Iniciativas para reducir la espera

1. Collegian (2014) 21, 359—366
Available online at www.sciencedirect.com
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Initiatives to reduce overcrowding and
access block in Australian emergency
departments: A literature review
Kimberley Crawford, PhD∗
, Julia Morphet, MN(Ed),
Tamsin Jones, MHP(Ed), Kelli Innes, MN(Ed),
Debra Griffiths, PhD, Allison Williams, PhD
Monash University, School of Nursing and Midwifery, Peninsula Campus, Australia
Received 31 May 2013; received in revised form 22 August 2013; accepted 17 September 2013
KEYWORDS
Emergency
department;
National Emergency
Access Target;
Overcrowding;
Access block;
Initiatives
Summary Australian emergency departments are experiencing an increasing demand for their
services. Patient throughput continues to expand resulting in overcrowding and access block
where patients cannot gain entry to appropriate hospital beds. This is despite both state and
federal governments implementing numerous schemes to address the complex causes of stress
on emergency departments. This paper explores the current literature and highlights the key
strategies adopted by different emergency departments to reduce delays and streamline patient
flow, including: waiting room nurses; streaming; rapid assessment teams; short stay units and
care coordination programmes. Many of these initiatives have proven successful at reducing
the number of people re-presenting to the emergency department, addressing time delays and
improving the management of existing resources and patient flow. More recent changes include
increasing the scope of practice and workload for triage nurses. With the recent introduc-
tion of the National Emergency Access Target, which requires that most patients presenting
to Australian emergency departments are reviewed and transferred or discharged from the
department within 4 h, traditional roles of nurses in the emergency department are changing
and expanding to meet the needs of modern healthcare systems.
© 2013 Australian College of Nursing Ltd. Published by Elsevier Ltd.
∗ Corresponding author at: Monash University, School of Nursing
and Midwifery, Peninsula Campus, PO Box 527, Frankston, Victoria
3199, Australia. Tel.: +61 3 9904 4152; fax: +61 3 9904 4402.
E-mail address: kimberley.crawford@monash.edu
(K. Crawford).
Introduction
The Australian healthcare system is under increasing pres-
sure to meet the growing demand for healthcare. As with
other developed countries, this pressure is a result of
an increase in our population who are ageing and more
likely to need healthcare services. In addition, there are
limited General Practitioner (GP) services and increasing
1322-7696/$ — see front matter © 2013 Australian College of Nursing Ltd. Published by Elsevier Ltd.
http://dx.doi.org/10.1016/j.colegn.2013.09.005

2. 360 K. Crawford et al.
costs associated with GP visits (New South Wales Health,
2007) and communities who are better informed about
their healthcare needs (Daly, Campbell, & Cameron, 2003).
In 2009—2010, Australian public hospitals treated 1.1 mil-
lion more emergency department (ED) patients than in
2005—2006 (Australian Institute of Health and Welfare,
2011). However, in the last two decades there has been a
decrease in available acute hospital beds (Cameron, Joseph,
& McCarthy, 2009) and federal funding cuts (Medew &
Martin, 2012; Nicholls, 2012) which have exacerbated the
pressure on EDs. Emergency departments are under a con-
stant strain to cope with this increasing demand and attempt
to assess, diagnose and treat patients in less time. Over-
crowding, where the number of patients waiting to be
assessed, treated and discharged far exceeds the physical
and staffing capability of the ED (Fatovich & Hirsch, 2003)
and access block, where patients are unable to gain access
to appropriate hospital beds within 8 h (Forero, McCarthy,
& Hillman, 2011), are major concerns for nurses wanting
to maintain quality services in Australian EDs. An increase
in waiting times is often associated with poor outcomes for
patients (Bernstein et al., 2009; Jones & Schimanski, 2010;
Richardson, 2006).
Background
There is no single event responsible for overcrowding and
access block within Australian EDs. The causes are com-
plex and often interrelated. The most common causes
include: increased complexity and acuity of patients pre-
senting to the ED; an overall increase in patient volume; a
lack of beds for patients admitted to the hospital; a short-
age of nursing and administrative staff; delays in receiving
results from radiology, the laboratory and ancillary services;
limited physical space within the ED; language and cultural
difficulties; and additional medical record documentation
requirements (Derlet & Richards, 2000; Fatovich & Hirsch,
2003).
