Meanwhile in WA hospitals (4 hour rule)

[mr friendly guy]

Now WA plans to implement a 4 hour rule where patients are seen, assessed and either discharge with treatment or admitted to the ward in 4 hours. This scheme is based on the British programme, which I will touch base on later. It was gradually introduced last year in phases.

linky on it

The Four Hour Rule comes to Australia
February 2009

WA health has taken another bold step in its continued quest to drive ‘long term system wide reform’ and implement strategies which will enhance the patient experience and ‘flow’ through the turbulent waters of ‘unscheduled care’. WA health has acknowledged that a radical change and expansion of improvement measures is required to have a significant impact on the increasing demand for emergency services in Western Australia.

As part of devising a solution to this problem, a group of clinicians from WA Health visited 12 hospital sites in the United Kingdom in November 2008 to look at the model used by the National Health Service (NHS). The model used in ‘most’ of the UK has been branded the ‘Four Hour Rule‘

Definition of the Four Hour Rule:

98% of patients arriving at the emergency department are to be seen and either admitted, discharged or transferred within four-hours from the time of triage.

Four Hour Rule Implementation in Western Australia:

The four-hour rule will be implemented in three stages, starting with adult tertiary hospitals (such as Sir Charles Gairdner Hospital (SCGH) and Royal Perth Hospital (RPH)) and Princess Margaret Hospital (PMH), then other metropolitan sites and finally, regional hospitals. Hospitals will have two years to ensure at least 98 per cent of their emergency patients either get a hospital bed or are discharged within four hours. The state’s tertiary hospitals and PMH will start phasing in the rule from April 14 2009.

The Intent of Implementation

The aim of this new program is to improve patient experiences by reducing delays in emergency departments (ED) and inpatient areas by streamlining processes for admission and discharge.

This is a serious reform of the way our hospitals operate and will take time to get right, but this is not simply about announcing a target -- Dr Kim Hames

editor's note - Kim Hames is the health minister

Contextualizing the Four Hour Rule

Implementing the four-hour rule will not just shake up the way emergency departments function, it will require a radical change to the way hospitals operate in general. A ‘localized version’ of the UK Four Hour Rule is essential, and it appears that the clinicians in the steering committee [Dr Frank Daly and Dr Robyn Lawrence] are looking closely at options to ‘skim the cream’ from the UK strategy to provide maximal benefit to the WA health system. The ability to observe the positive and negative aspects of the Four Hour Rule should provide a great platform from which to develop the most effective strategy for the WA hospital system.

The UK system will serve as a basis for the WA program, but the State Government will be refining the model to suit local conditions and community needs -- Dr Kim Hames

Editor's notes - remember the above line, because it will come back to haunt us.

Strategic options that could be reviewed include

Review and overhaul of the 5-tier Australasian Triage Scale (ATS) [triage system used to determine the priority for treating emergency patients]. Strategic implementation of a two-tier system ['majors' and 'minors'] or a three-tier system [category 1, category 2 and category 3-4-5]
Enhanced use of discharge lounges
Increasing 24 hour coverage [Dr Daly stated that 'hospital staff could be expected to work more night shifts and weekends under a patient-focused health service']
Earlier consultant/senior registrar review at triage
Increased use of GPs in Emergency Departments
Enhanced roles for nurses with more ‘defined’ nurse practitioner roles
Focused utilization of allied health services within the framework of the emergency department -- incorporating such as physiotherapy, occupational therapy, social work, psychiatric liaison, community health, HITH and
Implications:

Potential Positive Outcomes:

The current problem of ‘access block’ will be formally addressed. [Access Block occurs if the time from a patients presentation to their admission to an inpatient hospital bed exceeds 8 hours]. The current burden of access block rests with the emergency departments and has a significant impact on patient care.
The new ‘access block’ standard will be four hours not eight hours -- with ‘enforced’ high level compliance. This paradigm shift from ‘eight hours’ to ‘four hours’ would potentially solve the access block problem -- if achieved.
Implementation of the Four Hour Rule would force hospital administration to take responsibility for the problem of access block. The ramifications of poor patient flow would become a ‘hospital wide issue’ rather than purely an ED problem
The Four Hour Rule focuses staff on the assessment and management of patients at an early stage -- enhancing the use clinical judgment rather than waiting for the results of diagnostic tests.

