor ability vs 13%, P = 0.2) than did control subjects. There were strong trends for fewer subsequent visits to emergency departments (0.26 intervention vs 0.39 control, P = .06) and more advance directives in the intervention group (6.7% intervention vs 2.9% control, P = .07). There was no statistically or clinically significant difference in any other health outcome. The number of new dental or social services initiated per patient over the 3-month follow-up was nearly identical (1.7 in the intervention group vs 1.5 in the control). Results in subjects aged 75 years and older and those discharged home from the emergency department were essentially identical to those in the main group.
Conclusions: Numerous previously unrecognized geriatric medical and social problems can be detected in older persons visiting the emergency department. Despite this, an emergency department-based geriatric assessment and management program failed to produce improved outcomes. This suggests that either disease acuity is an overwhelming factor in subsequent outcome or, alternatively, more control over medical and social service delivery during and after the emergency department visit than was demonstrated in this program will be required before successful outcomes can be assured.

Ministerial Taskforce on Trauma and Emergency Services (1999). Review of Trauma and Emergency Services Victoria 1999. Melbourne, Department of Human Services.

EXECUTIVE SUMMARY
Background: Support has grown over recent years for the development of an integrated trauma system in Victoria. There are some indications that major trauma outcomes in Victoria are better than those in North America (Cameron et al., 1995), however research over the last five years has identified a number of system-wide deficiencies adversely impacting on the outcomes for severely injured patients.
A number of studies have drawn attention to this issue. The Consultative Council on Road Traffic Fatalities identified potentially preventable outcomes contributing to death in up to 38 per cent of road traffic fatalities in Victoria (McDermott et al. 1996, McDermott et al., 1998). The Major Trauma Management Study (Danne et al., 1998) identified similar potentially preventable outcomes from all aetiologies of trauma, as well as potentially preventable complications in survivors.
Both of these studies demonstrated recurring deficiencies in trauma management and system response. Problems were identified from the initial response through to definitive treatment, in both metropolitan and rural areas. Examples of these deficiencies were:
Inadequate availability of prehospital and emergency department advanced life support skills.
Prolonged times at the scene of accidents.
Inadequate reception in emergency departments by junior staff and delayed investigation and surgical consultation.
Triage of patients to hospitals without optimal skills or resources to manage time-critical major trauma patients.
Delays in, and inadequate medical escort for, rural and metropolitan interhospital transfer of major trauma patients.
Recognising the size and complexity of the task of developing an integrated trauma system across Victoria, the Minister for Health, the Hon Robert Knowles MP, established a review of trauma and emergency services in July 1997. The purpose of the review is to advise Government on an appropriate system-wide structure, arrangements for ongoing monitoring of the accessibility and responsiveness of emergency and trauma services, and education and training issues.
The benefits of creating an integrated trauma and emergency system were foreshadowed in the Metropolitan Health Care Services Plan, released by the Department of Human Services in 1996.
The concept of an integrated trauma system that matches the needs of injured patients to an appropriate level of treatment is formally supported by a number of colleges and organisations, including the Royal Australasian College of Surgeons, the Australasian College for Emergency Medicine, the Consultative Council on Emergency and Critical Care Services, the Australian and New Zealand College
of Anaesthetists, Metropolitan Ambulance Service, and the Neurosurgical Society
of Australasia.
Review Process: A Ministerial Taskforce and a Departmental Working Party were established to assist this review: the Ministerial Taskforce on Trauma and Emergency Services and the Working Party on Emergency and Trauma Services. In forming the membership of these committees, every effort was made to draw on a cross-section of knowledge and expertise across all relevant organisations and constituencies. Members were appointed as individuals rather than as representatives of any particular constituencies or organisations.
The Ministerial Taskforce on Trauma and Emergency Services and the Working Party on Emergency and Trauma Services worked closely together to develop recommendations for the future restructuring of the trauma system.
Ministerial Taskforce on Trauma and Emergency Services: The Ministerial Taskforce on Trauma and Emergency Services (the Taskforce) was initially established to examine Victoria's emergency and trauma services (see Appendix 1). Although trauma services clearly operate within the wider context of emergency services, the Taskforce considered that supporting local and international evidence was strongest for review and reform of the state's trauma services. The primary focus of the Taskforce was, therefore, to advise on an appropriate trauma system structure and components for cohesive operation of a trauma system. The title was selected to reflect the trauma focus within the wider emergency services context.
The Taskforce was chaired by Mr Robert Doyle MP, Parliamentary Secretary to the Minister for Health. In assessing options for developing major trauma services for Victoria, the Department of Human Services commissioned ACIL Consulting Pty Ltd to advise on selected options and report to the Taskforce.
Working Party on Emergency and Trauma Services: A Working Party on Emergency and Trauma Services (the Working Party) had already been established by the Department prior to setting up the Taskforce. Its role was to develop and prioritise pragmatic emergency and trauma system initiatives identified by the Consultative Committee on Road Traffic Fatalities and other relevant bodies (See Appendix 2). The CCRTF in association with representatives of the learned Colleges and Specialist Societies prepared a report advising on recommendations to reduce the identified problems. The Working Party has subsequently recommended a range of strategies in accordance with a best practice model. It established a close working relationship with the Taskforce through a number of joint memberships.
Victorian State Trauma System:
Target Population
Major trauma comprises a small proportion of overall emergency cases with an estimated current incidence of 1,000 - 1,200 cases annually in Victoria, if defined simply as those cases with Injury Severity Score (ISS) > 15 (Cameron et al., 1995). The Major Trauma Management Study identified an additional 30 per cent of major trauma cases using a broader definition, but with an ISS < 15 (Danne et al., 1998). This means that there may be considered to be up to 1,800 major trauma cases per year in Victoria. The principal component of major trauma is road trauma, which has been declining over time (see Appendix 3).
The incidence of major trauma may be relatively low, however this group of patients has high morbidity and mortality and, currently, a high level of preventable problems. These patients constitute the most severely injured subgroup of trauma patients and are 'time-critical', in that their morbidity and mortality increases with the time taken to reach definitive treatment.
Although all trauma patients require efficient, effective treatment, the proposed Victorian State Trauma System is targeted at major trauma patients (Figure 2.3). The Taskforce considered that this is the patient population that will benefit most from better organised and coordinated treatment.
The Taskforce considered that an appropriate definition of major trauma for defining the target population and for application in system evaluation and quality assurance involves the presence of at least one of the following:
Death after injury
Admission to an Intensive Care Unit for more than 24 hours, requiring mechanical ventilation.
Serious injury to two or more body systems (excluding integumentary).
Injury Severity Score (ISS)> 15.
Urgent surgery for intracranial, intrathoracic, or intraabdominal injury, or for fixation of pelvic or spinal fractures.
The Taskforce recognised that such a definition requires retrospective assessment after diagnosis is complete. Clearly, full diagnosis is not always possible during resuscitation and early management. The patient's diagnostic status necessarily evolves over time with each phase of care, as diagnosis in the prehospital is largely limited to physical assessment, and because many serious occult injuries are only revealed with time as clinical features emerge or diagnostic interventions are undertaken.
Undertriage, or failing to identify major trauma cases and activate a system response, potentially results in suboptimal clinical outcomes. Criteria are therefore required which are predictive of major trauma as defined above but which are also clinically applicable prospectively during early phases of care and which recognise the evolutionary nature of the diagnostic status in major trauma patients. The Taskforce has identified such criteria, in order to give optimal inclusion of major trauma patients into the Victorian State Trauma System. These are contained in the Prehospital Major Trauma Criteria (Appendix 7.2) and the Major Trauma Interhospital Transfer Guidelines (Appendix 7.4).
Benefits of a Trauma System Approach
There is now substantial evidence that early, appropriate, definitive management in major trauma results in optimal outcomes. Trauma management systems provide a coordinated and systematic means for delivering trauma patients rapidly to definitive care. Much of this evidence is from the United States where a number of statewide regionalised trauma systems have been in operation for more than 20 years (Cameron et al., 1995).
The key features of established international trauma systems associated with improved major trauma mortality were considered by the Taskforce. The collective published research and authoritative guidelines from professional bodies, both local and international, identify key features associated with optimal clinical outcomes. Generally, these centre around strategies for delivering the right patient to the right hospital by the fastest and safest means, and include:
Integration, coordination and inclusiveness of providers.
Designation of hospitals to receive major trauma.
Concentration of expertise in trauma management.
Agreed triage and transport protocols.
System Features and Optimal Outcomes:
Integration, Coordination and Inclusiveness
Within a trauma system, providers of trauma care are integrated and do not operate in isolation. Such integration includes prehospital and hospital providers as well as within and between trauma hospitals, particularly rural and metropolitan hospitals. Integration requires system providers to operate with the same terminology and approaches, such as standardised triage and clinical protocols, and to have a clear understanding of their role and areas of expertise within the system.
The system should have coordination mechanisms in place that allow rapid delivery of the trauma patient to 'definitive care' to reduce time from injury to definitive treatment. Coordination is, therefore, essential from time of notification of ambulance services through every phase of care.
A sustainable trauma system requires inclusive representation from rural and metropolitan providers in both system planning and maintenance.
Designation of Hospitals To Receive Major Trauma