In the last 20 years, Australian Federal and State Gov-
ernments have implemented various schemes to reduce
overcrowding and access block in the ED, with the intention
of improving patient flow and decreasing patient waiting
times (Forero et al., 2011). Traditional ways of working in
the ED have been challenged and hospitals are developing
innovative strategies to reduce the time a patient waits
to be seen, and the time taken to admit to hospital or
discharge the patient (Ashby, 2003; Cameron & Campbell,
2003; Fatovich, 2003; Hammett & Robinson, 2003; Hill,
2003; Richardson, 2003; Ruffin & Hooper, 2003). This paper
will examine initiatives being utilised by hospitals around
Australia and the changes made to improve the patient jour-
ney through the ED. The paper will offer recommendations
for nurses striving to maintain quality of care in a health
care system struggling to meet the needs of the community.
Literature review
Electronic data bases including Medline, Proquest, Pubmed
and Scopus were accessed to search the published lit-
erature relating to Australian EDs using combinations of
the key terms: overcrowding, access block, emergency
department, Australia, four or 4-h rule or target, National
Emergency Access Target, initiatives or innovations, stream-
ing, fast track, lean thinking from 1992 to 2013. Reports
released by Government agencies including: the Department
of Health, the Australian Institute of Health and Welfare,
the Metropolitan Health and Aged Care Services Division,
the National Health Performance Authority and the Depart-
ment of Human Services were used for informative purposes
and background research. Broadly speaking, initiatives have
either focused on the ED or on inpatient services. ED initia-
tives include changes to patient flow processes, introducing
new nursing roles with expanded scope of practice, the
management of specific patient groups, and programmes
to address frequent attenders to the ED. In conjunction
with these initiatives, hospital wide projects include the
National Emergency Access Target, implementation of care
coordination teams and discharge planning initiatives, the
use of transit lounges and the introduction of new types
of units that promote rapid assessment of patients (Ashby,
2003; Cameron & Campbell, 2003; Fatovich, 2003; Hammett
& Robinson, 2003; Hill, 2003; Richardson, 2003; Ruffin &
Hooper, 2003).
The introduction of the National Emergency
Access Target
In 2010, the Australian Government introduced the National
Emergency Access Target (NEAT), which requires that most
patients presenting to Australian EDs are reviewed and
transferred or discharged from the ED within 4 h. By 2015,
90% of all patients presenting to Australian EDs will need
to have left the department within 4 h to meet the NEAT
(Australian Government Department of Health and Ageing,
2011). The introduction of the NEAT was intended to ensure
that the responsibility and solutions for overcrowding and
access block were shared between the ED and the hospital
(Geelhoed & de Klerk, 2012). This initiative was modelled on
the scheme used in the United Kingdom (UK). In 2000, the UK
launched the National Health Service Plan with the intention
of improving delivery and access to health care, ambitiously
declaring that ‘By 2004 no one should wait longer than 4 h
in Accident and Emergency from arrival to admission, trans-
fer or discharge’ (Department of Health, 2001; Mortimore &
Cooper, 2007).
Western Australia introduced the four-hour rule in 2008
after persistent and damaging media attention on the con-
dition of that states’ ED, ambulance delays, cancelled
surgery and the risks to patients caused by these condi-
tions (Mountain, 2010). The objective was to firstly ensure
85% and eventually 98% of patients would either be dis-
charged or admitted to a ward within 4 h of presentation
to the ED (Geelhoed & de Klerk, 2012). Geelhoed and de
Klerk (2012) evaluated the effectiveness of the four-hour
rule in three tertiary hospitals in Western Australia, find-
ing an improvement in ED overcrowding, which resulted in
a reduced mortality rate.
In light of evidence that increased length of stay (time
spent within ED) results in increased mortality and morbidity
(Bernstein et al., 2009; Richardson, 2006; Sprivulis, Da Silva,
Jacobs, Frazer, & Jelinek, 2006), the four-hour rule was
introduced as a way of improving patient outcomes. Despite

3. Initiatives to reduce access block: A literature review 361
its intended aim, and the investment of £820 million, UK
studies reveal that the rule has not had a positive impact
on: the quality of care provided, patient outcomes (Jones &
Schimanski, 2010; Mason, Weber, Coster, Freeman, & Locker,
2012; Mortimore & Cooper, 2007), or reduced patient waiting
times (Jones & Schimanski, 2010). Finally, there is evidence
that much of the burden to meet the four-hour target in the
UK was placed on the shoulders of the clinical staff, espe-
cially the nurses (Lipley & Parish, 2008; Mortimore & Cooper,
2007). It is not surprising then, that nurses working in UK EDs
reported increased workloads and concern over the quality
of care provided (Mortimore & Cooper, 2007).