Potential Negative Outcomes:

Increased stress. Increased after hour shifts, weekend shifts and potentially 24 hour ED consultant cover to address the surges in patient presentations
The setting of ‘targets’ with or without punitive penalties may lead to ‘gaming’ of the facts, the figures and the flow e.g. admitting patients to a ward to wait for test results, admitting patients who have yet to be seen or just ‘doctoring’ the figures.
Reduction in the standard of emergency care delivered. Currently the Australian Emergency Department model emphasizes early patient care, diagnostic investigation and procedural intervention. This model has been shown to reduce the overall patient length of stay (LOS) and increase discharge rates. Stringent time-capped pressure may denude the emergency physician of clinical autonomy and impact negatively on patient outcomes.
Increased propensity for adverse patient outcomes and the risk of early discharge from the ED without a definitive diagnosis or appropriate treatment plan in place.
‘Emergency care’ may be reduced to ‘early referral and flow management’ heralding a return to the perception of EDs as ‘patient portals with advanced severity-filtering criteria‘ akin to the ‘Casualty Departments’ of the 1950s and 1960s.
Clinical Flow in the ED will become the ‘Gold Standard’. Excellence in flow will be rewarded and necessarily be given higher priority than patient care

Four Hour Rule -- Success?

Fundamental concerns still exist with the time and percentages of the ‘Four Hour Rule’. The College of Emergency Medicine in the UK has suggested that ‘a 95% six hour target would be more sustainable, and cost effective.’

WA will be a test case for the rest of Australasia. It will be difficult to turn the clock back or implement later change if this model proves incorrect or harmful to patients.

Reduced relevance of Emergency Medicine as a profession. This will lead to a further deterioration in recruitment and retention of trainees and specialists in Western Australia. Rapid patient processing, reduced diagnostic evaluation and procedural intervention will impact heavily on the learning experience of emergency personnel.

ED Clinical Care will be capped at four hours from presentation for 95-98% of ED presentations. This may lead to a culture of ‘time-capped clinical concern’ for patients.

Patients are no longer known by their names or by their conditions, they’re not even known by a number…patients are referred to by their time. By this I mean how long they’ve been in the department…as soon as a patient ticks past 3 hours their name lights up like a Christmas tree…If their stay approaches 3 hours 30… the managers start to appear… they don’t actually care…about Mr Jones who is having a heart attack…he’s got to go, wherever it may be, as long as its not ED…[UK Medical Student 2008]

It is paramount that before we undertake a complete paradigm shift in the structure and function of our emergency departments and the way in which we evaluate and treat patients presenting with acute medical conditions -- that we fully evaluate the positive and negative aspects of the Four Hour Rule implementation in the UK. CHKS [a UK organization providing independent analytical benchmarking to the NHS] has published an audit of acute admissions.

Over the past five years, approximately two million extra patients were admitted to hospital through emergency departments (ED) in England, an increase not seen in Scotland and Northern Ireland, which do not have the four-hour target. In Wales, which implemented the target later, the rise was delayed but appeared in 2005. More than 25% of emergency admissions are discharged the same day, most being patients admitted through the ED; same day discharges after ED admission rose by 65% between 2001 and 2005, when the four-hour target was introduced in England.

