Hospital Circulars

Hospital Circular 02/2006

Date Issued:17 March 2006

Distribution: Metropolitan Health Services, Metropolitan Ambulance Service, Rural Ambulance Victoria              

Subject: Guidelines for Hospital Early Warning Systems (HEWS) and hospital bypass for health service emergency departments

Purpose: To outline health service and ambulance service responsibilities during periods of peak demand or high workloads in an emergency department.

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Background:

This Circular provides an overview of the roles, responsibilities and agreed principles for implementing HEWS and hospital bypass and replaces the contents of Hospital Circular 4/1998.  This circular should be read in conjunction with the Hospital Early Warning (HEWS) Business Rules (refer www.health.vic.gov.au/emergency/ and the Statewide Emergency Program and Elective Surgery Program Business Rules 2005 (refer: http//www.health.vic.gov.au/hdms/busrule06).

Hospital Early Warning System (HEWS)

HEWS is a standardised internal hospital response to identified increased pressure in an emergency department (ED). It is instigated where occupancy and workload within the department is at a level that there is a high likelihood that bypass criteria will be reached within the next hour.

The goal of HEWS is to better manage access for emergency patients by improving communication across and within both the hospital and the emergency system.  The benefit of HEWS is derived from the internal escalation processes within hospitals that create additional capacity to deal with demand pressure.

Hospitals Roles and Responsibilities

The assessment of the need for HEWS should be undertaken by an executive nominated by the Chief Executive Officer of the hospital. Such an assessment relies on the experience and expertise of the senior staff and with reference to a range of agreed factors. The rigour in HEWS lies in compliance with a process that ensures a hospital wide response is activated.

The assessment of whether to initiate a HEWS event is made with reference to the:

• level of occupancy of the ED and inpatient areas
• workload - actual and predicted
• staffing levels (include skill mix and any shortfalls)
• other variables such as an external or internal disasters.

If HEWS is assessed as being required, the following actions take place:

• within the ED - A standardised approach is applied to identify and respond to increasing pressure in the ED

• internally across the Hospital – Implementation of a whole of system response to ED workload to create additional capacity and where possible avert the need for bypass.

• externally across the metropolitan system - Hospitals notification to MAS.

Ambulance Services Responsibilities

The Ambulance Services will support hospitals in their efforts to manage demand whilst maintaining their primary role and responsibility in the delivery of prehospital care. 

On receiving advice that an ED is on HEWS, the Ambulance Services advise relevant crews of the change in status and seek an alternative destination for non urgent patients, patients without a significant past history and patients not already in transit.  

Hospital Bypass

Hospital bypass of public hospital emergency departments should be minimised. Hospitals are required to manage patient flows to optimise their capacity to care for emergency patients. This requirement includes an appropriate admission policy and the integration of the functions of the emergency department with those of the rest of the hospital, to ensure smooth transfer of patients from the emergency department to inpatient facilities as required.
There will be occasions when a hospital initiates a request to  be bypassed by the ambulance service for a defined period. In these circumstances, the arrangements outlined below should apply.
Hospital Roles and Responsibilities
All emergency department requests for hospital bypass must be approved by an executive nominated by the Chief Executive Officer of the hospital. The health service will advise the ambulance service of the name/s of the senior officer/s who are authorised to seek hospital bypass.
Before seeking hospital bypass, the executive should be satisfied that:

• the emergency department has reached its maximum capacity

• the treatment of patients already in the emergency department could be significantly compromised by the delivery of additional patients requiring emergency treatment 

• that all possible steps have been taken by the hospital to avert the episode of bypass.

The hospital will notify MAS when hospital bypass is required.  MAS must be notified as soon as the hospital no longer requires hospital bypass.  If after two hours MAS has not been notified that bypass is no longer required, the hospital will return to open status.
Where a major metropolitan hospital initiates two or more bypasses in any given day (00.00 hours to 24:00 hours), details of these bypasses are to be reported to DHS through the Access and Metropolitan Performance Branch bypass reporting process, by email to bypass@dhs.vic.gov.au. This report should clearly outline the major issues leading to the initiation of the hospital bypass and what strategies have been initiated to minimise the potential for future episodes of bypass.  This report should be forwarded to the above e-mail address no later than midday the following business day.
Whenever there is a planned restriction of emergency department capacity, for example, for capital works purposes, the hospital is required to give the ambulance service, DHS and other hospitals likely to be affected as much advance notice as possible and provide details of the restrictions expected.
Ambulance Services Responsibilities

During a bypass period, the ambulance service will make every reasonable effort to transport non urgent patients to an alternative emergency department. Exceptions to this rule are:

• time critical patients who need to be taken to the nearest appropriate hospital
• other patients as agreed between the MAS duty clinician and the hospital emergency department.

The ambulance service will continue to monitor and report the incidence of hospital bypass requests to DHS.
Where a number of hospitals in the same area are simultaneously on bypass, MAS will notify those hospitals and inform them that in may not be possible to comply with the bypass request.