“A CROWDED HOUSE” Using an action research approach to address the problem of access block at Tertiary Referral Hospital. January to July 2003

Issue Addressed: Access block (the prolonged wait for an inpatient hospital bed after emergency department (ED) treatment) is regarded as oneof the major issues currently facing emergency medicine both in Australia and internationally. At this tertiary referral hospital review of existingdata has indicated that access block has continued to increase in recent years, with a sharp rise in emergency access problems since July 1999 andis now identified as a system wide problem.Objective: This research thesis sought to explore four main areas of inquiry concerning access issues within this hospital. The first objective wasto determine the current bed capacity of this hospital and identify the percentage of access block within this system. The second objective was toseek an understanding of hospital clinicians’ experiences of access block and to identify the factors they perceive directly influence patient accessto acute in-patient care. The third objective was to identify change strategies to improve patient access. The final objective was to determinewhether collaborative participation and involvement of clinicians would lead to a change in hospital culture and foster a collective ownership ofaccess block as a hospital wide problem.Method: In a participatory action research inquiry, hospital clinicians within this hospital were invited to be co-researchers. The process ofconcurrent investigation and action followed a five- part sequence of entry, issue identification, planning, action and reflection. Both qualitativeand quantitative research methods were used including in-depth semi structured interviews, focus groups, process mapping, control charts andstatistical analysis.Results: The research findings revealed a consistently high level of access block experienced by this hospital with bed occupancy rates in excessof 90%. During the study, hospital clinicians’ became actively involved in identifying major access issues. Six main delay categories evolved:Access delays due to limited imaging and diagnostic services, patient transport delays, barriers within the patient discharges process, insufficientaccess and availability to transitional, hostel, rehabilitation and nursing home beds and delays due to poor internal processes within the wards.Multi-disciplinary working parties were formed to implement six intervention strategies identified by the hospital clinicians. These included: thedevelopment of a patient access database and hospital wide alert system for code red status, the design of a pharmacy discharge prescriptiontracking system, the establishment of a patient discharge lounge, a quality study of the aged care assessment team within the ED and theformation of a transport working group to evaluate an electronic transport booking system within the hospital.Conclusion: In recording the qualitative process involved in gaining hospital clinicians’ perceptions of the problem of access block someindicators of engagement and empowerment were documented. The success of this participatory action approach is based on the simpleprincipal that those that are doing the job are in the best position to change or improve it