CHKS states “there is no obvious clinical reason why growth in emergency admissions should differ between UK countries… the 4-hour target in England has clearly had an impact and potentially cost the taxpayer more than £2 billion… primary care trusts pay as much as £1,000 per admission, compared with about £100 for an ED treated patient. Other possible explanations include changes to out-of-hours care and NHS Direct but most of the increase must be due to the target… an example of how targets that are good in principle can have unexpected effects.” A spokesman for CHKS says that it is unlikely (but cannot rule it out) that the increase in admission through the ED is because hospital finances benefit; with payment by results they earn much more. An erudite summary from a nursing perspective is also worthy of consumption.

I am in favour of enforced targets for admission times. Like many of my colleagues I believe that a fundamental overhaul of the process by which we facilitate the emergency management of patients will ultimately provide better patient outcomes. However, I believe the exact process required to achieve such altruistic gains has yet to be determined.

However, the British themselves are planning to scrap this oh soooo awesome plan.

linky

Waiting targets for accident and emergency to be scrappedHealth secretary Andrew Lansley reveals plan to abolish four-hour target, instead focusing on 'best possible results'
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Alexandra Topping and Dennis Campbell The Guardian, Thursday 10 June 2010 Article history

The government is to take the controversial and potentially unpopular step of scrapping four-hour waiting time targets in accident and emergency departments and instead focus on delivering the "best possible results for patients", it said yesterday.

The coalition government had already announced widespread cuts to NHS targets that have "no clinical justification" without stipulating where the axe was likely to fall. But yesterday the health secretary, Andrew Lansley, revealed the plan as he took questions in the House of Commons following his announcement of a full public inquiry into failings at Mid-Staffordshire NHS Foundation Trust.

"We are going to look, and we will look constructively, at how we can scrap the four-hour target as it currently exists and work on the basis of what the clinical evidence makes clear directly contributes to delivering the best possible results for patients," said Lansley.

Asked to clarify his remarks, he said: "I was very clear in what I had to say – I'm going to abolish the four-hour A&E target. I will issue guidance to the NHS shortly, the purpose of which … is in order to ensure that we deliver better quality."

The news was cautiously welcomed in some areas. Mark Porter, chairman of the The British Medical Association's Consultants Committee, said that it was vital that patients were treated on the basis of their clinical need.

"Waiting time targets – by focusing attention on every patient – have improved the NHS in many respects. However, in some cases they have also created pressure on staff to make inappropriate decisions that could compromise care," he said.

Katherine Murphy, director of the Patients Association, said that targets had caused problems as managers focused on financial gain rather than clinical outcomes, but they had to be replaced with benchmarks and a system that regularly assessed patient experience. "There does need to be rigour in the system otherwise we could go back to the days when people were waiting on trolleys for two or three days," she said.

The shadow health secretary, Andy Burnham, said abolishing this target would be a major backward step for the NHS. "It opens the door to a return to the bad old days when patients spent hours on end waiting to be seen," he said. "Now Andrew Lansley urgently needs to give clarity to the NHS by explaining what alternative plans he has."

Lansley said that lower waiting times were "not a measure of the result for patients" as had been shown at Stafford hospital where between 400 and 1,200 more people died than would have been expected over three years.

"What happened at Stafford was evidence, and we had other evidence in many other places, that the four-hour target was being pursued not in order to give the best possible care to patients – but in spite of what would be the best possible care for patients," he told MPs.

He announced that a public inquiry into the unnecessary deaths of at least 400 patients at Stafford hospital, which had been rejected by the Labour government, would question senior NHS officials at the hospital's trust, as well as the local and national NHS bodies.

Regulators found a catalogue of failings including poor accident and emergency care, bad hygiene, and patients being helped by relatives because staff were too busy.

Lansley said: "Why did the primary care trust and strategic health authority not see what was happening and intervene earlier?"

The inquiry will be headed by Robert Francis QC, who undertook an independent inquiry into the scandal for the Labour government and produced a damning report in February. Unlike his first inquiry, Francis will this time hold hearings in public and have the power to compel witnesses to attend and answer questions.