The stratification of hospitals to designated trauma care roles is important and is based on resource and geographical considerations (Appendix 6). Trauma patients are managed in a service that is appropriate for the level of care indicated by their injuries. Only a very limited number of such services are designated as Major Trauma Services, which provide a 'centre of excellence' in all aspects of trauma management.
Concentration of Expertise
The literature in general supports an inverse relationship between mortality rates and caseload volume, that is mortality rates diminish as clinician experience and institutional caseload increases. Designating a limited number of hospitals to receive major trauma, especially the Major Trauma Services where a large caseload of trauma is managed, effectively concentrates trauma expertise in a few institutions. Concentrating trauma expertise in a few specialist institutions then logically requires the majority of major trauma cases to be delivered to these sites, according to agreed triage and transfer protocols, in order to maximise outcome benefits for patients and maintain clinician skills. Concentration of expertise and volume:outcome issues are discussed further in the section, Major Trauma Services in Victoria - Consideration of Number and Location.
Triage and Transport Protocols
The prehospital and interhospital triage and transfer guidelines (Appendices 7 and 8) are designed to maximise the number of major trauma patients that will be treated in the Major Trauma Service. These guidelines necessarily involve bypass of non-Major Trauma Service hospitals, within defined logistic and safety constraints. Compliance with such agreed guidelines is integral to the efficacy of a trauma system.
Structure: The Victorian State Trauma System endorsed by the Taskforce involves designating a limited number of hospitals to receive major trauma. These trauma services will fit within a tiered structure. Different complexities of trauma care will be provided at each level of the system (Figure 2.4 Integrated Trauma System).
The Taskforce recommends that there be Major Trauma Services at The Alfred, Royal Melbourne Hospital and Royal Children's Hospital which will form the central hub of the integrated system. Available evidence, including international outcome studies, published guidelines and demand projections, while not unequivocal, assisted the Taskforce in the decision that a second adult Major Trauma Service was both sustainable and would address the current system-wide deficiencies in relation to higher level system functions. The Taskforce intends that the necessary clinical infrastructure is in place at the Major Trauma Service prior to the activation of triage and transfer protocols.
The Taskforce envisages that the Victorian State Trauma System will be led by the Major Trauma Services. The Major Trauma Services will treat most of the State's major trauma caseload, either through primary triage or secondary transfer, and will deliver leadership and support to the trauma system as a whole. This will be demonstrated by active involvement in education and performance feedback, implementation of triage policies and clinical protocols, and system monitoring and research.
The metropolitan component of the system should comprise:
The Major Trauma Services two adult and one paediatric.
A second level of trauma receiving hospitals called Metropolitan Trauma Services. They will receive major trauma unable, for safety or logistic reasons, to be triaged directly to the Major Trauma Services. They will undertake early transfer of such cases to the Major Trauma Services and provide definitive treatment to a very limited number of major trauma cases under defined conditions.
Primary Injury Services that are appropriate for the treatment of patients with minor injuries. Ambulance services, when transporting major trauma patients, will bypass these hospitals for a higher level service.
The regional component of the trauma system is also led by the Major Trauma Services. The regional Consultative Committees on Emergency and Critical Care Services will undertake a coordinating role in regional trauma management and system activities.
The clinical components of the regional system should then comprise:
Regional Trauma Services located in major regional centres providing regional focus for trauma management.
Urgent Care Services in small rural communities where higher levels of trauma care are not accessible and they provide initial resuscitation and stabilisation prior to early transfer.
Primary Injury Services in regional areas include some isolated hospitals that may need to provide initial resuscitation to major trauma cases on occasion. Other Primary Injury Services in areas less isolated may be designated for bypass of all major trauma cases on the advice of the regional Consultative Committee on Emergency and Critical Care Services.
Regional Issues: In a statewide trauma system, regional and rural trauma care providers share many common needs with their metropolitan counterparts, however some issues they face are different. The Taskforce recognises that:
Regional designation of hospitals to receive major trauma will require more detailed consideration of regional geographic, resource and demand factors.
Triage and bypass may be difficult in regions where resources are dispersed.
Effective and timely referral of major trauma to the Major Trauma Services will depend on a collaborative approach from the Major Trauma Services, a rapid response retrieval system and a reliable and streamlined process for referral.
Training and skill retention are problematic when exposure to major trauma is sporadic and access to training courses limited by time, distance or money.
These issues are common to a number of other medical and surgical specialties but warrant particular attention in the context of the proposed system and are discussed in the appropriate sections throughout the report.
Infrastructure:
System Organisation and Management
The successful development of the Victorian State Trauma System will depend on statewide coordination of a complex integrated service system. An organisational structure has been recommended to provide a central, system-wide, non-institutional focus; coordinate the efforts of all agencies involved in trauma care, and provide means to develop and implement strategies for improving trauma services.
System coordination and development will be assisted by a new committee structure led by an overarching Ministerial Emergency and Critical Care Committee addressing trauma system issues as well as the broader issues affecting emergency services in this State. A State Trauma Committee will act as a subcommittee to the Ministerial Emergency and Critical Care Committee and address trauma system issues exclusively and in detail. These two committees will be assisted in trauma system implementation and planning by a collaborative, cross-campus Major Trauma Service Statewide Coordination Unit with statewide responsibilities, and by enhanced integration of regional Consultative Committees on Emergency and Critical Care Services.
Triage and Transfer Protocols
The Taskforce has endorsed a service model where the application of trauma triage protocols will result in the majority of major trauma patients being managed at Major Trauma Services. Ideally, direct transport to Major Trauma Services would deliver patients from the scene of injury, requiring bypass of other hospitals within defined logistic and safety parameters. Where primary triage to Major Trauma Services will not be possible, patients will be delivered to another level trauma service for resuscitation and stabilisation. Early consultation by receiving trauma services with Major Trauma Services will occur and most patients will undergo timely and appropriate interhospital transfer from both metropolitan and regional trauma services to the Major Trauma Services.
Retrieval and Transfer
The Taskforce has considered the role of Victoria's medical retrieval system. These deliberations are from the perspective of identifying possible mechanisms for delivery of major trauma patients to definitive care in the safest and most expeditious manner. The proposed model focuses on integrating current retrieval services, achieving more timely retrieval and transfer of time-critical patients, and providing high standards of care during transport that match the patient's clinical needs. Recognition has been given to the need to consider fixed wing and rotary wing fleet upgrades.
Specifically, the Taskforce recommends medical staffing and system activation models, data integration between current services, educational strategies regarding the role of retrieval services and an aircraft capacity for the State. The proposed model will undergo wider consultation and development with emergency service system users and stakeholders.
Quality Management
The Taskforce considers that all phases of trauma management require process and outcome evaluation. A quality management structure will incorporate prehospital and hospital components. Opportunities for combined quality improvement processes across facets of the system will also be developed.
Establishment and expansion of specific trauma datasets are endorsed. Data collected will be incorporated in a quality improvement process involving development of quality indicators, processes for monitoring function, peer review, improvement activities and reevaluation. Audit and other quality improvement activities will be undertaken or overseen by the State Trauma Committee and Ministerial Emergency and Critical Care Committee.
Education and Training
The Taskforce considers that efficient and effective trauma management will be dependent on the provision of education and training programs that meet the needs of staff from diverse disciplines. A number of courses in trauma management are already available and the Taskforce considers that these should be integrated wherever possible.
Rural practitioners have particular educational needs. For some rural or regional clinicians, these relate to infrequent exposure to major trauma patients, geographical isolation from high level services and clinical advice, and barriers in accessing continuing and advanced training courses.
The Taskforce recommends strategies to establish a framework for meeting the requirements of trauma care practitioners. The State Trauma Committee, the Major Trauma Service Statewide Coordination Unit and Directors of Trauma Services will be responsible for implementing this framework.
Research, Service and Technology Developments
A number of potentially beneficial developments in diagnostics, treatment modalities and information technology applicable to trauma care have been identified by the Taskforce, though many technologies still require clear evidence for their effectiveness.
Clinical outcomes in major trauma patients will be rigorously evaluated through well-constructed clinical trials. The State Trauma Committee will set priorities for trauma research relevant to, and requiring participation of, all levels and facets of the trauma system.
Funding
Purchasing approaches will incorporate incentives to promote quality outcomes and system efficiency, in line with the Taskforce recommendations. In particular, purchasing approaches will support the agreed triage and transfer protocols delivering the majority of major trauma patients to Major Trauma Services.
The Taskforce recommends developing purchasing options for policy in consultation with other key providers and stakeholders at implementation stage.
The Taskforce notes that the proposed Victorian State Trauma System has some significant resource requirements. These are justifiable when viewed in the context of the high human and financial costs currently associated with potentially preventable outcomes in major trauma patients.
Conclusion: Trauma care and systems have had, and will continue to have, considerable fluidity and scope for debate. The Taskforce recommends system restructuring aimed at integrating trauma care and further improving patient outcomes.
This report sets out the framework for developing the Victorian State Trauma System. It discusses the system and the rationale behind recommended improvements, and identifies priority strategies for implementation.

