Overview
Summary
We describe results from a multi-agency study into the causes of access block, described by the Australasian College for Emergency Medicine as the single most serious issue facing health systems in Australia and New Zealand.
Dates: January 2022 - ongoing
Implementation sites: Queensland statewide
Partnerships: Queensland Ambulance Service, Queensland Health, University of Queensland, CSIRO and Emergency Medicine Foundation
Aim
The aim of the study was to establish an evidence base for factors leading to access block. Our study helped identify system-wide and local solutions that are most effective and efficient to improve emergency access across the state.
Outcomes
Our study highlights that access block originates inside inpatient wards, rather than the Emergency Department (ED). Traditional interventions targeted at the ED will not substantially improve access block and an urgent whole of system approach is needed to unblock patient flow at the inpatient ward. Measuring and managing our inpatient care pathways with the same intensity as we measure and monitor ED activity is necessary. Focusing efforts at the 'back end' of the inpatient journey is a critical step to improve emergency care outcomes.
As measures of impact, the findings have been:
a) published in leading peer-reviewed journals (seven so far - refer to References)
b) incorporated into policy and QH budget planning;
c) presented to ACEM, AMA, Qld Clinical Senate, QH's COO, DG and DDG, and two state health ministers
Background
Overcrowding in hospitals is a worldwide public health problem, a crucial safety issue, and a sentinel indicator of health system functioning. This submission to the 2026 CEQ Showcase is based on the successful delivery of a multi-agency study into the causes of access block, described by the Australasian College for Emergency Medicine as the single most serious issue facing health systems in Australia and New Zealand. Access block and ambulance ramping are frequently politicised, exposing government to opposition criticism and media scrutiny. The study carried enormous expectations from the Health Minister, clinical colleges and other external stakeholders, that we would deliver strong, evidence-based analysis and identify actionable solutions and recommendations in this contentious area.
For background, in 2022, Queensland Health commissioned the Emergency Medicine Foundation (EMF) to coordinate an academically robust study that assessed access block causes and solutions to improve patient flow across Queensland's public hospitals. EMF is a non-profit organisation dedicated to enhancing patient emergency healthcare experience and outcomes, saving lives and promoting system sustainability in Queensland. EMF is collaborating with Queensland Health on a large research program to find effective, evidence-based solutions to improve patient flow in Queensland's public hospitals. The first component of this program was to analyse patient flow in Queensland hospitals, including consideration of the Queensland Ambulance Service. In response to a request to submit proposals to conduct this study, a team was formed comprising personnel from Queensland Health, Queensland Ambulance Service, the University of Queensland, and CSIRO. The partner organisations represent the perspectives of vital stakeholders to the problem being addressed. Together they represent the hospital, ambulance and health system viewpoints supported with evidence-based analysis from one of Australia's leading research and teaching universities and Australia's national science agency.
Recommendations developed from the modelling undertaken in this study considered how access block, and other system factors, impact ED patient flow for both admitted and non-admitted patients, and adoption of these recommendations will minimise access block and ED length of stay. It is well recognised that minimising access block is not solely an ED issue; moving a patient from emergency to inpatient care is the critical bottleneck in ED system performance, thus the need for a whole-of-hospital effort to address flow bottlenecks.
Methods
The study comprised five components to provide a system-wide view of access issues and challenges, and inform the design of interventions/solutions to improve patient flow at a system level:
1. A literature review that provided a comprehensive and up-to-date summary of:
- the challenges impeding patient flow in the ED.
- the evidence regarding proven, disproven, and unproven patient flow interventions.
2. A scientific analytical study employing publicly available data to determine contextual insights into causes of access block.
3. A scientific analytical study employing retrospective data from ambulance, emergency and inpatient encounters from 25 of the largest Queensland public hospitals that:
- identified and measured system-wide barriers to patient flow in the ED,
- quantified the impact of local and system-wide solutions (inside and outside the ED) in addressing these identified barriers and improving patient flow through the ED.
4. A qualitative assessment exploring barriers to discharging patients to offer a cross-sectional view of the experiences and opinions of service providers and consumers.
5. A key set of findings and recommendations that supported the development of solutions that are practical and actionable.
This study adopted a system-wide view to capture relationships and interactions between flow metrics to identify access issues and inform the design of interventions/solutions to improve patient flow at a system level. A system-wide approach covering prehospital and ED services offers the potential for improving patient flow at the ambulance/hospital interface. By integrating ambulance, ED and inpatient data, it was possible to identify blockages along the entire patient journey that have a flow-on effect on ED access. It was also possible to identify critical hospital and ambulance service levels when performance starts to degrade, suggesting where the system would benefit from revised strategies.
