Emergency Department Crowding – by pengxiuhui

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									Emergency Department Crowding
  – A Literature Based Review

                                     Prepared by:
                                     Neil Roy, MD
              Christiana Care Health Services EM1
            Overall Objectives

• Current literature
• Causes of crowding
• Explore the most efficient solutions
• Future goals

• Causes of ED Crowding
  – Input Factors
    • What brings patients into the
  – Throughput Factors
    • Bottlenecks within the ED
  – Output Factors
    • Obstacles outside the ED

• Effects
   – Adverse Outcomes
      • Patient Mortality

   – Reduced Quality
      • Transport Delays
      • Treatment Delays

   – Impaired Access
      • Ambulance Diversion
      • Patient Elopement

   – Provider Losses
      • Financial Effects

• Solutions
  – Increased Resources
    • Additional Personnel
    • Observation Units
    • Hospital Bed Access

  – Demand Management
    • Non-urgent Referrals
    • Ambulance Diversion
    • Destination Control

• Ambulance Diversion:
  – Ambulances are diverted to other, less-crowded
• Inpatient Boarding:
  – Patients remain in the ED after already being
    admitted to the hospital
• Destination Control:
  – Use of internet-accessible operating information to
    redistribute ambulances
              Causes: Input Factors

Non-Urgent Visits
• Definition: Low-acuity ED patients seeking care
  in the ED.
  – Present even in hospitals with dedicated fast-track
  – Reasoning: Typically insufficient access or/and
    untimely access to primary care.

• Account for a small portion of total ED
              Causes: Input Factors

Frequent Flyers
• Definition: 4 or more annual visits to the ED
  – Responsible for 8-14 percent of the total ED visits
  – Often non-urgent complaints
  – This includes: Chronic illness, drug seeking patients,

• However, among these patients a good
  portion frequently have serious pathology.
              Causes: Input Factors

Sudden influx in ill patients
  Example: Influenza Season
  – Los Angeles county hospitals recorded a four fold
    increase in ambulance diversion compared to other
    times of the year.
  – 100 local cases of flu then resulted in an increase of
    2.5 hrs per week of ambulance diversion.
         Causes: Throughput Factors

• Definition: Throughput factors are intra-
  emergency departmental obstacles
• Average Nurse: Cares for 4 patients
• Average Physician: Cares for 10 patients
       Causes: Throughput Factors

• Ancillary Service Use:
  – Definition: Ancillary Services include ED
    procedures, lab tests, and imaging modalities.
  – No study has been done documenting ED
    wait times in comparison to the amount of
    studies ordered.
  – However, the use of ancillary services has
    been shown to prolong ED length of stay
    among surgical critical care patients.
          Causes: Output Factors

• Inpatient Boarding:
  – Half of American ED’s have extending
    boarding times.
  – A point-prevalence study indicates that 22
    percent of all ED patients were actually
    boarded patients.
  – In short – ED Boarding is one of the
    largest factors slowing a patients stay in
    the Emergency Department.
          Causes: Output Factors

• Hospital Bed Shortages:
  – Correlation between ED treatment time and
    hospital bed occupancy well documented.
  – Specifically – when a hospitals occupancy
    exceeded 90 percent, ED wait times were
    shown to drastically increase.
         Effects: Adverse Outcomes

• Patient Mortality:
  – At one Australian ED, high occupancy was
    estimated to cause 13 deaths per year.
  – A study done in Houston identified a
    statistically insignificant trend in which there
    was a correlation between higher mortality
    among trauma patients and those who were
    admitted during trauma ambulance diversion.
         Effects: Reduced Quality

• Transport Delays:
  – Patient transport time increases because
    crowded hospitals are forced to divert
    ambulances elsewhere.

• Treatment Delays:
  – Longer door to doctor
  – Longer door to needle for AMI
  – Delay in pain assessments
          Effects: Provider Losses

• Estimated 204 dollars lost per patient with
  an extended boarding time.
• Boarded patients in the ED for greater
  than a day stayed in the hospital longer.
  – Estimated increase in 6.8 billion dollars
    over 3 years
     Solutions: Increased Resources

• Ways that have been shown to effectively
  decrease ED stays:
  – A permanent increase in ED physician
  – Activation of reserve personnel during peak
    • For Example: Influenza Season
     Solutions: Increased Resources

• Observation Units:
  – Reduced LOS for patients with chest pain and
    asthma exacerbation.

• Acute Care Units (ED managed):
  – Reduced ambulance diversion by 40 percent.
  – Decreased boarded patients from 14 to 8
    during a 2 year period.
     Solutions: Increased Resources

• Hospital Bed Access:
  – At one studied hospital, increasing the
    number of critical care beds from 47 to 67
    decreased ambulance diversion by nearly 66
  – During the past decade, emergency
    department visits have increased by 26%,
    while the number of emergency departments
    has decreased by 9% and hospitals have
    closed 198,000 beds (View Graph).
Solutions: Increased Resources

   Kellermann AL. Crisis in the emergency department. N Engl J Med 2006 Sep
      Solutions: Increased Resources

• Point-of-care Laboratory Testing:
  – Shown to decrease length of stay by 41

• Improved ED Ancillary Service Staffing:
  – Shown in numerous studies to increase
    efficiency, and decrease wait times.
      Solutions: Demand Management

• Non-urgent Referrals:
  – 38 percent would swap their ED visit for a
    primary care appointment within 72 hours.
  – 94 percent of patients who were referred to a
    community based care center reported their
    conditions were better or unchanged.
      Solutions: Demand Management

• Destination Control:
  – Use of internet accessible operating
    information to redistribute ambulances.
  – Physician directed ambulance destination
    control reduced ambulance diversion by 41

• Not Causes for ED crowding:
  – NOT because of non-urgent visits
  – NOT because of frequent-flyer visits

• Main Causes for ED crowding:
  – Inpatient boarding
  – Other hospital related factors

• Most Beneficial Interventions:
  – Alter operation of the hospital
  – Community services
  – Not altering the ED itself
                The Next Step?

• Scarcity of Randomized Control Trials:
  – Why? Because ED operational changes
    typically involve the entire department rather
    than individual patients that can be
               The Next Step?

• Ways to improve the ED further?
  – Focus on ED-Hospital Integration
  – Examine hospital and multi-center community
    networks in larger studies

1. Bohan JS. Emergency Care: A System in Crisis. JWatch Emergency Med. 2006; 1-1

2. Burt CW, McCaig LF, Valverde RH. Analysis of ambulance transports and diversions
   among US emergency departments. Ann Emerg Med. 2006; 47:317-326

3.   Hoot NR, Aronsky D. Systematic Review of Emergency Department Crowding. Ann
     Emerg Med. 2008; 52: 126-136.

4. Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006; 355: 1300–1303

5. Pines JM, Locallo AR, Bast WG. The Impact of Emergency Department Crowding
   Measures on Time to Antibiotics for Patients with Community Acquired Pneumonia. Ann
   Emerg Med. 2007; 50: 510-516.

6. Pines JM, Hollander JE, Locallo AR. The Association between Emergency Department
   Crowding and Hospital Performance on Antibiotic Timing for Pneumonia and Percutaneous
   Intervention for Myocardial Infarction. Acad Emerg Med. 2006; 13: 873-878.

7. The Lewin Group. Emergency department overload: a growing crisis — the results of the
   American Hospital Association Survey of Emergency Department (ED) and Hospital
   Capacity. Falls Church, VA: American Hospital Association, 2002.

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