Scottish Government.
Dumfries and Galloway Royal Infirmary.
Emerg Med J. 2017 Dec;34(12):A875-A876. doi: 10.1136/emermed-2017-207308.21.
ED crowding is associated with increased mortality, poor staff and patient experience, an increased inpatient length of stay and poor compliance with the four-hour emergency access standard. Where crowding is caused by exit block, the focus needs to be on whole system patient management, reducing the temporal mismatch between admissions and discharges since at times of peak demand hospitals may become gridlocked until patients are discharged.In an attempt to tackle exit block, the Scottish Government Unscheduled Care Team have implemented the Daily Dynamic Discharge (DDD) approach, which aims to increase the number of inpatient discharges by 12 pm, thus enabling more timeous flow through the ED.
A series of meetings were held between the Unscheduled Care Team and the clinical and managerial staff of Dumfries and Galloway Royal Infirmary over a two-week period to train staff on implementing the elements of the Daily Dynamic Discharge approach. These included holding a daily whiteboard meeting with input from the multidisciplinary team, early determination of an Estimated Date of Discharge (EDD) for each patient, and conducting 'golden hour' ward rounds whereby the highest acuity patients were seen first followed by those who were expected to be discharged that day, thus increasing the number of discharges by 12 pm.
Over a twelve-week period the average number of weekly discharges increased from 26.5 to 30.2, i.e., an average increase of 3.7 discharges per week. Average length of stay dropped from 6.8 days to 6.2 days, a saving of 0.6 days.The median discharge time was 32 min earlier once DDD had been implemented. Previously, a third (33%) of patients were discharged before 4 pm; after implementation, this rose to 44%.
Emergency Department activity, and particularly crowding, is the barometer for the rest of the hospital, and the only way to guarantee that patients who require admission, get into the right bed, and in a timely way, is to ensure that the downstream wards discharge sufficient numbers early in the day to accommodate admissions from the ED.The DDD approach has been shown to be effective in increasing the number of discharges by 12 pm, smoothing the admission/discharge profile, and is now being adopted in other hospitals throughout Scotland.
Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust2006;184(5):213-216.
急诊拥堵与死亡率增加、医护人员和患者体验不佳、住院时间延长以及未能遵守四小时急诊就诊标准有关。如果拥堵是由于出院受阻导致的,那么需要关注整个系统的患者管理,减少入院和出院之间的时间不匹配,因为在需求高峰期,医院可能会陷入僵局,直到患者出院。为了解决出院受阻的问题,苏格兰政府非计划性护理团队实施了每日动态出院(DDD)方法,旨在增加 12 点前的住院患者出院人数,从而使急诊的患者流量更加及时。
在两周的时间里,非计划性护理团队与邓弗里斯和加洛韦皇家医院的临床和管理人员举行了一系列会议,培训工作人员实施每日动态出院方法的各项内容。这些内容包括每天与多学科团队一起举行白板会议、为每位患者确定预计出院日期(EDD)、进行“黄金时间”病房查房,首先查看最高危患者,然后查看当天预计出院的患者,从而在 12 点前增加出院人数。
在 12 周的时间里,每周出院人数从 26.5 人增加到 30.2 人,即每周平均增加 3.7 人。平均住院时间从 6.8 天减少到 6.2 天,节省了 0.6 天。实施 DDD 后,中位数出院时间提前了 32 分钟。此前,有三分之一(33%)的患者在下午 4 点前出院;实施后,这一比例上升到 44%。
急诊的活动量,尤其是拥堵情况,是医院其他部门的晴雨表,要确保需要住院的患者能够及时入住合适的床位,唯一的方法是确保下游病房在当天早些时候出院足够数量的患者,以容纳来自急诊的入院患者。DDD 方法已被证明可以有效地增加 12 点前的出院人数,使入院/出院情况更加平稳,现在正在苏格兰的其他医院采用。
Richardson DB. 急诊拥堵与患者 10 天后死亡率升高相关。澳大利亚医学杂志 2006;184(5):213-216.