I will come back when time permits to discuss what I think worked and what I thought sucked with this type of plan. However I will just like to say why are we going ahead with a plan which even the UK has scrapped because it didn't work. Hey at least we didn't copy the UK idea of homeopathic outpatient clinics (snigger snigger).

[mr friendly guy]

For those of us Australians living in WA, you would no doubt have heard about this from the media with the government touting this as a type of reform.

Now people reading this might be wondering, what is the big deal? Isn't it good that patients are seen in a rapid time frame? Well there are also quite a few cons as well as pros to this plan.

On principle it sounds good. The idea is to try to avoid the stories of people waiting in long queues in emergency departments waiting to be seen. Now the problem with long waiting times, ramping (where an ambulance waits outside the ED as there are just no beds for the patients) is real, however you can't just arbitarily declare that patients will be seen in 4 hours and expect it to happen. So what do you do? Increase funding? Nope. You put pressure on the hospitals in the hope that they develop some methods to see these patients in 4 hours. Fortunately the UK hospitals have already done that so we can just copy their plan. Right?

So like the banks which moved imaginary numbers around, hospitals can do similar things, albeit not as blatant. How do we do this?

1. Set up a separate unit where the patients get admitted real quick. When I say admitted it means that on the system they are registered as admitted even if they haven't been fully assessed. Lets call this unit the Medical Admission Unit (MAU) for medical patients and an equivalent one for surgical patients and lets call it the Acute Surgical Unit (ASU).

Before I go on, its important that I give some background on this. In the old days the process to admission would go like this.
a) Patient assessed by ED after being triaged. ED does the appropriate investigations eg blood tests etc.
b) Referred to the appropriate specialty eg medical or surgical or psychiatric etc.
c) Assessed by that specialty team IN THE EMERGENCY DEPARTMENT.
d) Admitted by that team and sent to a ward bed.

Note point D is the final step and occurs AFTER patient has been assessed by the admitting team and they of course agree with ED's assessment that they need admission. Now with the four hour rule it can go like this.

Situation one
a) Patient barely assessed by ED, which mainly just does some triaging ( lets assume in this example the patient has a medical as opposed to a surgical problem).
b) Referred to the MAU regardless of what medical specialty they fit under. After all let the MAU guys sort it out.
c) Once its in MAU its counted as having been "admitted" even if the MAU doctor is just starting to assess them. MAU serves the purpose of a rapid transit point where once its out of ED it counts as "admitted" for the purpose of massaging the numbers to say that the patient has been admitted in record time.
d) MAU doctor now starts to assess the patient.

Note essentially steps c and steps d have just been interchanged, ergo the same things will happen in the same amount of time but for the purpose of number keeping the patient has been "admitted" earlier. This is brought about because the patient is now assessed out of ED by the specialty team instead of in ED. Whoopeee. Now this is a particularly powerful tool because the patient may still wait in MAU for some time before being assessed (since the MAU doctor could be seeing another patient) and if its a busy day this delay won't affect the numbers. To elaborate in the old days if the referring team was busy and they have a large number of referals, all of those referals would be stuck in ED until the team could get to see them, and if we were keeping score they would have all breached 4 hours. However since they are now admitted even if NOT seen none of them will officially breach 4 hours even if they take hours longer to be actually seen.

To be fair, if the patient is out of ED it does allow them to free up a bed to see more patients and start the process anew. However there isn't really a reason the patient can't be assessed out of ED without massaging the numbers.

situation two

a) Patient barely assessed by ED, which mainly just does some triaging
b) Referred to the appropriate specialty
c) Patient is sent to the ward and counted as "admitted" even WITHOUT being assessed.

