Repairing the front door: how the Emergency Department model in Australia is changing
The Emergency Department (ED) has long served as the ‘front door’ to the hospital system. Not only is it an important source of hospital admissions – accounting for 36 percent of public hospital admissions in Australia in 2022-231– but it is also an access and treatment point in its own right, with 6.3 million presentations to EDs being discharged without admission each year.2
The growing challenge
Demand growth for public hospital ED services has consistently exceeded population growth for over a decade. While population growth itself has been a driver of increasing demand, the rise in presentations per capita has played a significant role above and beyond this, rising 1.4 percent per annum prior to 2019 and continuing at 0.3 percent per annum since the COVID-19 pandemic.
Emergency department presentations to public hospitals, Australia, 2013-23
EDs are being asked to do more in an increasingly challenging environment and they are struggling to keep up with the increasing demand. Patients are now staying longer in EDs; in 2022-23, only 56 percent of ED visits were completed within four hours, a sharp decline from 61 percent in 2021-22 and 70 percent in 2018-19. The proportion of patients seen on time3 also decreased from 71 percent in 2018-19 to 65 percent in 2022-23.4 Ambulance ramping performance across states and territories has also deteriorated. In New South Wales, only 80.1 percent of patients were transferred within 30 minutes in 2021-22, a decline from 84.8 percent the previous year.5 Similarly, Victoria’s on time transfer rate (under 40 minutes) was only 61.3 percent in 2021-22, down from 72.7 percent the previous year, and falling well short of its 90 percent target.
Beneath the headline numbers, there are significant underlying shifts. Populations are ageing, patients have increasingly complex and chronic needs, social isolation and vulnerability is now a more commonly identified factor and mental health needs are increasing. Additionally, ED presentations are often those that may be more appropriate for lower acuity services—nearly half of all emergency presentations were classified as semi-urgent (Category 4, 36 percent) or non-urgent (Category 5, 8.6 percent) in Australia in 2021-2022.6 Lower acuity ED presentations are amplified by challenges in accessing primary care and other services, due to both the availability of those services and rising out-of-pocket costs. From 2019-20 to 2022-23, the average annual growth in General Practitioner (GP) out-of-pocket costs rose by ~3.2 percent per annum, from an average of AUD $41.46 to AUD $48.26.7 During the same period, the GP bulk billing rate dropped by 8.8 percentage points from 85.9 percent to 77.1 percent.8
Beyond the demand side of the equation, providers also face mounting workforce pressures. COVID-19 placed significant demands on the health workforce, particularly those working in EDs, leading to high burnout rates. In Australia, 21 percent of nurse respondents indicated they were likely to leave their current role in direct patient care within a year9.
In parallel, providers are still investigating how to best integrate the rapid advances in data and digital technology into their care models. The field of alternative digital technologies remains crowded, despite many applications developed during the pandemic being discontinued.
How Australian health systems are responding
In Australia, hospital leaders are responding by seeking to innovate across all four stages of the patient pathway.
While many of the innovations span more than one stage, they do typically emphasise one particular aspect.
1. Identification of care need
The first step in the ED patient pathway—identifying a care need and determining the most appropriate setting for treatment—provides an early opportunity to assist patients in understanding their care needs and guiding them to the most appropriate care setting, which may not be the physical ED. There are several government-led programs assisting patients in identifying care needs through online self-checks or telehealth consultations. For example, Healthdirect Australia offers the Healthdirect Symptom Checker, which allows users to check their symptoms online in approximately six minutes. It helps patients determine if they need medical care and suggests the appropriate setting, whether it be self-care, visiting a pharmacist, consulting a doctor or going to the hospital.10 In FY2023, the Healthdirect Symptom Checker was used 3.1 million times.11 Similarly, 13Health, a 24/7 health advice service provided by the Queensland Government, is staffed by registered nurses who recommend whether self-care, a GP visit, or emergency care is appropriate.12 In South Australia, the ICCnet SA (Integrated Cardiovascular Clinical Network SA) offers a 24/7 remote health monitoring service to rural and regional populations to reduce avoidable emergency visits. This service involves intensive monitoring of GP-referred patients, ranging from self-scheduled data uploads to round-the-clock remote supervision with medical intervention by specialist nurses or GPs as needed.13 Additionally, an after-hours medical services, the National Home Doctor Service (known by its contact number 13SICK), provide home visits and teleconsultations outside regular general practice hours by doctors to patients needing urgent care, helping to alleviate pressure on emergency departments.