New, T (2000). "Clinical decision support tools in A&E nursing: A preliminary study." Nursing Standard 14(34): 32-9.

Aim: This article describes how a large trust in the north east of England is in the process of developing a unique service for non-emergency patients in one of its main A&E departments. The Urgent Need Assessment Service (UNAS), co-located within the main A&E department, features the use of NHS Direct computerised algorithms to enable nurses to recommend the best treatment or course of action accurately and safely, for all patients attending the department who are categorised as blue or green status in accordance with the Manchester triage model of A&E assessment. The UNAS facility incorporates discretely staffed minor injuries and minor ailments services.
Method: UNAS assessment nurses are specially trained to use their A&E experience, together with the computer model, and to make an assessment in partnership with the patient, sharing information displayed on the computer screen and working together to reach a jointly agreed treatment plan or outcome. The UNAS pilot and evaluation commenced in September 1999 and results and outcomes are presented for the period from September 3 to December 31 2000.
Results: Approximately 75 per cent of all A&E attenders are given blue or green status. UNAS has led to faster treatment and reduced waiting times for these people, increasing patient satisfaction while enabling the A&E department to concentrate its resources on treating more serious cases.
Conclusion: This pilot study has proved to be highly satisfactory to the majority of people who have been treated at UNAS. Those previously regarded as 'inappropriate attenders' might be better suited to treatment in a different department, separate from the traditional A&E department, with reduced waiting times, and under the care of specially trained nurses.

New Zealand Health Technology Assessment (1998). Emergency Department Attendance. A Critical Appraisal of the Literature. Christchurch, New Zealand Health Technology Assessment: 1-42.