We also analysed the drivers of access block and ED demand, looking not just at the ambulance and hospital system, but also at external drivers such as primary care use and coverage, residential aged care, and elements from the Commonwealth Home Support Programme. The analysis included spatial modelling of effects such as education level, socioeconomic advantage and disadvantage, age, remoteness and employment. In an Australian first, we also applied age-period-cohort models to longitudinally follow cohorts of patients as they aged to identify attributes that might increase their risk of attending the ED.
Discussion
A factor in this project's success was the multidisciplinary approach that incorporated the disciplines of mathematics, social science and emergency medicine delivering diverse insights for maximal impact. The study design was also an important factor, as incorporating both qualitative and quantitative approaches allowed the team to gain perspectives from historical hospital records as well as from patients and healthcare workers about what hinders flow and explore solutions to flow challenges.
The scale of this study makes it unique, encompassing every ambulance record, ED presentation, inpatient episode of care and ward transfer over six years for the 25 largest hospitals in Queensland, from the busiest ED in the country to regional EDs.
The contentious issue of providing adequate health services for populations wins elections and it was imperative that the analysis was independent, watertight and not based on opinion to ensure any debate by our elected leaders and their opposition was based on scientific fact and robust evidence. The results of the research provide independent, evidence-based recommendations in this contentious area, and are informing government policy about timely access to hospital care. Health Minister Nicholls acknowledged the study's impact on shaping healthcare policy in 2025:
EMF's work, particularly the large-scale research project on patient flow that was undertaken, informed some of the decisions and policies that we took to the election, and will help inform us and drive the change we need to make.
As well as the points highlighted in the Outcomes section above, the work has been highlighted at the EMF Patient Flow Symposium and the digital health community's key annual event HIC, and has instigated a follow-up successful EMF grant between project collaborators. Combined, these facets of the study position the results for translation. Our recommendations for policy makers in addressing patient flow challenges are planned for publication in 2026.
References
Peer reviewed journal articles published so far from the study:
[1] Samadbeik M, Staib A, Boyle J, Khanna S, Bosley E, Bodnar D, Lind J, Austin JA, Tanner S, Meshkat Y, de Courten B, Sullivan C. Patient flow in emergency departments: a comprehensive umbrella review of solutions and challenges across the health system. BMC Health Serv Res. 2024 Mar 5;24(1):274. doi: 10.1186/s12913-024-10725-6.
[2] Yoon HJ, Boyle J, Diouf I, Bosley E, Staib A, Riahi V, Hassanzadeh H, Samadbeik M, Sullivan C, Khanna S, Lind JF. The Association Between Access Block And Ambulance Ramping, And The Impact of COVID-19: A Retrospective Observational Cohort Study of 25 Queensland Hospitals. Med J Aust. 2026 Feb;224(2):e70141.
[3] Riahi V, Boyle J, Yoon HJ, Hassanzadeh H, Diouf I, Khanna S, Staib A, Samadbeik M, Sullivan C, Bosley E, Lind JF. The Impact of Hospital Bed Occupancy on Patient Flow and Emergency Department Access: A 25-Hospital Cohort Study. Med J Aust. 2026 Feb;224(2):e70143. doi: 10.5694/mja2.70143
[4] Hassanzadeh H, Boyle J, Riahi V, Yoon HJ, Diouf I, Khanna S, Sullivan C, Staib A, Bosley E, Samadbeik M, Lind JF. Strategies for Reducing Access Block and Waiting Time for Patients Seeking Emergency Hospital Care: Results of a Ward-Level Discrete Event Simulation at Queensland's Largest Public Hospitals. Med J Aust. 2026 Feb;224(2):e70142. doi: 10.5694/mja2.70142.
[5] Samadbeik M, Staib A, Boyle J, Khanna S, Bosley E, McCourt E, Bodnar D, Lind J, Austin JA, Sullivan C. "A banana in the tailpipe": a qualitative study of patient flow in the healthcare system. BMC Health Serv Res. 2025 May 23;25(1):745. doi: 10.1186/s12913-025-12873-9.
[6] Diouf I, Boyle J, Yoon HJ, Riahi V, Bosley E, Staib A, Samadbeik M, Sullivan C, Lind J, Hassanzadeh H, Khanna S. Time Trends in the Rates of ED Visits in Australia, an Age-Period-Cohort Approach. Emerg Med Australas. 2026 Feb;38(1):e702
[7] Yoon HJ, Boyle J, Diouf I, Riahi V, Hassanzadeh H, Khanna S. gEDWIN: a simple and practical index for real-time monitoring of emergency department crowding. BMC Emerg Med. 2025 Nov 25;25(1):244. doi: 10.1186/s12873-025-01397-4.