2. Presentation and triage
Innovation in the second stage, presentation and triage, has largely focused on the use of digital alternatives and platforms that allow patients to present, be triaged, as well as then potentially treated via phone or video.
Several virtual and telehealth services optimise the triage process by providing medical care at home or remotely for non-life-threatening issues, thereby reducing avoidable emergency visits. For example, the Victorian Virtual Emergency Department offers an alternative care pathway at the point of triage, where patients with non-life-threatening conditions are treated in a virtual emergency department environment. Likewise, WA Virtual Emergency Department (WAVED) offers patients the option of receiving urgent medical care virtually via telehealth in their homes, rather than waiting in an ED.14 The WAVED program, which launched in September 2023, is currently available in the Perth metropolitan area and is being expanded to serve a broader range of patient groups. My Emergency Doctor is a privately run national virtual service staffed by specialist emergency physicians, designed to provide access to an emergency specialist for acute medical conditions.15
3. Diagnosis and treatment
The third step in the patient pathway—diagnosis and treatment in the ED—presents an opportunity to optimise patient flow, reduce wait times and deliver better patient outcomes. Various approaches to this step have been taken.
First, there are cases where pre-hospital settings are equipped with advanced diagnostics tools or virtual/ in-person specialists to optimise patient care on the way to the ED. For example, the Mobile Stroke Unit (MSU) at Royal Melbourne Hospital is a fully equipped and custom-built specialist ambulance with a built-in CT scanner and acute stroke specialists onboard17. MSU staff can assess, scan, and treat stroke patients immediately, without waiting to arrive at the hospital. Similarly, the New South Wales (NSW) Telestroke service, which has been scaled throughout NSW Health, enables rapid delivery of acute care, and improved clinical outcomes for patients in rural settings. It connects 23 rural and regional hospitals across NSW with a network of virtual specialist stroke doctors, managed by the Prince of Wales Hospital. 18
Additionally, there are methods to utilise advanced technology in EDs to accelerate clinical decision-making. For example, an ongoing trial in South Australia, the RAPIDx AI project19 deploys an AI-based diagnostic algorithm for patients with potential Type I or Type II myocardial infarction (MI) and myocardial injury within the EDs of six South Australian hospitals. Its goal is to deliver more efficient and effective patient care for those with suspected cardiac chest pain, and significantly reduce ED congestion.
4. Discharge and planning
The final step in the patient pathway—discharge and care planning—not only provides an alternative to the front door but also allow offers a more comprehensive follow-on care pathway. First, there are methods to discharge patients directly from the ED to relieve pressure on hospital admissions. St Vincent’s Australia’s HITH (Hospital In The Home) offers a short-term care service for conditions requiring no more than seven days of hospital care, with doctors/ nurses or allied health professionals reviewing patients every day at home or via a virtual platform.20
Meanwhile, there are programs that assist with discharge and planning from the ward/ hospital stay to reduce avoidable readmissions, which often come through the ED. For example, the Transition Care Programme (TCP) funded by the Australian Government helps older Australians recover after a hospital stay by providing short-term care for up to 12 weeks.21 Another example is Virtual Clinical Care (VCC) Home Tele-Monitoring Service in regional South Australia which provides a short-term at-home monitoring and health coaching service. The VCC program is designed for adults living with chronic disease or with a history of emergency visits and/or hospital admissions with exacerbations.22
How others around the world are responding
Globally, some health systems are looking to create a seamless omnichannel experience that integrates digital platforms, primary care, and EDs. This approach moves beyond relying solely on physical EDs as the entry point and focuses on enhancing collaboration among stakeholders across the care pathway.
For example, the National Health Service (NHS) in the UK uses an approach that combines a digital platform, primary care networks and emergency services. The NHS offers phone and online triage services to direct patients to the appropriate care setting across the health system.23 The NHS App allows patients to access numerous services including booking appointments, checking symptoms and accessing medical records.24 Similarly, Mayo Clinic has developed multiple methods to digitise the front door, with a combination of virtual appointments for quick, convenient care of common conditions (Mayo Clinic Express Care) and remote monitoring for chronic disease management and post-operative care (Mayo Clinic Advanced Care at Home)25. And when the patients present at Mayo Clinic’s EDs, the triage system is integrated with these digital health tools and primary care providers, enabling referrals and access to patients’ health records across different platforms.