Aim: This report aims to examine the key literature that has assessed the appropriateness of attendance at the emergency department.
Data sources: This review did not involve a single structured search strategy but was the result of a number of small, topic-based searches undertaken in conjunction with the review of acute medical admissions (NZHTA Report 6). Topic-based searches were conducted by searching under three MeSH headings (emergency department, hospital and emergency service, hospital) and then using different text words (for example, appropriate, minor injury). The searches were undertaken on the following bibliographic databases: Medline, HealthStar, Cinahl and Current Contents.
Searches were limited to English language material from 1993 onwards and were mainly run between mid-December 1997 and mid-January 1998.
Study selection: Studies were selected if they examined the appropriateness of emergency department attendance. A broad range of study designs were eligible for appraisal including meta-analyses, randomised controlled trials, quasi-experimental studies, cohort studies, cross-sectional studies, descriptive studies, economic evaluations and some expert opinion articles.
Criteria for exclusion from appraisal were: studies with discrepancies in their description of methods/results, studies that did not clearly describe the methods/results, limited generalisability to the New Zealand population, letters and non-English language studies.
A single reviewer applied these criteria.
The report includes interventions for both adults and children.
Data extraction: Critical appraisal forms standardised by study design were used to extract and appraise the literature. These forms were designed for use by the Group Health Co-operative of Puget Sound and were adopted by the New Zealand Guidelines Group (New Zealand Guidelines Group, 1997). A single reviewer conducted the appraisal of studies.
The level of evidence was determined using a modified version of the US Preventive Services task Force protocol (US Preventive Services task force, 1989).
Data synthesis and conclusions:
Conclusions about inappropriate ED use
While studies that have described the inappropriate use of the ED were relatively plentiful, remarkably few studies have evaluated the health outcomes associated with alternatives to ED-based care.
ED attendance is not included in the National Minimum Dataset and consequently no published national data exists that describes the trends in ED attendance in New Zealand.
Although published data is not available, consistent opinion suggests that ED attendances have been increasing in New Zealand.
No valid and reliable method exists to define inappropriate care at an ED. Clinicians, administrators and consumers have markedly heterogeneous definitions of appropriate attendance at the ED.
A medical viewpoint of appropriateness has usually been presented in the literature. That is, patients presenting for non-urgent care that could be provided by a primary care physician are often designated as inappropriate ED attenders.
Attendance at an emergency department by patients seeking medical care for non-urgent conditions has been labeled fiscally improvident, as it is considered to be more expensive for health funders as well as medically undesirable due to the discontinuous and unco-ordinated care that is provided. No conclusive evidence exists for either of these assertions (Franco et al., 1997).
A large number of studies have examined the appropriateness of ED-based care in a number of settings and have produced a wide variation in their estimates of the percentage of attendances that were designated as being appropriate (this review identified that between 3% and 59% of ED attendances have been deemed to be inappropriate in the literature).
Conclusions about the effectiveness of interventions to reduce inappropriate ED use
Without a valid and reliable measure of inappropriate ED attendance, the absolute effectiveness of interventions to reduce these attendances cannot be accurately assessed.
The evidence for the relative effectiveness of alternatives to ED-based care was found to be patchy in coverage and quality. Relatively little research has been undertaken to evaluate major new developments in primary or secondary care that have an important bearing on the interface between these levels of care. These new developments include: new deputising arrangements for out-of-hours GP care, and the provision of minor injury units located in a variety of settings and staffed by a range of different professionals (see Appendix 2).
Most of the research that has evaluated the effectiveness of new organisational arrangements for inappropriate ED attenders has used a quasi-experimental study design rather than a randomised controlled trial methodology. Only four randomised controlled trials of interventions to reduce inappropriate ED use were identified by this review.
Despite the general limitations of the research, some evidence was available for the effectiveness of restricted ED access and expanded access to primary care and the efficacy of cost-sharing which have consistently been found to be effective methods to restrict ED use (although the reduction may apply to all types of users and not just inappropriate users). Less robust evidence exists for the effectiveness of social workers in the ED or certain specific medical interventions.
Available (although generally poor quality) evidence suggests that the following interventions are ineffective at reducing the number of inappropriate ED attendance: triage, patient education and changes in the characteristics of GP services.
Several major changes in service delivery such as the provision of out-of-hours GP clinics and the development of hospital-based minor injuries clinics have somewhat remarkably not been evaluated in regard to their effect on ED usage.
Interventions to reduce non-urgent visits to the ED need to be multi-faceted to account for the wide range of determinants that lead patients to seek care at that venue. Single interventions are unlikely to be successful whereas those that involve multiple strategies that include the patient, physician and system changes are more likely to be successful.
A notable problem with the literature is that most of the research has been based on the provision of primary care to people in the US where an emphasis has traditionally been on specialist-based services. It is possible that the marginal gains for the provision of primary care-based interventions in the US setting may be substantially greater than could be achieved in the UK, Australian or New Zealand setting where primary care is already well established.
Finally, it should be remembered that interventions to change ED utilisation have been driven by an increase in demand and are sponsored by supply side organisations (hospitals and the funders of ED and hospitals). It should therefore be remembered that new interventions must still provide a satisfactory service to patients. In addition, alternatives to ED-based services have no guarantee of producing overall savings in resources because it is possible that these services (for example, minor injury units) may actually service patient problems that previously would not have been presented to the health system. A crucial issue, therefore, when managing demand for primary and secondary care services is the need to furnish additional support for patients to appropriately manage their own minor health problems and appreciate when assistance may be needed.
An alternative to focusing on the inappropriate use of the ED and developing interventions to reduce this use of the department, is to accept that many patients choose to attend the department and therefore the imperative is to expand the scope of the ED to meet the demand for non-urgent care. This could be done, for example, by allowing primary care workers (practice nurses and GPs) to staff EDs or by developing the ED as a primary care centre (Dale et al., 1996).

NSW Health (1999). Emergency and Elective Performance in NSW Hospitals. Sydney, NSW Health.

This document provides details of performance monitoring in NSW for elective surgery and emergency departments.

NSW Health (2001). NSW Government Action Plan for Health. Emergency Department Services Plan. Sydney, NSW Health: 1-34.

Emergency Departments are key entry points into the acute hospital system, working at the interface between the hospital and the community. Emergency Departments are highly visible, highly utilised and highly valued. Their location generally reflects hospital planning, often without specific reference to factors such as access to clinical support services and system-wide workforce availability. All Emergency Departments must be able to provide a minimum standard of care to patients presenting there, despite sub-specialisation of inpatient units in the hospital. This Plan aims to rationalise the way in which Emergency Department services are developed, managed, coordinated and supported.
The Plan recommends the adoption of a network model within Area Health Services, formalising and strengthening links within the network and ensuring that there are common standards, guidelines and procedures. In addition, it recommends that the future planning of Emergency Department services by Area Health Services aims to meet community need and improve service delivery.
Improved networking of Emergency Department services in metropolitan and rural areas and across Area Health Service boundaries will ensure that a person presenting to any department across a network will benefit from the collective expertise of the network.
It is acknowledged that significant work has been undertaken in the past. Documents such as Emergency Department Strategic Directions - Priorities and Planning Guidelines for the NSW Health System 1997-2000 (1997), 'Better Practice Guidelines for Bed Management' (1998) and 'Emergency Department Access Block - Working Party Report' (1999) should be used in conjunction with the Emergency Department Service Plan.
Other important aspects of the Government Action Plan for Health relating to Emergency Departments are the development of new funding models, including the introduction of episode funding, new funding arrangements for health priority areas, Emergency Departments and intensive care services and modifications to the Resource Distribution Formula.
This document has been prepared in an environment of change. Concurrently, there are processes under way to better manage the care of those people with chronic and complex health conditions, the delivery of primary care services, and to improve the collaboration between Emergency Departments and general practitioners. These factors will positively impact on the evolution of Emergency Department services and the care of people in NSW.

O'Connor, R and Reese, C (2001). "Correlation between emergency department patients' recall of length of stay and their actual time in the department." Academic Emergency Medicine 8(5): 577.