In response to these findings, the UK Secretary of State
for Health said the four-hour rule ‘‘provides incentive to
move patients through ED quickly, but does nothing to ensure
patients are receiving the highest quality care’’ (Lansley,
2010). In 2010, he proposed the rule be abolished (Goh,
2011; Letham & Gray, 2012). In light of the evidence that the
four-hour rule did not improve patient outcomes, a suite of
clinical quality indicators were introduced with the inten-
tion of providing a more balanced approach to measuring
quality of care in the ED (Department of Health (United
Kingdom), 2010; Woodcock, Poots, & Bell, 2013).
There has been scant research examining the effect
of the four-hour rule on patient outcomes in Australia.
To identify if the four-hour rule is a success, ED qual-
ity of care indicators such as: proportion of people who
left without being seen; patient re-presentation within 48 h
of discharge, mortality rates, and ED times to analgesia,
antibiotics, reperfusion, and asthma treatment, must be
examined (Jones et al., 2012).
Nurse initiated interventions
In an attempt to shorten patient length of stay, several
EDs have increased the scope of nursing practice, allowing
nurses to initiate investigations and interventions including
blood tests, analgesia, and radiography. Nurse initiated anal-
gesia has been found to significantly decrease time to pain
assessment and analgesia and has reduced ED length of stay.
In one study the median time for pain assessment decreased
from 47 min to 1 min, while the time to administration of
analgesia decreased from a median time of 98 min to 28 min
(Finn et al., 2012).
‘Testing’, which includes blood tests, urinalysis, ECG and
radiography, has been shown to extend patient ED length
of stay. Patients requiring blood tests were found to stay
72 min longer than patients who did not require blood tests
(Kocher, Meurer, Desmond, & Nallamothu, 2012). Allowing
nurses to initiate pathology as soon as the patient arrives in
the ED ensures results are likely to be available by the time
the patient is assessed by a medical officer, and decisions
about care can therefore be made more rapidly.
Similarly, nurse initiated X-ray has been introduced in
several EDs to decrease length of stay for patients with minor
injuries (Blank, Santoro, Maynard, Provost, & Keyes, 2007;
Bowman & Gerdtz, 2006; Fry, 2001; Parris, McCarthy, Kelly, &
Richardson, 1997), and has been shown to decrease patient
length of ED stay (Tambimuttu, Hawley, & Marshall, 2002).
It has also been reported that patient satisfaction increased
and staff perceived that patients were treated more quickly
as a result of nurse initiated X-ray (Bowman & Gerdtz, 2006;
Fry, 2001; Parris et al., 1997).
Increasing nurses’ scope of practice to encompass nurse
initiated analgesia, testing, and X-rays at triage has been
shown to reduce patient length of stay and patient quality of
care indicators. However, triage is recognised as one of the
busiest areas of the ED, and expanding the scope of practice
for triage nurses, significantly adds to the triage workload,
which must be reflected with improved triage staffing.
Waiting room nurse
In response to escalating triage workloads, increasing wait-
ing times and deteriorating patients in the waiting room,
some EDs have introduced waiting room nurses. The primary
role of the waiting room nurse is to reassess and moni-
tor patients in the waiting room. Any deterioration in the
patient’s condition will then be reported to the triage nurse,
so that appropriate management can be initiated (Blank
et al., 2007; Hudson & Marshall, 2008). The waiting room
nurse is well positioned to initiate analgesia, order simple
limb X-rays, order and take pathology, and reassess patients
who have waited for extended periods. Emergency depart-
ments that have introduced the waiting room nurse have
reported a reduction in patient length of stay, the number
of adverse incidents in the waiting room, a reduction in the
number of patients who have left without treatment (com-
monly referred to as ‘did not wait’), as well as a higher level
of patient satisfaction (Blank et al., 2007; Taylor & Benger,
2004).
Patient streaming
Patient streaming is a way of directing patient flow, so
that patients with minor injuries or illnesses can be seen
in a separate area of the ED than patients with complex
care requirements. The most common example of stream-
ing minor presentations is called fast track (Department
of Human Services Victoria, 2008; Oredsson et al., 2011).