Straight away we can see some problems, both in regards to patients safety and doctor training. In no particular order

1. ED has become a glorified triaging service. Eventually they will do less emergency management except with serious situations where the patients for example needs resuscitation. This has two effects
a) Decreases the attractiveness for ED as a specialty for trainees
b) decreases exposure to medical conditions for junior doctors who work in ED, ie it will effect their training

2. In situation one the patient has essentially been "worked up" in the same amount of time. The numbers have been massaged to show that they were admitted quicker. While in principle this doesn't do any harm to the patient (if the numbers are small), we shouldn't pretend that the same amount of work happens faster because of the 4 hour rule. Now if the number of patients waiting in MAU to be seen is high, it could potentially be dangerous as one patient could deteriorate while the doctors there are seeing to another patient. At least while the patient is kept in ED, there would be more staff to be able to spread the load out.

Note - now with the advent of setting up a specialty ward to help with the rapid transit it does have some advantages. That is that patients are seen in one ward so logistically it is easier for the Doctors to get to them, as opposed to patients being spread out over different parts of the hospital (which most likely is a natural outgrowth as the hospital and population expand). The other advantage as I eluded to earlier is that it frees up a bed in ED and allows them to assess faster by starting to see the next patient who would otherwise be waiting to get a bed in ED.

3. In situation two the situation is clearly dangerous if they haven't been properly assessed. This is no brainer and no doctor will be pleased when a patient who is supposedly under their care dies when they haven't even seen the patient. This situation will tend to be a bigger problem for surgeons since they are in theatre and may be difficult to contact. In the old days ED will just have to wait for the surgical registrar to assess. Nowadays they can be sent to the ward without being seen if they are in danger of breaching the 4 hours time frame.

What happens if the patient wasn't that well (lets say not quite requiring a code blue to be called on them at the time of ED's assessment) and starts deteriorating later on. Most wards do not have the same facilities as ED (duh, ED is the Emergency Department). Most nurses on the ward are good at dealing with that specialty and can do basic resuscitation. However ED staff know how to work various machines like CPAP and BiPAP which helps you breath. ED can start running inotropes to support circulation which is failing. Not all the wards have these machines on hand nor have the staff who are familiar enough to work them.

4. In the UK model hospitals which underperformed were punished. This is silly without assessing why they are underperforming. Maybe its because you didn't provide adequate funding? With this type of punitive measures it just encourages hospitals to "game the system."


Now there are a few other good things to come out from this.
1. To avoid breaching, people are now suggesting that interhospital transfers bypass ED altogether and go straight to the ward, ergo they get admitted right away. Now that we have created a ward just for rapid transfers, well this new MAU ward fits the bill. It saves ED in the receiving (tertiary) hospital from assessing again (since they will have already been assessed by the sending, usually a peripheral hospital). Of course this relies on an accurate assessment by the Doctor from the sending hospital (ie a patient is sent to specialty x when in reality the diagnosis done by ED is incorrect and it requires specialty y), however generally we aren't too bad. This is better for the patient in that they just need to be seen again by the admitting team rather than seen twice in ED. This again frees up ED to do other things.

2. To run the new MAU ward we hired more doctors. OMG having more doctors actually makes patient care run faster? Who would have thunk that? I could have told the government that without the need for this 4 hour rule beaurecracy. With some of the methods my hospital tried to make things run faster, there was a clear delineation of duties between the MAU doctor and other admitting doctors with the proviso that we help each other if one got busy.

In summary good things from trying to implement the 4 hour rule are

1. They hired more doctors to run newly created units to help implement this rule
2. Interhospital transfers can bypass ED into a newly created unit thus saving time for assessment and the need for the patient to be seen by ED again in the receiving hospital.
3. ED patient flow is better because by sending a patient out of ED to MAU they allow ED to see another patient.

Note point one can be achieved without the need for the four hour rule and by hiring more doctors you will help with point 3. I would argue that it would help better with patient care since patients would be PROPERLY assessed faster as opposed to just dumping them onto a ward and counting that as being admitted even if the doctor hasn't actually seen them.

Bad, stupid things from trying to implement the 4 hour rule
1. Its unsafe to admit someone to a ward without proper assessment (granted they now get a quick ED assessment, but that can't compare to the doctor actually getting down and taking a good history, exam and diagnostic tests).