Introduction: Length of stay (LOS) is routinely measured for ED patients, owing to its impact on patient satisfaction and those who leave without seeing a physician. Previously reported data indicate that ED personnel grossly overestimated average patient LOS; however, studies examining patients' perceptions are lacking. We conducted this study to determine the degree of correlation between the ED patients' estimated LOS and the actual measured LOS.
Methods: This study was conducted at a tertiary care medical center with an annual ED census of 125,000. All patients presenting to the ED were evaluated by nursing staff on arrival, and assigned a level of priority for being seen by a physician. The time interval (in minutes) from triage presentation to disposition order or patient discharge from the ED was measured to determine LOS. Subjects were selected by a randomized block design. A group of patients and their families were surveyed approximately 2 to 4 weeks after the visit, and asked to estimate (in minutes) their ED LOS. Statistical analysis was performed using the Pearson correlation coefficient and the Spearman rank correlation.
Results: A total of 3,332 patients responded. The mean measured LOS was 5.5 ± 2.5 hours (median = 3.3, range 0 to 29.2). The mean estimated LOS was 5.1 ± 2.3 hours (median = 3.3, range 0 to 16.0). The Pearson r was 0.65 (p 0.0001) and the Spearman rank correlation was 0.74 (p 0.0001). Stratification of actual ED LOS in ranges of 1 hour, 1 to 4 hours, 4 to 8 hours, and 8 hours revealed a trend to underestimate LOS only for shorter LOS.
Conclusions: The degree of correlation between the ED patient's estimated LOS and the actual measured LOS is moderate to high. There is a trend for patients to underestimate their LOS, especially in the range of shorter intervals. LOS, when used to correlate with satisfaction, is reliably recalled by patients, and may be more accurate than the LOS estimated by ED personnel.

O'Rourke, M, Ladd-Hudson, K, et al. (1985). The development of pre-hospital emergency services in Australia. Canberra, National Heart Foundation,: 23-5.

There are throughout Australia a variety of emergency ambulance transport services and a variety of systems designed to deal with emergencies and acute heart attack. This article seeks to describe the development of these services in the different states and territories, and their present status.
Emergency ambulance services differ from those in the USA in that there are in Australia different systems for fire fighting and for health care; both aspects are not handled by the Fire Department of city, town or county as they are in the USA. In most parts of the USA, there are different systems again for elective transport of the sick and infirm, and these are usually run for profit by private companies.

Patient Management Task Force (2001). A Ten-Point Plan for the Future. Melbourne, Department of Human Services: 1-26.

The ten-point plan is drawn from a much wider set of recommendations contained in the Task Force's issues papers. It draws together the principal areas for action and identifies the major initiatives that are likely to have the greatest impact.
The Task Force believes that there is a need for a new model of collaboration in which the Department, health service managers, clinicians and consumers/community have a shared responsibility to work together towards better patient management. The metropolitan chief executives group and the metropolitan board chairs have indicated a willingness to take on more responsibility and they should play their part with the Department in fostering the implementation of this plan.
Access to Care in Hospital
1. Establish three emergency services clusters and coordinating hospitals
2. Create effective alternatives to emergency care
3. Improve elective surgery patient flow
4. Expand ambulatory care
5. Extend use of care pathways and new models of care
Access to Care Before and After Hospital
6. Focus on care for older Victorians
7. Improve relationships with residential care, community and home-based
services
Incentives and Strategies to Bring About Change
8. Foster collaboration and leadership
9. Introduce new incentives and focus on performance
10. Develop metropolitan wide hospital plans

Rainer, T (1996). "Critical analysis of an accident and emergency ward." Journal of Accident and Emergency Medicine 13(5): 325-9.

Objectives: To describe the work, both qualitatively and quantitatively, of an accident and emergency (A&E) ward, and discuss some of the advantages and disadvantages associated with this ward.
Methods: An observational study was carried out of all patients admitted to the A&E ward of Glasgow Royal Infirmary from 1 January 1992 to 31 December 1992. Epidemiological and management data were collected for all patients admitted.
Results: There were 2460 admissions, of which 69% were related to trauma and 45% to head injury; 47% of the patients had consumed alcohol before admission. Accidental trauma was the commonest reason for admission (57%), followed by assault (33%). Ninety two per cent of admissions stayed for less than 3 d, but 33% of the workload was spent on a small number of patients admitted for longer than 7 d.
Conclusions: This A&E ward presents a significant workload, and some of its most serious problems lie with those patients who stay longer than 72 h. The safe and effective use of the ward depends upon it being well resourced, along with the department it serves.

Richardson, D (2001). "Association of access block with decreased ED performance." Academic Emergency Medicine 8(5): 575-6.

Objectives: Access block (AB) refers to the situation where ED patients requiring inpatient care are unable to gain access to hospital wards for prolonged periods. In Australasia ED presentations are triaged according to the 5-category National Triage Scale (NTS), which prescribes the maximum time a patient should wait to be seen. ED performance is measured by achievement of waiting times within these time thresholds. This study aims to determine if an association exists between daily AB and ED performance.
Methods: Retrospective study of all 48,423 presentations to a tertiary ED in 1999. Data from information systems were merged to create a record of waiting time (from arrival to seeing a doctor) and assessment time (from seeing a doctor to leaving the ED). AB was defined as assessment time >8 hr for any case leading to inpatient admission. The number of AB cases was calculated for each day and days were categorized as having nil, one, two, or 3 or more (3+) AB cases. The null hypothesis was that the proportion of waiting times within the relevant NTS threshold did not vary between days with different levels of AB.
Results: There was a major association between AB and performance (P < 10 E-50 chi-square) independent of differences in daily workload. There was a direct relationship between daily AB (range 0-9) and median waiting time. Each additional daily AB was associated with a 2.5% decrease in achievement of waiting time thresholds, a 3.4-min increase in median wait, and a 9.9-min increase in 90th centile wait. Subgroup analysis showed that waiting times were preserved in the more urgent NTS categories, but increased in the less urgent categories with increasing AB.
Conclusions: Increasing access block is directly associated with a decrease in ED performance by standard measures.

Rosen, P (1998). "Resource utilisation in the emergency department." Journal of Emergency Medicine 16(3): 484.

Editorial in support of article in same issue by Larkin GL, Weber JE, Moskop JC "Resource utilisation in the emergency department: the duty of stewardship". J Emerg Med 1998; 16: 499-503.

Sarver, J and Cydulka, R (2001). "Emergency department provision of nonurgent care and waiting time to see a physician." Academic Emergency Medicine 8(5): 576.