Triage nurses perform a rapid assessment of all patients, and
then allocate suitable patients to the fast track area. Med-
ical and nursing staff are allocated to the fast track area
specifically to provide care to this patient cohort. Effec-
tively, this reduces the total number of patients remaining
in the ED and improves the flow for ‘fast track’ patients,
as they are not queuing up behind more acute or complex
patients.
Streaming has been reported to benefit all ED patients,
not just those in fast track. Australian studies reveal that
all ED patients were seen by a doctor more quickly fol-
lowing the implementation of streaming (Ieraci, Digiusto,
Sonntag, Dann, & Fox, 2008; Kelly, Bryant, Cox, & Jolley,
2007; King, Ben-Tovim, & Bassham, 2006). ED length of
stay has also been significantly reduced following stream-
ing (Ieraci et al., 2008; King et al., 2006; O’Brien, Williams,
Blondell, & Jelinek, 2006).
Another reported benefit of streaming was a reduction in
patients’ who did not wait for treatment (Ieraci et al., 2008;
King et al., 2006; Kwa & Blake, 2008; O’Brien et al., 2006).
Studies indicate that the percentage of patients who did
not wait reduced between 2.3% (2686 patients per annum

4. 362 K. Crawford et al.
compared with 1592 patients per annum) (King et al., 2006)
to 17% (29.3 patients per week compared with 18.3 patients
per week) (O’Brien et al., 2006) following the introduction
of streaming.
In contrast to these positive findings, one Australian
study reported an increase in re-presentation rates of non-
admitted patients from 3.2% to 4% (Ieraci et al., 2008).
Unplanned return to hospital is considered an adverse
event and might result from inappropriate discharge (Jones
et al., 2012). Discussion regarding the cause of increased
re-presentation rates centres on the perception of staff in
fast track. It is widely accepted that patients in fast track
are not complex and typically do not require admission.
This perception may risk failure to look for complexities or
comorbidities which may indicate admission.
Another concern for triage nurses in relation to streaming
is that some EDs are electing to use streaming in place of
the Australasian Triage Scale. In practice, this means that
‘‘in the absence of threat to life or limb’’ patients are
seen in order of arrival rather than per their triage cate-
gory (King et al., 2006). This practice is in opposition to
the Australian College of Emergency Medicine and College
of Emergency Nursing Australasia triage recommendations
(Australasian College for Emergency Medicine, 2006; College
of Emergency Nursing Australasia, 2012). While it is reported
that this change in practice resulted in reduced time to
‘‘initiation of meaningful treatment’’ (King et al., 2006), it
places a greater burden on the triage nurse, who is responsi-
ble for all patients in the waiting room, and may now expect
more acute patients to wait for treatment, while less acute
patients are seen by medical staff, simply because they
arrived first.
Rapid assessment teams
Also directing patient flow, rapid assessment areas in the
ED facilitate flow of patients from the waiting room to
the next point of care in a timely manner. Various inclu-
sion criteria have been reported for rapid assessment areas
(Eller, 2009; Shetty, Gunja, Byth, & Vukasovic, 2012; Tsai,
Sharieff, Kanegaye, Carlson, & Harley, 2012), but the pro-
cesses and goals of rapid assessment teams are similar.
Following triage, patients who meet the criteria for rapid
assessment are seen by the ‘rapid assessment team’ of med-
ical and nursing staff. Like the expanded scope of practice
for triage nurses, this expedited assessment process enables
early ordering of interventions, and also facilitates disposi-
tion to an appropriate area within the ED (Ardagh et al.,
2002; Bullard et al., 2012; Considine, Lucas, Martin, et al.,
2012; Considine, Lucas, Payne, et al., 2012; Eller, 2009;
Shetty et al., 2012; Tsai et al., 2012).
The rapid assessment process has been reported to
reduce patient waiting times, contributing to improved
ED flow and better patient outcomes. Studies indicate
that rapid assessment teams have significantly reduced
patient length of ED stay (Ardagh et al., 2002; Eller, 2009;
Sethuraman, Kannikeswaran, Chen, & Mahajan, 2011; Shetty
et al., 2012; Tsai et al., 2012), ranging from 58 min (Tsai
et al., 2012) to 208 min (Eller, 2009). There has also been a
reduction in off stretcher times and the number of patients
who did not wait (Ardagh et al., 2002; Bullard et al., 2012;
Considine, Lucas, Martin, et al., 2012; Considine, Lucas,
Payne, et al., 2012; Eller, 2009; Sethuraman et al., 2011;
Tsai et al., 2012), with studies showing a reduction ranging
from 1.1% (p = 0.02) (Shetty et al., 2012) to 11% (Tsai et al.,
2012).