Denmark's Capital Region has introduced a system mandating referrals to EDs from GPs or the local medical helpline. The 1813 medical helpline centralises patient triage; specialist nurses and doctors assess the severity of conditions through phone and video calls and then streamline urgent cases to EDs with the shortest wait times or direct lower acuity cases to appropriate settings of care26. Intended primarily for use outside regular GP office hours, this system is integrated with the regional healthcare platform, which maintains a digital record of all patient details. Triage notes are integrated into the electronic health record and transferred along the care pathway, ensuring continuity of care. New policy was introduced to enable this system and its use has been widely adopted by the region’s population, becoming the norm to enter the urgent care system.
What comes next for Australian EDs?
Whilst Australia has many examples of specific innovations to the ED model, the next horizon of delivering a true omnichannel experience that spans physical departments, digital care platforms as well as primary care is still some distance away. Given the pressures on EDs and the repair that is needed, providers in Australia need to find a way to collaborate across the system in a rapid way. This includes building on and scaling the innovation we’re already seeing, but also collaborating with other players in the system who may not have worked closely together in the past. To do this, new approaches to governance models, incentive structures and workforce will be required. And given the increased acceptance of digital health services by both the public and healthcare professionals post-COVID-19, this is an ideal moment to drive forward these efforts. Action is needed now for Australia to develop a more resilient and efficient healthcare system that ultimately better serves its population.
The authors would like to acknowledge the contribution of Associate Professor Michael Ben-Meir
1 AIHW (Australian Institute of Health and Welfare) database, Emergency department care, 2022-23; AIHW database, Admitted patient care, 2022-2023
2 AIHW (Australian Institute of Health and Welfare) database, Emergency department care, 2022-23
3 A patient is considered to have been 'seen on time' when the time between arrival at the ED and the time that their clinical care starts is within the time specified in the definition of the triage category they are assigned: Resuscitation: Immediate (within seconds) / Emergency: within 10 minutes / Urgent: within 30 minutes / Semi-urgent: within 60 minutes / Non-urgent: within 120 minutes.
4 https://www.aihw.gov.au/reports-data/myhospitals/sectors/emergency-department-care
5 https://www.ama.com.au/articles/2023-ambulance-ramping-report-card
6 Use of emergency departments for lower urgency care; AIHW analysis of the NNAPEDCD, 2021-22., 2024
7 GP NRA (Non-Referred Attendance) out-of-pocket costs, As of Q3, Medicare Benefits Scheme Funded services; monthly data, AIHW, 21 Jun 2024 https://www.aihw.gov.au/reports/medicare/mbs-funded-services-data/data
9 From March 16 to 30, 2022, McKinsey surveyed 867 frontline nurses who are currently providing direct patient care across seven countries to better understand their experiences, needs, preferences, and career intentions. Gretchen Berlin, Connor Essick, Meredith Lapointe, and Faith Lyons, “Around the world, nurses say meaningful work keeps them going,” McKinsey, May 12, 2022.
10 Healthdirect website (https://www.healthdirect.gov.au/symptom-checker)
11 https://media.healthdirect.org.au/publications/HDA_Annual_Report_FY23.pdf
12 Queensland Government website (https://www.qld.gov.au/health/contacts/advice/13health)
13 https://www.iccnetsa.org.au/
14 https://www.health.wa.gov.au/Improving-WA-Health/WA-Virtual-Emergency-Department
15 https://www.myemergencydr.com/patients/
17 https://www.thermh.org.au/services/neurology-stroke/about-neurology-stroke/mobile-stroke-unit
18 https://www.nsw.gov.au/health/virtual-care-hub/telestroke#toc-service-overview
21 https://www.health.vic.gov.au/patient-care/transition-care-program
24 https://www.nhs.uk/nhs-app/about-the-nhs-app/
25 https://www.mayoclinichealthsystem.org/convenient-care-options#setup