Objectives: Explore factors related to patient waiting time (WT) in the ED. The hypothesis was that an increased proportion of nonurgent care (NUC) increases WT.
Methods: Data were from the 1997-1998 National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative sample of all EDs. Variables hypothesized to influence WT to see provider were race, sex, age, method of payment, triage assignment, pain assessment, 3 diagnoses, mode of arrival, time of day, hospital ownership, region, urban vs. rural, and proportion of nonurgent visits. Multiple linear regression adjusted for correlation between visits at the same hospital was used to assess the independent effects of the variables on WTs. Mantel-Haenzel estimates were used to determine effects of NUC on WT after stratifying for the first 3 diagnoses and triage assessment.
Results: 64% (29,861/46,384) of ED visits had information on WTs. Mean WT = 41 min (±18 sec). 43% (±0.2%) of visits were coded nonurgent (not needing attention within 1 hr). In multiple regression adjusting for year of presentation, race, sex, triage assignment, age, source of payment, region, arrival time, arrival mode, pain level, and urban vs. rural, each 10% increase in proportion of nonurgent visits resulted in 36-sec increase in WT (p = 0.038). Stratified regression/same adjustments, patients triaged to be seen in less than 15 min had WT 19 min (95% CI 16.5, 21.0) in EDs in the lowest quintile of NUC (0-11.5%) and 32 min (95% CI 24.4, 39.2) in EDs in highest quintile (84.7-100%). Patients triaged to be seen in 15-60 min had WT of 37 min (95% CI 34.1, 39.7) in EDs in the lowest quintile of NUC and 45 min (95% CI 39.8, 49.2) in EDs in highest quintile. No difference in WTs among those triaged to be seen in 1-24 hours was noted. Odds ratio of highest versus lowest quintile WT was 2.14 (p = 0.012; 95% CI 1.17, 3.93) in EDs in the highest quintile NUC vs. EDs in lowest quintile.
Conclusions: EDs providing a high proportion of NUC do not attend to urgent patients as promptly as do EDs with a lower proportion of NUC.

Schull, M, Ferris, L, et al. (2001). "Problems in clinical judgement: 3. Thinking clearly in an emergency." Canadian Medical Association Journal 164(8): 1170-5.

The resuscitation of a patient in extremis is frequently characterized by chaos and disorganization, and is one of the most stressful situations in medicine. We reviewed selected studies from the fields of anesthesia, emergency medicine and critical care that address the process of responding to a critically ill patient. Individual clinicians can improve their performance by increased exposure to emergencies during training and by the incorporation of teamwork, communication and crisis resource management principles into existing critical care courses. Team performance may be enhanced by assessing personality factors when selecting personnel for high-stress areas, explicit assignment of roles, ensuring a common "culture" in the team and routine debriefings. Overreliance on technology and instinct at the expense of systematic responses should be avoided. Better training and teamwork may allow for clearer thinking in emergencies, so that knowledge can be translated into effective action and better patient outcomes.

Scottish Executive Health Department (2001). A & E Waiting Times Survey. Scotland, Scottish Executive Health Department.

This health briefing presents information from the eighth Scotland-wide survey of waiting times for
patients presenting at A & E departments. The survey was carried out in 32 A & E departments in
Scotland and each department conducted the survey during one chosen week in March / April 2000
- information was recorded for more than 22,800 cases, almost 1,800 more than was recorded during
the previous survey in March / April 1999.

Selker, H, Zalenski, R, et al. (1997). "An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: A report from a National Heart Attack Alert Program Working Group." Annals of Emergency Medicine 29(1): 13-87.

The authors state that recommendations regarding the use of a technology should be based on both ED diagnostic performance and clinical impact data obtained in high-quality or substantial studies. Of the various diagnostic technologies evaluated in the 14 sections, however, only five met this highly desirable standard of evaluation: the original ACI predictive instrument; the ACI-TIPI; the pre- hospital ECG; the Goldman chest pain protocol; and the ECG exercise stress test.
The original ACI predictive instrument was excellent for diagnostic performance and substantial clinical impact, and therefore it could be recommended for general use in practice. The general use of other technologies assessed in the review cannot be recommended based on the currently available evidence.

Sempere-Selva, T, Peiró, S, et al. (2001). "Inappropriate use of an accident and emergency department: Magnitude, associated factors, and reasons - An approach with explicit criteria." Annals of Emergency Medicine 37(6): 568-79.

Background: We evaluate the appropriateness of medical visits to the accident and emergency department (A&ED) of a university hospital using an instrument based on explicit and objective criteria, analyze the association between inappropriate visits and certain factors, and identify reasons for inappropriate use.
Methods: This concurrent review of a random sample of 2,980 adult medical patients' visits to the A&ED of the hospital of Elche uses the Hospital Urgencies Appropriateness Protocol, an instrument based on explicit criteria. We analyze the association between inappropriate use and specific factors, and provide a descriptive analysis of reasons for inappropriate use assigned by A&ED staff.
Results: Of the total number, 882 (29.6%) of the visits were evaluated as inappropriate. Inappropriate use was associated with younger patients, use of own means of transportation, referral by the hospital, certain months of the year, and certain diagnostic groups of lesser severity. The most frequent reasons for inappropriate use were the patients' greater trust in the hospital than primary care (451 [51.1%]), inappropriate use of services by patients (160 [18.1%]), and inappropriate referrals by primary care physicians (142 [16.1%]).
Conclusion: Inappropriate use represents an important percentage of use of the A&ED. Many reasons contribute to it, although foremost among them is patient preference (and the convenience and accessibility) of these services compared with primary care. [Sempere-Selva T, Peiró S, Sendra-Pina P, Martínez-Espín C, López-Aguilera I. Inappropriate use of an accident and emergency department: magnitude, associated factors, and reasons-an approach with explicit criteria.

Shah, S, Noor, H, et al. (2001). "Clinical effectiveness evaluation of an emergency department cardiac decision unit." British Journal of Clinical Governance 6(1): 40-5.

The aim was to test the feasibility of using automated data, and evaluate the impact of an emergency cardiac decision unit (CDU) on the overall outcomes of patients seen for chest discomfort. We used a retrospective, quasi-experimental design to identify patients who had cardiac enzymes measured and an electrocardiogram performed during an ED visit in two six-month periods, pre-CDU (1 January-30 June 1995) and post-CDU (1 January-30 June 1996). A total of 4,336 patients had outcomes assessed. After opening, 14.8 per cent of all chest pain cases were treated in the CDU. Hospital admission rates were reduced from 81.1 per cent to 66.7 per cent. Length of stay, myocardial infarction rates, and mortality were unchanged. The 14-day revisit rates increased from 5.3 per cent to 10.3 per cent. We conclude that cardiac decision units decrease hospital admissions but increase ED revisit rates as a consequence of this now frequently used care pathway.

Sosnin, M, Young, D, et al. (1989). "A study of emergency ambulance utilisation." Australian Family Physician 18(3): 233-4, 236, 238.

An analysis of 373 emergency ambulance calls within the Broadmeadows municipality of Melbourne showed that eighty-seven per cent were handled by standard road car (RC) ambulance, and 13 per cent by mobile intensive care ambulance (MICA). Calls most commonly were associated with cardiorespiratory episodes, loss of consciousness and trauma. Twenty-three per cent of calls did not result in a patient being transferred to hospital mainly because of patient refusal or the absence of a medical need. Forty-two per cent of calls were categorised "not urgent" or eventually the ambulance was not required. This review highlights important topics for further study of ambulance services.

