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Abstract
We used routinely available data to identify the likelihood of exit block within type 1 EDs across acute trusts in England. While the findings are based on exploratory work and should be treated with caution, some patterns appeared to emerge from the data and require further exploration. NHS Trusts at risk of exit block were more likely to be large trusts, located in larger catchment areas, having higher admission rates and inpatient bed occupancy and higher levels of patients leaving the ED without being seen or reattending. Some of the factors identified may well be symptomatic of exit block rather than causal, while other factors may be acting as proxies for differences in casemix, social deprivation or ability to access alternative urgent care services.
- quality
- performance improvement
- emergency care systems, emergency departments
- emergency department operations
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- quality
- performance improvement
- emergency care systems, emergency departments
- emergency department operations
Introduction
Exit block (sometimes termed as ‘access block’) has been defined when ‘patients in the ED requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame’,1 and is of international significance with research evidence emerging from a number of countries, but predominantly Australia.2 ,3 To date, no scientific studies have been published in relation to exit block in the UK. We suggest that the commonly held definition of exit block, among ED clinicians, is that it occurs when patients are unable to be discharged from the ED, in addition to, when there are delays in accessing an inpatient bed, that is that exit block occurs when patients are unable to ‘exit’ the department. When exit block occurs, patients in the ED are highly likely to breach the maximum 4 h they are expected to spend there. We explored whether there are characteristics of NHS acute trusts and type 1 EDs which are associated with exit block, using the ‘4 h standard’ as a proxy measure for exit block.
Design
Routinely available A&E SitRep data were analysed to identify the likelihood of exit block within type 1 EDs across NHS acute trusts in England. We extracted the data containing the per cent of (type 1) A&E attendances admitted, transferred or discharged within 4 h of ED arrival, and used this as a proxy for exit block. We made the assumption that those NHS Trusts showing a higher percentage were experiencing lower levels of exit block than those with a lower percentage. We calculated the average of this variable during a 4-week period for three individual months in 2014 (June, October and December).
In each month, 10% (n=14) of all NHS acute trusts with a type 1 ED were selected to ascertain if there were any common characteristics of those trusts identified as having higher levels of exit block compared with those with lower levels. We identified seven NHS Trusts with lower compliance on the 4 h waiting target, and seven NHS Trusts reporting higher compliance levels. Compliance levels during the data collection periods varied (table 1). For this exploratory analysis, we simply compared the Trusts with lower compliance levels versus those with higher levels, and provide a descriptive analysis.
Trusts with lower compliance of 4 h target (ie, those at risk of exit block)
We used a literature review,4 to identify factors associated with exit block, and were able to identify data sources for some of these factors. Where data were routinely available, we retrieved the most recently available data. Other data had previously been collected as part of other studies undertaken by the authors.
Discussion
We were limited in exploring variables where data were routinely available, and acknowledge there are other factors that may be attributable to exit block (eg, staffing levels and throughput efficiency). However, there appeared to be some convergence between this data and our literature review,4 particularly during the periods of June and October. NHS Trusts at risk of exit block were more likely to be located in larger catchment areas, a finding borne out in the international literature.2 International evidence also suggests that inpatient occupancy is associated with exit block.5 NHS Trusts more likely to be at risk of exit block also had higher than average bed occupancy. The presence of exit block may influence the number of patients leaving the ED without being seen6 which we have found there was some association within the data. Some of the factors identified may well be symptomatic of exit block rather than causal, for example left-without-being-seen rates. Other factors may be acting as proxies for differences in casemix, social deprivation or ability to access alternative urgent care services.
December 2014 was a time of intense pressure for EDs in England and as a result hospital trusts introduce ‘emergency’ protocols to manage the increased demand. These can involve increasing bed capacity, employing more temporary staff and cancelling elective work in order to manage the increase in emergency admissions. These temporary measures may influence the relationship between the variables identified and performance.
Conclusion
Acknowledging that the findings are descriptive and should be treated with caution, some patterns appeared to emerge from the data and require further exploration. Building on the typology described here, and given the lack of UK-based evidence, we suggest that a statistical analysis of routine data is undertaken to establish where block is more prevalent, and further in-depth work exploring causal relationships between factors.
Footnotes
Contributors EK and SMM designed the study. CS participated in the data collection. EK prepared a first draft of the manuscript that all authors contributed to.
Funding Royal College of Emergency Medicine.
Competing interests SMM is a member of the Royal College of Emergency Medicine.
Provenance and peer review Not commissioned; externally peer reviewed.