Overcrowding Eric Revue, MD Secretary of the international committee of the French Society of Emergency Medicine (SFMU) Chair of the EuSEM Website Dreux (France)

Overcrowding in Clinical perception ? 2.Is there a model ? 3.New concept ? 4.Measures ? 5.What tools ? 6.Is it a curse ? 7.Solutions ????

Clinical opinion/perception Overcrowding American College of Emergency Physicians (ACEP) Crowding Resources Task Force (2002) when there are more patients requiring acute care than there are available staff or treatment beds; when wait times exceed a reasonable period; when patients are monitored in the hallways; when patients are forced to wait for treatment space or inpatient beds.

PRE-CHARGE Treatment rising precharge: Decrease volume POST-CHARGE Treatment: rise capacity Heart failure / overcrowding concept ? ED Hospital THROUGHPUT Resistances Diuretics Fast Track Ambulance diversion OUTPUT Rise capacity: vasodilatadors Bed management observation unit Rise bed capacity Alternatives to hospitalization cardiotonics Organization, protocols, procedures, lab tests, X rays.. HUMAN MODEL EMERGENCY DEPT IN PUT Treatment: stimulate HEART Thanks to Dr Santiago Ferrandiz

TRIAGE Med/ Trauma Med/ Trauma Med/tra uma Med/Tr auma Pediatrics FAST TRACK 60 % FAST TRACK 60 % Shock Room < 5 % Shock Room < 5 % 20 % Causes of Overcrowding in ED…. 1.Lack of physical inpatient beds 2.Inflexible nurses to patient staffing ratios 3.Delays cleaning rooms after patient discharge 4.Overreliance on ICU or telemetry beds 5.Delays in discharging hospitalized patients to post- acute care facilities

Why/What patients are waiting in the ED? TRIAGE = 5 % ER = 17 % Emergency Physician = 13 % Laboratory X Ray = 25 % Specialist = 5% Treatment = 4,5 % Bed = 13 % Papers = 4,6 % Transport = 1,6 % Diagnosis = 12 % > 25 % Length of stay > 4h (> 24 h )

Beds, beds, beds ….my kingdom for a bed ! France : 1974 – 2003 N beds/1000 habitants UK : Canada: 1960 – 2002USA: %- 49 % - 45 % Source: WHO

Measures of crowding in ED 1.Clinical opinion 2.Input factors 3.Throughput factors 4.Out put factors 5.Multidimensional scales 2660 papers (January Sept 2009) in PubMed (MedLine), CINAHL,Embase, Cochrane database 71 crowding measures

Clinician opinion (3) 71 unique crowding measures Input measures (17) Throughput measures (21) Output measures (21) N counts or % patients Waiting room (Waiting times, arrivals, triage) Total N patients in ED ++ ED capacity, occupancy rate N counts or % ED LOS Time/ patient care N counts, % admission, patients boarding, hospital beds.boarding time Multidimensional indices (9) ED Work Index (EDWIN) National Emergency Department Overcrowding Scale (NEDOCS)

Flow Non Flow How to measure crowding ? Time intervals Numerical counts ED census WR patients N boarders ED total LOS on boarding time ED Work Index (EDWIN) correlate with impressions of crowding by physicians, nurses National Emergency Department Overcrowding Scale (NEDOCS): linear regression model associates 5 operational variables with the degree of crowding

Solution (s) to overcrowding ??

SolutionsLiteratureResults on ED visits Walk in CentersSalisbury 2002,2003, – 43 % if 24h/day, close ED,protocols, triage GP “gate keeper” “SOS Doctors” Franco 1997, Hurley 1989,Piehls % SAMU NHS DirectMunro 2000Impact on LOS ? Pay ED visitReed 2005, Rice 2004, Bunn – 30 % ? Triage to GPSchull and al 2007LOS ? Manchester TriageCheung 2002, Subash 2004LOS +++ if nurse + EP Fast TrackDarrab 2006, Cooke 2003LOS – 20 %, LWBS ? Nurse Pract, seniorMuphy 1997, Gerbeaux 2000Xray,cost % lab Point of care testingKendall 1998,Murray 1999LOS idem Geriat Mobile UnitRoussel 2005, Chermak 2002LOS admit+ 20% ComputerizeMEAHLOS, quality of care Beds AdmissionBellou 2005, SFMU % of beds Short Cuts (End of life..) Billault 2004Direct admission

Decrease LOS PossibleTo explore Fast trackWalk in CentreNurse Practitioner Primary CarePoint of care testingCopayment Senior EP in EDShort cuts (ACS, End of life…) Organization in the ED Triage in EDTriage before admit ComputerTriage Dispatch phone call Centre Number of beds

Reducing overcrowding Hire access coordinators to expedite the decision-making process for both admitted and discharged patients = Bed managers Open Hustle Up Beds (HUB) where 4 patients are immediately transferred ED Open rapid access clinics for internal medicine, cardiovascular, neuro, and pediatrics Initiate a Geriatric nurse program with protocols for admission Initiate nurse protocols, specifically asthma; ACS.. Increase bed capacity Open transitional care or sub-acute beds Initiate laboratory and diagnostics point-of-care program Formalize volunteer hours to help admission and customer relations Initiate a hospital list program where GPs are on site 24/7

Hospitalization “at home” Short cuts

Conclusions No “miracle recipe” ! But …… Overcrowding depends on Flow/Non Flow usefull Computerize model EDWIN NEDOCS ? Organization of the ED …and of the hospital !!! Organization of the throughput and NOT the input Development of GP’s houses ? Fast Track Short cuts ! (ACS, Stroke, ICU, palliative care….) Bed manager key role operational capacity and control Protocols senior houses and Mobile Geriatric Unit in the ED Alternatives to the admission ? Home care ? Short stay Unit capacity Polyvalent Medicine department close to ED with LOS < 5 days

Join the EuSEM Thank you !! Asterix (Uderzo )