Emergency Department Crowding – A Literature Based Review

1. Emergency Department Crowding – A Literature Based Review Prepared by: Neil Roy, MD Christiana Care Health Services EM1

2. Overall Objectives • Current literature • Causes of crowding • Explore the most efficient solutions • Future goals

3. 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

4. Overview • Effects • Adverse Outcomes • Patient Mortality • Reduced Quality • Transport Delays • Treatment Delays • Impaired Access • Ambulance Diversion • Patient Elopement • Provider Losses • Financial Effects

5. Overview • Solutions • Increased Resources • Additional Personnel • Observation Units • Hospital Bed Access • Demand Management • Non-urgent Referrals • Ambulance Diversion • Destination Control

6. 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

7. 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.

8. 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.

9. 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.

10. 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

11. 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.

12. 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.

13. 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.

14. 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.

15. 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

16. 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

17. 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

18. 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.

19. 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).

20. Solutions: Increased Resources Kellermann AL. Crisis in the emergency department. N Engl J Med2006Sep28;355(13):1300–1303.

21. 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.

22. 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.

23. 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.

24. 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

25. Discussion • Most Beneficial Interventions: • Alter operation of the hospital • Community services • Not altering the ED itself

26. 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.

27. The Next Step? • Ways to improve the ED further? • Focus on ED-Hospital Integration • Examine hospital and multi-center community networks in larger studies

28. References • Bohan JS. Emergency Care: A System in Crisis. JWatch Emergency Med. 2006; 1-1 • 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. • Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006; 355: 1300–1303 • 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. • 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. • 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.