21†Daily dynamic discharge - a whole system solution to ED crowding.

INTRODUCTION: 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.1 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. METHODS: 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. RESULTS: 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%. DISCUSSION: 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. REFERENCE: Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust2006;184(5):213-216.

Implications of full compliance with the computed tomography scanning recommendations of the National Institute for Clinical Excellence and Scottish Intercollegiate Guidelines Network guidelines for the management of head injury.

A prospective study was conducted to examine clinical practices in the management of head-injured patients preinception and postinception of the Scottish Intercollegiate Guidelines Network guidelines. Comparison was made between the Scottish Intercollegiate Guidelines Network and National Institute for Clinical Excellence guidelines on their indications for computed tomography scanning. Information was available on 2827 adult patients. Two hundred and thirty-two patients satisfied one or more Scottish Intercollegiate Guidelines Network criteria for computed tomography scanning. Four hundred and seventy-eight patients fulfilled one or more National Institute for Clinical Excellence criteria for scanning. No patient with Scottish Intercollegiate Guidelines Network or National Institute for Clinical Excellence indications for computed tomography scanning and who was not scanned, subsequently required neurosurgical treatment for a complication related to their injury. Full compliance with the scanning recommendations in the Scottish Intercollegiate Guidelines Network and National Institute for Clinical Excellence guidelines will require a significant increase in scanning resource and is unlikely to lead to the identification of a significant additional number of patients with intracranial lesions requiring neurosurgical intervention.

A survey of information given to head-injured patients on direct discharge from emergency departments in Scotland.

AIM: To survey the information provided to head-injured patients on discharge from emergency departments (EDs) in Scotland. METHODS: EDs throughout Scotland were asked to supply a copy of their head injury advice pamphlet for analysis. Each pamphlet was assessed against a template and an Excel spreadsheet was created. RESULTS: All 30 (100%) Scottish EDs responded. The frequency with which specific features appeared varied widely, with most pamphlets concentrating on emergency features, with less emphasis on postconcussion symptoms. CONCLUSIONS: Head injury discharge advice should be standardised throughout EDs, with more emphasis given to postconcussion features.