Sowney, R (2000). "All in a day in A&E." Nursing Standard 14(49): 73.

New courses and the creation of a faculty of emergency nursing help to develop a clear career pathway. Robert Sowney explains how.

Stewart, R (1979). "Pre-hospital care. A problem for GPs, ambulance officers and the community." Australian Family Physician 8(11): 1202-9.

This is the phase of care which occurs from the time the patients receive first aid, to the time they are received into the casualty area. It is a most important aspect of care and one which some very professional people are only now beginning to handle.

Tinkoff, G, O'Connor, R, et al. (1996). "Impact of a two-tiered trauma response in the emergency department: Promoting efficient resource utilization." Journal of Trauma-Injury Infection and Critical Care 41(4): 735-40.

Objective: The purpose of this prospective study was to assess the impact of a two-tiered trauma response protocol on the expediency of identification, evaluation, and treatment of trauma patients in the Emergency Department.
Materials and Methods: At a Level I Trauma Centre serving a suburban/urban population of approximately one million people, Emergency Department length of stay was tabulated for all consecutive Trauma Service admissions 6 months before and 6 months after implementation of a two-tiered trauma response protocol. This protocol, which uses specific triage criteria, consisted of the standard Surgery-supervised trauma code response and an additional Emergency Medicine-supervised trauma alert response.
Results: Trauma Service admissions numbered 532 in the pre-protocol period and 512 in the period after implementation of the protocol. In the first period, the Emergency Department length of stay was 289 minutes; in the second period, it was 241 minutes. Of the 512 patients in the post-protocol period, 183 were triaged to the new trauma alert group, reducing the number of Trauma Service consultations and decreasing Emergency Department length of stay by 139 minutes. The two levels of trauma response allowed accurate identification of the most seriously injured patients and improved the ability to predict those patients who would require direct disposition to the operating room or intensive care unit.
Conclusions: Implementation of a two-tiered trauma response significantly decreased Emergency Department length of stay, allowed Emergency Medicine physicians to more rapidly identify, evaluate, and treat trauma patients requiring hospitalisation, improved identification of patients requiring operating room or intensive care unit resources, and was time efficient and resource efficient.

Toncich, G, Cameron, P, et al. (2000). "Institute for Health Care Improvement collaborative trial to improve process time in an Australian emergency department." Journal of Quality in Clinical Practice 20: 79-86.

This study describes an Australian emergency department's (ED) experience with a quality improvement methodology from the USA. The Institute for Health Care Improvement (IHI) conducts collaboratives between clinical groups with similar interests, in this case ED. Their quality improvement model is described. Our involvement with the IHI showed the model to be transferable outside the USA. In applying the model to operational and clinical projects we were successful in meeting our goals to reduce clinical times: for time to analgesia (P = 0.34), time to thrombolysis (P = 0.30) and time to antibiotics in neutropenic patients (P = 0.015). We were unable to reach statistical significance in improvements due to the small sample sizes and sampling techniques. Changes in operational times were not clinically significant but almost reached statistical significance (e.g. median total length of stay in the ED fell 4 min (P = 0.06)). The near statistical significance of a small change was due to the large numbers of patients sampled.

Toy, A and Foley, B (2001). Checking vital signs. The Age. Melbourne: 13.

FULL TEXT
It's 25 July - the day after Hannah Beazley's now famous encounter with the public hospital system in Perth. And on the other side of the country another young woman is lying on a trolley and rapidly losing faith in the system.
Roxanne Peart is 17 and she's been in the emergency department at the Mornington Peninsula Hospital for 37 hours. Because Mornington can't find her a bed, Roxanne's family - which has full health cover - opts to move into the private system. Just like Hannah Beazley.
But while Hannah found her mother's insurance could buy her a bed and a theatre and a surgeon, Roxanne's mother Sharen is startled to discover that there's no room for her daughter even in the private system.
Eventually, her daughter is found a bed in the maternity ward at Mornington. The nursing care was terrific, says Sharen Peart, but that doesn't make up for her distress at that long wait for a bed and the chance to recover from a serious asthma attack.
While the politicians fight about the health of public hospitals - about what Kim Beazley did or didn't say about his daughter's brush with the system - Ms Peart has no hesitation in giving her diagnosis. "There is a crisis," she says. "I want to know why - even with private health insurance - I could not get a bed for my daughter? If it's going to be like that I will save my money."
Sherene Devanesen, chief executive of Peninsula Health, explains that the Pearts were victims of industrial action by nurses, which closed 30 beds in the Frankston hospital, causing backlogs in emergency.
But the nurses bans alone are not the problem. Presentations to the hospital's emergency department have increased 21 per cent in the past three years, Ms Devanesen says. Part of the reason, she says, is that there are fewer general practitioners willing to see patients out of hours or to do nursing home visits. So when illness or injury occurs out-of-hours, what option is there but the local casualty department?
Roxanne Peart's case will never attract the sort of heat and controversy raging around Hannah Beazley. But in its modest way, Ms Peart's experience - and Ms Devanesen's explanation - provide a neat illustration of the problems afflicting public hospitals more generally. The consensus from patients, bureaucrats and carers is that the care's still there, the will is there, but the resources are sometimes stretched so thinly that they quickly fail under any additional strain.
There are problems with resources, waiting lists and ambulance bypass systems, acknowledges Victoria's Health Services Commissioner, Beth Wilson. In her capacity as independent overseer of the system, she has heard many stories like those of Roxanne Peart and Hannah Beazley. But Wilson says significant moves have been made to identify and fix these problems - at least in Victoria, where the State Government is now acting on the recommendations of an extensive investigation of the public hospital system.
The report - by the Patient Management Taskforce - came up with a 10-point strategy for improving access to public hospitals. But the problems it identified are as important as the solutions.
Why are so many more people showing up in accident and emergency departments with problems that are not urgent? Because there are no 24-hour general practice clinics operating. Few doctors will make housecalls after dark. So where else do people go?
Then there is the backlog caused by the number of elderly patients remaining in hospital beds while they wait for a place in a nursing home. And there's the general shortage of nurses. So when the Victorian Government offered sweeteners to lure nurses back into hospitals - and many of them left nursing homes for the improved pay and conditions of the acute system - one solution quickly exacerbated another problem.
Michael Walsh - head of the Alfred hospital and chair of the patient management taskforce - says for all their problems, hospitals are now doing 30 per cent more work than they did a decade ago. The range of services is "streets ahead" of what it was.
"Ten years ago we had just built the Alfred trauma centre and we now have the best trauma service in the country and heart-lung transplants didn't exist. People died because they didn't get this service and now there are 75 to 80 Victorians a year whose lives have been saved."
"The system is improving," says Wilson. "We have seen a genuine effort by the Victorian Government to tackle the problems. They have really tried to make a big effort in terms of resources and in terms of commissioning important work like the patient taskforce.
"But at the federal level, they need to come to terms with the fact there is a crisis in nursing home places which they must address. By having appropriate places for these people, they will release pressure from overstretched hospitals. Not only that, the people will get the care that is appropriate for them and their needs."
Mukesh Haikerwal, Victorian president of the Australian Medical Association and a general practitioner, says the hospital system is in worse shape now than it was 10 years ago. Patients are waiting longer in emergency until a bed is found and then after treatment, especially if they were elderly, waiting longer to be discharged because there is no nursing home or rehabilitation bed for them.
Professor Stephen Duckett, Dean of La Trobe University's health sciences faculty, and former head of the federal health department under Labor Health Minister Carmen Lawrence, says public hospitals aren't in crisis "but it's fair to say they are stretched".
"There are problems of access represented both by long waiting times for elective surgery and crowded emergency departments but it's not immediately clear that it is worse than it was 10 years ago," Professor Duckett says. "Health workers, health professionals, are very dedicated and are continuing to struggle but it's like an elastic band, you can't keep pulling it forever.
According to Professor Duckett, the Federal Government policy of subsidising private health insurance is a waste of money. He says the $2 billion now being poured into the private system would help more people if it was invested in public hospitals.
The subsidy has lifted the number with private insurance to 45 per cent of the population, but there is little evidence so far that it has taken any of the strain off public hospitals. One unexpected impact has been that it has become almost as hard to get a private hospital bed these days - as Roxanne Peart discovered.