Care coordination teams
In Victoria the Hospital Admission Risk Programme was
introduced to promote specialised client-centred medical
care and care coordination that integrates hospital and com-
munity resources. Hospitals were encouraged to initiate
programmes that would reduce the demand on hospital ser-
vices and improve patient health through new approaches
to patient management (Bird, Noronha, & Sinnott, 2010;
Department of Human Services, 2006).
As part of this initiative, many EDs established Care Coor-
dination Teams that consist of allied health and/or nursing
personnel whose role is to identify and treat patients at risk
and facilitate their safe discharge thus reducing representa-
tion. The care coordination teams target high risk patients,
in particular: the elderly; those who frequently attend the
ED; the homeless; and those with drug and alcohol prob-
lems (Corbett, Lim, Davis, & Elkins, 2005; Moss et al., 2002;
Phillips, Brophy, Weiland, Chenhall, & Dent, 2006).
A study of Melbourne metropolitan EDs by Taylor,
Bennett, and Cameron (2004) found that care coordination
teams comprise a multidisciplinary team; 92% of care coor-
dination teams consist of an occupational therapist, a social
worker, and a registered nurse (aged care, emergency, com-
munity nursing or discharge planning specialist), 75% also
include a physiotherapist and 8% a dietician. An evaluation
of a care coordination team at a large metropolitan hospital
in Victoria, found that significantly fewer patients required
admission from the ED after the service commenced, com-
pared to the 12 month period before the introduction of the
team (13,420 patients, 30.9% [95% CI 30.5—31.3] compared
to 14,217 patients, 32.6% [95% CI 32.2—33.0]; p < 0.001)
(Moss et al., 2002). Surveys revealed that there was a high
degree of staff satisfaction with the team and patients
reported that the care coordination team provided a high
quality service (Moss et al., 2002).
A similar care coordination programme at another Vic-
torian metropolitan hospital also reported promising results
(Corbett et al., 2005). During the 4 year evaluation of the
programme, the number of patients presenting to the ED
increased by 7.84% but since the introduction of care coor-
dination, inpatient bed numbers remained stable.
The efficiency of these care coordination programmes
was occasionally hampered by variations in staffing levels,
an inability to recruit staff from diverse backgrounds and
resource limitations of community services, including: inad-
equate places in aged care facilities, rehabilitation units
and limited after-hours services (Corbett et al., 2005; Moss
et al., 2002).
Short Stay Observation Units
Short Stay Observation Units have been co-located with
many EDs to reduce the length of patient stay in the ED
(Konnyu, Kwok, Skidmore, & Moher, 2012). These units

5. Initiatives to reduce access block: A literature review 363
accommodate patients requiring more than 4 h of observa-
tion or treatment, but who are deemed unlikely to require
admission to a hospital ward (Daly et al., 2003; Konnyu et al.,
2012). The admission criteria to the Short Stay Observation
Unit varies between hospitals, ranging from >24 h to <72 h
(Taylor et al., 2004). The use of the Short Stay Observation
Unit has been deemed to work well when care is straight-
forward, protocols for treating common conditions are well
developed and nurses have the power to advance patients to
the next step in their treatment pathways once agreed crite-
ria are met. The most important feature of these units is that
patients, carers and staff are all aware that the patient will
only stay for a designated period (O’Connell et al., 2008).
Discussion
With the introduction of the National Emergency Access Tar-
get, EDs must ensure that patients are assessed, treated and
discharged within 4 h. This paper has examined key Aus-
tralian initiatives that were introduced with the intention
of improving the patient experience by: reducing delays
in the ED, streamlining patient flow and introducing new
processes to manage patients. As this paper reported,
it has been demonstrated that some of these initiatives
have been effective in: reducing the number of people re-
presenting to the ED, improving the management of existing
resources, increasing patient flow and tackling time delays
(Blank et al., 2007; Ieraci et al., 2008; Moss et al., 2002;
Tambimuttu et al., 2002).
