A paradigm shift in the nature of care provision in emergency departments.

OBJECTIVES Access block to acute hospital inpatient beds has pressured emergency departments (EDs) to develop strategies to facilitate the management of patients in the community (new services) and to streamline ED care (facilitative initiatives). The aim of this study was to determine the nature and extent of those strategies introduced into the 17 public hospital EDs in Melbourne, Australia, since 1998. METHODS This was a cross sectional survey of ED directors and/or nurse unit managers undertaken in November and December, 2002. Face to face or telephone interviews were conducted using a researcher administered questionnaire. RESULTS All 17 EDs participated. A total of 15 strategies had been introduced into 15 (88.2%) EDs. New services included care coordination teams (12 ED, 70.6%), short stay units (10, 58.8%), psychiatric services (10, 58.8%), chest pain units (7, 41.2%), pharmacy services (3, 17.7%), sexual assault service (1, 5.9%), and hospital in the home within the ED (1, 5.9%). Facilitative initiatives included nurse initiated management (12, 70.6%), fast track processes (10, 58.8%), multidisciplinary triage (4, 23.5%), disposition nurses/communication clerks (3, 17.7%), and day treatment clinics (2, 11.8%). CONCLUSIONS Melbourne's EDs have adapted rapidly to external pressures of access block and increasing patient numbers. Many traditional inpatient services have now been incorporated into the EDs. These EDs now provide a different and expanded paradigm of care.