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Emergency Department Crowding – A Literature Based Review

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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 intraemergency 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
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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