2. It encourages hospitals to game the system, giving a false impression that things are improving when its just numbers being moved around.

3. Dumbs down ED and makes things harder for the referring team since ED does less to help us.

4. Increase pressure on the medical staff, which in turn encourages point two, and puts pressure on staff to make faster clinical decisions which may not necessarily be the correct one vs taking a bit more time and a more measured approach.

[Twoyboy]

The funniest bit behind the rule is the implication that the hospitals can deal with the patients faster, they just don't want to. I mean, you give arbitrary time frame to 3 year olds you are trying to discipline. Do they really think the rule will have someone just snapping their fingers and making it happen?

Or are they actually planning that the hospitals will rort the system in the way Mr Friendly Guy describes so they can claim success? People are awfully hard on inept governments, they'd better hope no one dies because they get rushed through...

[The Yosemite Bear]

I thought at first that you post said WV, and I was wondering how this was going to effect Nitram's health problems....

[SirNitram]

HAving sat in Waiting Room Hell myself, it'd be nice to be seen within four hours, period. But it requires flagrant over-redundancy.

[mr friendly guy]

The funniest bit behind the rule is the implication that the hospitals can deal with the patients faster, they just don't want to. I mean, you give arbitrary time frame to 3 year olds you are trying to discipline. Do they really think the rule will have someone just snapping their fingers and making it happen?

The problem is, it gives little benefit and runs quite a bit of risk, namely the issue of safety, (see the article I linked where the UK scrapped this system). The pressure put on by the bed managers / flow coordinators etc means that a patient is sent the ward and may not be completely assessed properly. What happens if their condition deteriorates because they weren't that stable in the first place? If it happens in ED they have full resuscitation gear, staff, CPAP, BiPAP machines etc. If it happens on a regular ward not all these facilities are available. Wonder what will happen then.

Can you imagine a doctor who says I will look after you to a patient but doesn't even bother taking a history or examing them (or having a team member do the same). Now what happens when the patient has an adverse outcome. Would be pretty negligent no? Well this is what can and has happen in some cases by decree from higher ups, patients being admitted to the ward without being assessed and if the team cannot get to a patient in time before they move (usually because they have other patients to see) then tough luck. *

* Note this is different from a doctor saying over the phone that a patient should present for a proper assessment in ED based on a description by a person on the other end.

Or are they actually planning that the hospitals will rort the system in the way Mr Friendly Guy describes so they can claim success? People are awfully hard on inept governments, they'd better hope no one dies because they get rushed through...

Dude, we are already doing that. It happened to me last night. I was told that a patient already on the ward is now under the care of medics because in the rush for beds she was sent to an orthopaedic ward post fall, but she didn't actually have a fracture (so she should go to medics with view for rehab). Unfortunately with 2 sick patients I wasn't able to exactly stop what I was doing and see that patient. Thus the patient sat there unassessed until we manage to see her. Fortunately there was no adverse outcomes but there is always the risk and my consultant was not pleased with the situation.

linky from the UK circa 2009

I won't repost the whole article, however I will point out the pertinent points.

Forty per cent of nurses believe their colleagues are involved in helping to meet waiting time targets by underhand means, often referred to as ‘gaming’.

And one in 10 hospital nurses say they have personally been asked to engage in gaming to help meet waiting times this autumn.

The figures are revealed as part of Nursing Times’ investigation into pressures on the front line, which included an online survey of around 600 acute sector nurses.

Nottingham University Hospitals Trust was forced to apologise last month after admitting it had altered figures to meet the target.

Other examples include patients being temporarily moved from A&E – for example, to observation areas, corridors and in one case the theatre recovery ward – and patients being unnecessarily admitted to mixed-sex bays or sent to specialist wards without being seen by a doctor first.

I am an easy going guy and since we have been informed that we can't be seen to oppose this plan because of the intense political pressure to make this "work." I try and keep my head down and just do my job, however after working with this implementation I can't say that I am happy with this oh sooooo awesome plan.