Overcrowding and access block have the potential to
threaten the safety of patients; a growing number of stud-
ies have been conducted that document the adverse effects
of ED crowding on clinically important outcomes (Bernstein
et al., 2009; Richardson, 2006; Sprivulis et al., 2006).
Australia’s response to overcrowding and access block was
to introduce the 4-h rule. There remains much debate about
the positive and negative consequences of setting targets in
health. Advocates suggest that the target has the potential
to drive hospital-wide initiatives and will result in patients
being treated more quickly (Bevan, 2009; Maumill et al.,
2013). Those against the target claim that there will be a
preoccupation with meeting targets rather than focusing on
the patient hospital journey, and further argue the target
places a burden on staff, especially nurses, to achieve the
time target (Gubb, 2009). Weber, Mason, Carter, and Hew
(2011) reported that the burden of the four-hour target in
the UK seemed to fall heavily on ED nurses. In addition to
caring for their own patients in the allocated time, nurses
felt they needed to urge physicians for decisions and were
constantly aware of the clock. Furthermore, the NEAT is
often identified as an ED target; thus releasing others of
the responsibility for achieving this target and resulting in
limited improvements beyond the ED (Weber et al., 2011).
Many hospitals have implemented programmes which
ensure that the burden of the four-hour target is a hospital-
wide problem and not the sole responsibility of the ED. Some
hospital initiatives are designed to improve the discharge of
patients from the hospital wards (Cameron et al., 2009) or
utilise the transit lounges that provide low level nursing care
to patients who are awaiting admission to or discharge from
a ward (Fatovich, 2003; Forero et al., 2010; Richardson,
2003).
In order to tackle patient flow and time delays, rapid
access to diagnostic services, such as radiology and pathol-
ogy from the ED is important (Forero et al., 2011). Nurse
initiated interventions, including the waiting room nurse,
have increased the scope of nursing practice within the ED.
As this paper described, studies that have assessed these ini-
tiatives have reported improvements in ED quality of care
indicators (Blank et al., 2007; Finn et al., 2012; Tambimuttu
et al., 2002). Despite these positive results, the introduc-
tion of these initiatives should not increase the workload
of nurses beyond what is feasible; where nurses feel that
the burden of this time target is solely their responsibility,
or where triage and nurse initiated interventions outstrip
nursing resources.
Following the introduction of the four-hour target in the
UK, nurses were provided with further training for new clin-
ical and leadership roles and enhanced autonomy. The UK
nurses also felt empowered to initiate diagnostic testing
(Weber et al., 2011). If implemented correctly, programs
such as nurse initiated interventions offer the possibility of
effectively utilising a nurse’s skills and knowledge to the full
potential, but there is a clear need for increased nursing
hours if nurses are to increase their scope of practice.
Most of the initiatives this paper has examined have been
in place for the last 10 years. Reports indicate that that the
introduction of these initiatives has improved important ED
quality indicators but hospitals are still experiencing over-
crowding and access block. Furthermore, a large number of
initiatives that have been introduced into Australian hospi-
tals have not been formally evaluated. It is difficult to see
how the NEAT will improve ED processes without compro-
mising patient safety. In the UK, the proportion of patients
seen and treated within 4 h improved from 2003 to 2006;
however, Mason et al. (2012) found that the proportion of
patients leaving the ED in the final 20 min of the 4 h length
of stay increased from 4.7% of all patients in 2003 to 8.4%
in 2006. This suggests that hospitals are performing to the
target but may not be improving patient care (Mason et al.,
2012).
When the UK initially introduced a time target, they
wanted all patients to be seen and discharged or admitted
within 4 h (Mortimore & Cooper, 2007). There were con-
cerns that this stringent target did not guarantee patient
care (Mason et al., 2012). Australia has learnt from the
UK experiences; the NEAT does provide some flexibility
for difficult or complex patients to be managed accord-
ingly. The target requires that 90% of patients should be
admitted or discharged within 4 h. Therefore, patients with
multiple and complex needs will not be included in the
performance indicator; these patients can receive the addi-
tional attention they require so that their health is not
compromised.
Reports from the UK suggest that whether the ED achieves
its target and avoids producing negative consequences is, to
a large extent, dependent on how the target is implemented
(Weber et al., 2011). This paper has reported that the intro-
duction of these ED initiatives has improved some quality
of care indicators; however, these improvements must be
sustainable. The key to sustainability is to implement a com-
bination of initiatives that will work together; ensuring that

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