Valenzuela, T and Copass, M (2001). "Clinical research on out-of-hospital emergency care." New England Journal of Medicine 345(9): 689-90.

In this issues, Alldredge et al report the results of a prospective clinical trial comparing the efficacy of two drugs when used by paramedics to halt status epilepticus. Obviously transferring therapies from the hospital setting to the out-of-hospital setting requires careful study due to the challenging nature of the setting.
Two challenges should be highlighted: identifying clinically relevant outcomes and working appropriately within guidelines regarding informed consent.
Despite the logistic difficulties, well-designed and carefully executed clinical studies should address important issues in the provision of out-of-hospital emergency care. Otherwise the potential of such are to prevent futher illness, unjury or death will not be fully realised.

Walker, D (1995). "The handover process." Australian Journal of Emergency Care 2(2): 11-2.

During a one week placement at Preston and Northcote Community Hospital (PANCH), Victoria, the author observed a number of patients arrive at the Emergency Department in ambulance care. As a result of these observations, the author found two distinct methods (called type 1 and type 2) of handover are used by ambulance officers when handing over to nursing staff. To achieve insight into the handover process from a hospital point of view, the handover process was discussed with the nurse-in-charge. Her opinions were sought regarding the type of handover information from ambulance officers desired by medical and nursing staff in the Emergency Department.

Wallis, L and Guly, H (2001). "Improving care in accident and emergency departments." British Medical Journal 323: 39-42.

Many articles have highlighted deficiencies in the care delivered by accident and emergency departments in the United Kingdom. We examined the provision of services in these UK departments, on the basis of a systematic review of the literature and an analysis of papers critical of the services.

Whelan, J (2001). A genuine emergency. Sydney Morning Herald. Sydney.

Six-hour delays for ambulances, patients bumped off surgery lists - one major Sydney hospital is barely coping. Judith Whelan reports.

Whelan, J (2001). Six-hour wait a real pain in the neck. Sydney Morning Herald. Sydney.

FULL TEXT
Adam Samuel is the star of Bossley Park High School's soccer squad. He is the team captain. He's in the Fairfield Wolves Under-18s. "He's a very good soccer player," said his mother, Evelyn.
But this year, the 17-year-old's season stopped before it had really begun. Last Wednesday, at training before the first big game of the year, he slipped. As he fell, he heard and felt his neck crack.
According to Adam, school staff called an ambulance but were told the wait could be more than half an hour. They then phoned his father, who drove Adam and Evelyn to the closest hospital, Fairfield.
Staff at Fairfield put a brace around Adam's neck but did nothing else beyond giving him morphine for the pain. Since the early 1990s, Liverpool Hospital has been the designated trauma centre for south-western Sydney. That means all trauma cases - patients involved in such things as car accidents and falls - in the area from Bankstown out to Camden and down past Moss Vale must be brought to Liverpool for treatment.
Because Adam had been admitted to Fairfield, he had to wait for an ambulance to take him to Liverpool. He waited six hours before one was free.
Once he arrived at Liverpool, his treatment was fast. As the ambulance approached, an alert went out to the emergency staff. They were waiting in the resuscitation area when Adam was brought in. Within five minutes, his neck was being x-rayed with a portable machine brought to his bed. Within 15, he had heard that the doctors thought he had not much to worry about, that his injuries were to the ligaments and muscles, not the bones, and his spinal cord appeared to be intact.
In the pediatric area nearby, Julie and Steve Harrison were trying to entertain their two daughters. Julie had been brought in with them by ambulance soon after 4pm. She had mistakenly poured turps over them in the bath: she said their painter must have left it in one of their cups; she had no idea why.
"I'm not winning any awards for mother of the year this year," she said, embarrassed and distressed that she had caused the redness covering three-year-old Jayde's face.
They had waited about 10 minutes to be taken on the ambulance trolley into the pediatric emergency bay. Before a doctor had time to give the two girls a proper examination, one of the nurses began to rinse them in the bath with saline solution. The girls' protests could be heard around the department.
It was almost 8pm before Lisa Bell had a chance to really look the girls over. By then, they were more cheerful. Amber was asleep in her mother's arms and cried as she was woken up to check the redness around her bottom from where she had sat in the turps in the bath. Neither had sustained significant injury - Jayde had some burning of her eye which was to be treated with the same drops she might be given for conjunctivitis.
But the family was not able to leave the emergency room. Because Amber's burns were to her genital area, the case had to be referred to the Department of Community Services. Steve and Julie were taken to the social worker's office while the legislation was explained. "We were told that anything involving children's genitalia has to be explained," Julie said. "We were fine with that."
And then they had to wait for the doctor to be able to put the drops in Jayde's eyes. Nurses are no longer allowed to administer such medicine. "If the nurse could have put the drops in we would have been out a lot sooner. As it was, we got home at 11.30.

Whelan, J (2001). A sigh of relief. Sydney Morning Herald. Sydney.

The strains on the State's health system are as starkly evident at Liverpool Hospital as anywhere. The 560-bed facility in Sydney's south-west finds itself caught between the twin pressures of the city's fastest growing local population and the region's increasing social disadvantage. Despite a major rebuilding program over the past decade, its dedicated and professional staff are barely able to cope with the demands made on them. As the Herald reported in its weekend edition, emergency patients can wait many hours to be seen by a doctor, and many more for a bed. Often the load becomes so heavy the emergency department has to close its doors to all but the most dire cases. There are similar pressures on surgical services. Patients are forced to wait days, or even weeks, because of a lack of beds, operating time or staff. And every day patients with life-threatening illnesses such as cancer and heart disease are bumped off surgery lists. In the second and final part of the series, Judith Whelan meets a hard-pressed surgical team - and one very lucky patient.