An operational analysis of the Accident & Emergency Department at St. Luke's Hospital.

Abstract

Introduction: Every year the number of patients visiting the only Accident and Emergency department in the country is increasing. In 2002, 118,785 patients visited the department; this is equivalent to one quarter of the whole Maltese population (397,296 at end of 2002). St. Luke's Emergency department has become synonymous with long waiting times. Long delays can affect the health of patients and the eventual clinical outcome. Objective: To conduct an operational analysis of the A&E department at SLH and develop evidence-based proposals for reforming Emergency care. Methodology: Five different study designs were used in this management project. A prospective observation of patients' progress through the A&E department was done over a two week period by collecting the time taken by the patients at each stage, from arrival up to discharge/admission. A descriptive research design was done by collecting retrospective data of the daily number and hours of work of all the casualty nurses and doctors together with the total number of patients registering for the whole month of September 2002 and March 2003. A survey method was done to assess nurses' triage. Interviews with staff (doctors and nurses) regarding their views on the department. Interviews with patients regarding their satisfaction on the service provided Results: Through process mapping, four stages where identified as areas causing delays and increasing waiting times during a patient's journey through the current system: 1. Waiting to be seen for initial assessment by doctor after Triage (overall average waiting time is 0.5 hr for a priority 1 case, 1 hr for a priority two case and 1.5 hrs for a priority three case). 2. Waiting for a blood result (average waiting time was 1 hour 23 minutes) 3. Waiting for an X-ray result (average waiting time was 35.7 minutes). 4. Waiting to be seen by the SHO on call for a second assessment (average waiting time was 38.2 minutes). There is a mismatch between demand and supply; the staffing levels do not correspond to the peaks and dips of the arrival pattern. The level of agreement between the triage nurses was variable. Variability in triage category allocation related directly to variability in patient waiting times. Recommendations: Reforming the Emergency care to improve patient satisfaction by decreasing waiting time involves the following changes: 1. Introducing Streaming for the different categories of patients. 2. Appropriate Staff Matching with demand 3. Training of staff especially for triage 4. Adequate diagnostic and other services 5. Demarcation of working practices 6. Appropriate management infrastructure 7. Appropriate IT systems in place Conclusion: Waiting time is a key indicator of Accident and Emergency department's performance. Implementation of the above changes can produce significant improvement in the average patient waiting time without compromising the quality of service. The overall result is improved patient satisfaction, better utilization of resources, a service which centres on the patient, a decrease in the number of complaints by patients, a reduction in verbal abuse towards staff, decreased stress on staff, improved staff motivation and improvement in the overall image of the department.