[PainRack]

Just out of curiousity, how do the patients view the system?

I do know that when patients come into the ward proper, some of them are quite upset by the numerous transfers they have been through. Indeed, the routine transfer from our equivalent of the MAU to the proper ward itself has some of them believing that their condition must had been quite serious to warrant such transfers in the space of 24 hours.

[mr friendly guy]

I am not sure how patients view the system. However anecdotally patients and relatives aren't pleased when they move wards even when its not related to the 4 hour rule. So I can't imagine why they would suddenly mind being moved just to configure some numbers.

Now usually to be safe hospitals must run somewhat under capacity, ie so they have spare meds in case of emergencies etc. If they run close to capacity they have to cancel things like elective surgery to make the beds. Now I heard that two of the 3 major hospitals in WA are running at 97% and 98% respectively, which is a strain already. The other tertiary hospital is running at 110% capacity daily on average. Think about that. There are more patients than beds available so they wait in corridors etc and the bed managers do the equivalent of musical chairs with beds.

Ultimately the government declaring we must see patients within 4 hours etc will play second fiddle to the real problem, a lack of beds vs the growing population.

Now people who see me post in Australian health threads will see that I do make suggestions, for example keeping costs down etc. I will now make suggestions on how to help with this problem, but the government won't like it because it involves something called money. Which they don't like giving out except if you are a druggie who can't qualify for a second liver transplant after screwing up your first one.

But here goes

1. Improve the peripheral hospitals so they are less likely to send referals to tertiary ones. This includes at least a high dependency unit if not an intensive care unit. To some extent the government is doing that, however they can nationalise a certain private hospital which is run for profit so they just take care of mainly easy cases and send complicated cases to the tertiary hospitals to pick up the tab. Now where are we going to get this money from. Well I hear that Rio Tinto made a bigger than expected profit and we just increase mining royalties at the same time hypocritically bitching about the Federal government's mining tax because its done by the ALP. I also hear of a project called Gorgon and a certain country with the 2nd largest economy by PPP and maybe even second largest by nominal GDP which is starting to buy our minerals again.

2. Scrap the beaurecracy with approving elderly for nursing homes. Make it easier so that all the paperwork and forms can be filled out quicker and then we can clear these elderly patients who are simply awaiting nursing homes out and free up the bed. One way we can do this is so that the forms to approve a nursing home / hostel placement is the same form to approve them to a Care Awaiting Placement bed (essentially a bed where they wait until a nursing home is found, without the level of care and cost a full hospital bed provides because they don't need it). This of course is I suspect in the realms of the Federal government rather than the state one.

However we seem to lack the ability to cooperate with the Federal government prefering to engage in dick waving and grand standing.

3. That brings me to the next point. We may need more social workers to do their relevant aspect of these paper work, or as I suggest above make it less beaurecratic and there we go.

4. Encourage GPs to arrange the Aged Care assessments (ACAT) in the community for at risk patients. So when these patients present to hospital not able to cope at home because of dementia etc, the paper work is already done and thus we can shorten their stay.

5. This is going to be controversial, but consider paying specialists more money to do various procedures on a saturday. For example gastroscopies, colonoscopies and echocardiograms. This will cut down the weight list, and if the inpatients aren't competing as much with the outpatients for procedures, they maybe able to get it done earlier, hence earlier discharge.

6. Maybe have the new Fiona Stanley hospital have more beds instead of this private hospital mentality of single rooms, as opposed to say two to four patients in a room. This gives us more beds. Single rooms should only be used for isolation purposes. IIRC the new hospital is proposed to have less beds than RPH and Fremantle combined, when it was meant to essentially replace these hospitals. Now thats less likely since we decided not to scrap RPH. However to keep RPH running they have to find cash somewhere, yet they can't come up with cash for other purposes in their budget even when they planned to scrap it.