Emergency Department Crowding вЂ“ A Literature Based Review Prepared by: Neil Roy, MD Christiana Care Health Services EM1 Overall Objectives вЂў Current literature вЂў Causes of crowding вЂў Explore the most efficient solutions вЂў Future goals Overview вЂў Causes of ED Crowding вЂ“ Input Factors вЂў What brings patients into the ED вЂ“ Throughput Factors вЂў Bottlenecks within the ED вЂ“ Output Factors вЂў Obstacles outside the ED Overview вЂў Effects вЂ“ Adverse Outcomes вЂў Patient Mortality вЂ“ Reduced Quality вЂў Transport Delays вЂў Treatment Delays вЂ“ Impaired Access вЂў Ambulance Diversion вЂў Patient Elopement вЂ“ Provider Losses вЂў Financial Effects Overview вЂў Solutions вЂ“ Increased Resources вЂў Additional Personnel вЂў Observation Units вЂў Hospital Bed Access вЂ“ Demand Management вЂў Non-urgent Referrals вЂў Ambulance Diversion вЂў Destination Control Definitions вЂў Ambulance Diversion: вЂ“ Ambulances are diverted to other, less-crowded hospitals вЂў Inpatient Boarding: вЂ“ Patients remain in the ED after already being admitted to the hospital вЂў Destination Control: вЂ“ Use of internet-accessible operating information to redistribute ambulances Causes: Input Factors Non-Urgent Visits вЂў Definition: Low-acuity ED patients seeking care in the ED. вЂ“ Present even in hospitals with dedicated fast-track systems. вЂ“ Reasoning: Typically insufficient access or/and untimely access to primary care. вЂў Account for a small portion of total ED volume. Causes: Input Factors Frequent Flyers вЂў Definition: 4 or more annual visits to the ED вЂ“ Responsible for 8-14 percent of the total ED visits вЂ“ Often non-urgent complaints вЂ“ This includes: Chronic illness, drug seeking patients, malingers вЂў However, among these patients a good portion frequently have serious pathology. Causes: Input Factors Sudden influx in ill patients Example: Influenza Season вЂ“ Los Angeles county hospitals recorded a four fold increase in ambulance diversion compared to other times of the year. вЂ“ 100 local cases of flu then resulted in an increase of 2.5 hrs per week of ambulance diversion. Causes: Throughput Factors вЂў Definition: Throughput factors are intraemergency departmental obstacles вЂў Average Nurse: Cares for 4 patients simultaneously вЂў Average Physician: Cares for 10 patients simultaneously Causes: Throughput Factors вЂў Ancillary Service Use: вЂ“ Definition: Ancillary Services include ED procedures, lab tests, and imaging modalities. вЂ“ No study has been done documenting ED wait times in comparison to the amount of studies ordered. вЂ“ However, the use of ancillary services has been shown to prolong ED length of stay among surgical critical care patients. Causes: Output Factors вЂў Inpatient Boarding: вЂ“ Half of American EDвЂ™s have extending boarding times. вЂ“ A point-prevalence study indicates that 22 percent of all ED patients were actually boarded patients. вЂ“ In short вЂ“ ED Boarding is one of the largest factors slowing a patients stay in the Emergency Department. Causes: Output Factors вЂў Hospital Bed Shortages: вЂ“ Correlation between ED treatment time and hospital bed occupancy well documented. вЂ“ Specifically вЂ“ when a hospitals occupancy exceeded 90 percent, ED wait times were shown to drastically increase. Effects: Adverse Outcomes вЂў Patient Mortality: вЂ“ At one Australian ED, high occupancy was estimated to cause 13 deaths per year. вЂ“ 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 вЂў Transport Delays: вЂ“ Patient transport time increases because crowded hospitals are forced to divert ambulances elsewhere. вЂў Treatment Delays: вЂ“ Longer door to doctor вЂ“ Longer door to needle for AMI вЂ“ Delay in pain assessments Effects: Provider Losses вЂў Estimated 204 dollars lost per patient with an extended boarding time. вЂў Boarded patients in the ED for greater than a day stayed in the hospital longer. вЂ“ Estimated increase in 6.8 billion dollars over 3 years Solutions: Increased Resources вЂў Ways that have been shown to effectively decrease ED stays: вЂ“ A permanent increase in ED physician staffing. вЂ“ Activation of reserve personnel during peak times. вЂў For Example: Influenza Season Solutions: Increased Resources вЂў Observation Units: вЂ“ Reduced LOS for patients with chest pain and asthma exacerbation. вЂў Acute Care Units (ED managed): вЂ“ Reduced ambulance diversion by 40 percent. вЂ“ Decreased boarded patients from 14 to 8 during a 2 year period. Solutions: Increased Resources вЂў Hospital Bed Access: вЂ“ At one studied hospital, increasing the number of critical care beds from 47 to 67 decreased ambulance diversion by nearly 66 percent. вЂ“ 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):1300вЂ“1303. Solutions: Increased Resources вЂў Point-of-care Laboratory Testing: вЂ“ Shown to decrease length of stay by 41 minutes. вЂў Improved ED Ancillary Service Staffing: вЂ“ Shown in numerous studies to increase efficiency, and decrease wait times. Solutions: Demand Management вЂў Non-urgent Referrals: вЂ“ 38 percent would swap their ED visit for a primary care appointment within 72 hours. вЂ“ 94 percent of patients who were referred to a community based care center reported their conditions were better or unchanged. Solutions: Demand Management вЂў Destination Control: вЂ“ Use of internet accessible operating information to redistribute ambulances. вЂ“ Physician directed ambulance destination control reduced ambulance diversion by 41 percent. Discussion вЂў Not Causes for ED crowding: вЂ“ NOT because of non-urgent visits вЂ“ NOT because of frequent-flyer visits вЂў Main Causes for ED crowding: вЂ“ Inpatient boarding вЂ“ Other hospital related factors Discussion вЂў Most Beneficial Interventions: вЂ“ Alter operation of the hospital вЂ“ Community services вЂ“ Not altering the ED itself The Next Step? вЂў Scarcity of Randomized Control Trials: вЂ“ Why? Because ED operational changes typically involve the entire department rather than individual patients that can be randomized. The Next Step? вЂў Ways to improve the ED further? вЂ“ Focus on ED-Hospital Integration вЂ“ 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: 1300вЂ“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 вЂ” the results of the American Hospital Association Survey of Emergency Department (ED) and Hospital Capacity. Falls Church, VA: American Hospital Association, 2002.