Emergency Department Crowding – A Literature Based Review

Prepared by:Neil Roy, MD

Christiana Care Health Services EM1

• Current literature

• Causes of crowding

• Explore the most efficient solutions

• Future goals

Overall Objectives

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.