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 Overview • Causes of ED Crowding – Input Factors • What brings patients into the ED – Throughput Factors • Bottlenecks within the ED – Output Factors • Obstacles outside the ED Overview • Effects – Adverse Outcomes • Patient Mortality – Reduced Quality • Transport Delays • Treatment Delays – Impaired Access • Ambulance Diversion • Patient Elopement – Provider Losses • Financial Effects Overview • Solutions – Increased Resources • Additional Personnel • Observation Units • Hospital Bed Access – Demand Management • Non-urgent Referrals • Ambulance Diversion • Destination Control Definitions • Ambulance Diversion: – Ambulances are diverted to other, less-crowded hospitals • 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 systems. – Reasoning: Typically insufficient access or/and untimely access to primary care. • Account for a small portion of total ED volume. 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, malingers • 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 simultaneously • Average Physician: Cares for 10 patients simultaneously 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 staffing. – Activation of reserve personnel during peak times. • 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 percent. – 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 28;355(13):1300–1303. Solutions: Increased Resources • Point-of-care Laboratory Testing: – Shown to decrease length of stay by 41 minutes. • 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 percent. Discussion • 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 Discussion • 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 randomized. The Next Step? • Ways to improve the ED further? – Focus on ED-Hospital Integration – Examine hospital and multi-center community networks in larger studies References 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.