title: Clearing emergency departments and clogging wards: National Emergency Access Target and the law of unintended consequences.
abstract: OBJECTIVE
  To assess ED length of stay (EDLOS), access block, inpatient length of stay (IPLOS) and waiting times before and after the implementation of the National Emergency Access Target (NEAT).
  
  
  METHODS
  This was designed as a retrospective cohort study and data was collected from electronic patient management systems. The control group represented all emergency presentations between June 2011 and September 2011, 1 year prior to the introduction of NEAT. The study groups were assessed and included all ED presentations between June and September 2012 and 2013 respectively. Main outcome measures were waiting times, EDLOS, proportion of patients cleared from the ED within NEAT goals, hospital length of stay and hospital mortality rates.
  
  
  RESULTS
  A cumulative total of 76 935 patients were included in the study. During the course of the study, clearance from the ED within NEAT targets rose from 49.0% to 53.2% [relative risk (RR) 1.09; 95% CI, 1.07-1.11; P < 0.001]. ED waiting times decreased from 1.05 h [interquartile range (IQR), 0.43-2.27] to 0.45 h (IQR, 0.17-1.22) (P < 0.001) and time from bed-request to ward access increased. Utilisation of emergency short stay units (SSU) increased significantly across the study period from 6.5% to 13.4% (P < 0.001). Rates of inpatient transfers increased eightfold (RR, 7.93; 95% CI, 5.98-10.51; P < 0.001) and IPLOS increased by 21% from 2.05 (IQR, 0.75-4.96) to 2.50 days (IQR, 1.12-4.99) (P < 0.001). Hospital mortality remained unchanged from 3.0% to 3.3% (RR, 1.10; 95% CI, 0.91-1.34; P = 0.311).
  
  
  CONCLUSIONS
  At the current institution NEAT success has been guarded, likely secondary to availability of inpatient beds. The implementation of NEAT appears to have reduced emergency waiting times. These early results suggest concurrent a detrimental effect on IPLOS; however, some of this effect may be a result of a large increase in short stay admissions.
authors.affiliation: Department of Surgery, Western Health, Melbourne, Victoria, Australia.
authors.forename: Marlon L
authors.initials: ML
authors.lastname: Perera
authors.forename: Alexander W
authors.initials: AW
authors.lastname: Davies
authors.forename: Neiraja
authors.initials: N
authors.lastname: Gnaneswaran
authors.forename: Marian
authors.initials: M
authors.lastname: Giles
authors.forename: Danny
authors.initials: D
authors.lastname: Liew
authors.forename: Peter
authors.initials: P
authors.lastname: Ritchie
authors.forename: Steven T F
authors.initials: ST
authors.lastname: Chan
mesh_terms: D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D004636:Emergency Service, Hospital / Q000331:legislation & jurisprudence / Q000458:organization & administration* / Q000706:statistics & numerical data; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000706:statistics & numerical data; D012044:Regression Analysis; D012189:Retrospective Studies; D013997:Time Factors; D014739:Victoria / Q000453:epidemiology; D014850:Waiting Lists; D055815:Young Adult
keywords: crowding; emergency service; health services accessibility; length of stay