Overcrowding in Europe Eric REVUE, MD erevue@ch-chartres.fr Head of Emergency Medicine Department and Prehospital Emergency Medicine EMS (SMUR) Louis Pasteur Hospital, Chartres, France Secretary of the International Council of the French Society of Emergency Medicine (SFMU) Chair of the Website of the European Society for Emergency Medicine (EuSEM) Overcrowding is a worldwide phenomenon with regional influences, as exemplified when analyzing the problem in Europe compared to that of the United States. In both regions, an aging population, limited hospital resources, staff shortages and delayed ancillary services are key contributors; however, because the structure of healthcare differs from country to country, varying influences affect the issue of crowding. The approach to healthcare delivery as a right of all people, as opposed to a free market commodity, depends on governmental organization and appropriation of funds. www.eusem.org No conflict of interest

a Worldwide problem…

Crowding Resources Task Force (2002) Overcrowding in US ACEP Crowding Resources Task Force (2002) more patients requiring acute beds available staff or treatment beds wait times exceed a reasonable period patients are monitored in the hallways patients are forced to wait for treatment space or inpatient beds increased patient acuity, hospital bed shortage, increasing ED volume, radiology delays, insufficient ED space, laboratory delays, consultation delays, nursing shortage, physician shortage managed care issues.

Overcrowding in Europe 8 Increased Hospital Occupancy Increasing Patient Acuity Patient Self-Referral Inadequate Out-of-Hours Services Triage in the ED Inexperienced Medical Staff Staff Shortages Delayed Ancillary Services Jayaprakash et al. Western Journal of Emergency Medicine Volume X, no. 4 : November 2009

funding. 44 While the U. S. spent 15 funding.44 While the U.S. spent 15.2% of its Gross Domestic Product (GDP) on healthcare in 2004, the EU average was 9.43% (Figure 1).45,46 Despite this, the share of public spending on health in the U.S. is 45% compared to well over 80% in the UK and parts of Scandinavia. Public insurance covered just 26.2% of the U.S. population in 2005,47 UK, F : Ministry of Health GER, IT, SP : Healthcare decentralized (2004) Gross Domestic Product on Healthcare: US spent 15,2 % vs EU : 9.43 % the share of public spending on health U.S. : 45% < 80% vs UK,Scandinavia.

European ED and overcrowding 14 University 82 % Regional 85 % District 77 % General 66 % Private 26 % (AUT,BEL,CYP, GER,MAT,POL,SPA) Triage Protocols Standardized (89 %) MTS at national level (30%) Computer recording (35%) All European countries have a legal framework of healthcare delivery for the general population. It is planned and administered centrally by the respective government ministries with a variety of delivery systems. For example, in France and the UK the system is controlled centrally with management directly responsible to the Ministry of Health. In Germany, Italy and Spain the healthcare delivery system is decentralized and local government bodies have the autonomy to pass their own legislation.19,27 In Ireland, delivery of health services is the responsibility of the HSE, while the Department of Health and Children oversees the development and overall strategic management of the health system in accordance with legislation.43

Germany 12 million ED visits in 2007 (+ 4% in 2006 and 8% in 2007) DGINA (German Association for Emergency Medicine) Emergency care in Germany has greatly increased in significance in recent years rise in visits in German Eds the number of patients in German hospital EDs will rise as long as there is 12 million ED visits in 2007 (+ 4% in 2006 and 8% in 2007) no national programs to reduce waiting times no change in the structure of financial incentives for provision of emergency care by physicians in private practice

SPAIN Population : 40 millions 17 regions Society of EM SEMES (Sociedad española de Médicina de Urgencias y Emergencias) www.semes.org Specialty of EM : 2006 Specificity Prehospital EMS: EP if needed Number of ED: 788 ± 10000 EP : no qualification Triage : yes Analysis of patient flow in the emergency department and the effect of an extensive reorganisation Ò Miró, M Sánchez, G Espinosa, B Coll-Vinent, E Bragulat, J Millá Emerg Med J 2003;20:143–148

ITALY Population : 60 millions 20 regions Society of EM SIMEU (Società Italiana di Medicina d’ Emergenza – Urgenza)  www.simeu.it Specialty EM 2006 Specificity Prehospital EMS : yes ED: 1300 ( no autonomy ) No qualification in EM Triage : yes Overcrowding in Emergency Departments (ED) is a common phenomenon worldwide, especially in metropolitan areas. The main reason for overcrowding is not inappropriate emergency department use by patients but rather a shortage of available hospital beds which results in extended ED stays for patients who need emergency admission. The aims of this study, conducted at the San Giovanni Battista (Molinette) University hospital in Turin (Italy), were a) to verify the existence of overcrowding in the hospital ED and b) to test whether, as stated in the literature, overcrowding is due to restricted access to hospital beds for patients needing emergency admission, and to identify contributing factors. Results show the existence of overcrowding and confirm the hypothesized cause. A ‘‘see-and-treat’’ strategy is in the advanced phase of study in the region of Tuscany(no data available) ED visits have grown by 5- 6% / year over the past 5 years, with 30 million ED visits in 2009 a‘‘desirable time of stay’’ in the ED is (less than 4 hours) is rarely achieved.

GREECE NHS created in 1981 EMS 1987 http://www.hesem.gr/ 27 Overcrowding is directly related to non- urgent cases and inappropriate visits. Half the patients will wait until dawn to be examined by a doctor. Those who will need to be hospitalised will probably lie in camp beds in the hospital’s corridor until noon, and only one or two of them who need urgent medical care will be placed in a bed in one of the hospital’s units—not necessarily the appropriate one as it might already be overcrowded. In Greece the national health system (called E.S.Y. in Greece) was created in 1981! Also the ambulance emergency medical system was established in 1987 (after a heat stroke ‘epidemic’)! Greece still hasn’t adapted the EWTD (European Working Time Directive) European directive that says that doctors should not work more than 48 hours weekly. In Greece, in many hospitals, doctors work even 60 – 70 hours weekly! That means that they have even 10 shifts monthly! However, when the doctors in Greece refused to follow EWTD because they earn more money by doing extra shifts, even though this make them vulnerable on making mistakes!  The Greek Health Care System can be characterised as a mixed system: the health care branches of the various social insurance funds co-exist with the National Health System (ESY- Ethniko Systima Ygeias). 1·5 million immigrants visit the national hospitals have no medical insurance. Greece spends € 25 billion each year on medical services EWTD Doctors shouldn’t work > 48h/week… They work 60-70 h/week (10 shifts/month) earn more money (www.thelancet.com Vol 378 July 23, 2011) Eur J Emerg Med. 2004 Apr;11(2):81-5. Workload and case-mix in a Greek emergency department. Agouridakis P, Hatzakis K, Chatzimichali K, Psaromichalaki M, Askitopoulou H.

UK Population : 60 millions Society of EM British Association for Accident and Emergency Medicine (A§E) creation in 1967 www.emergencymed.org.uk Specialty of EM since 1992 Specificity NHS Direct = Call 999 (dispatching ambulances) 237 A§E departments and 198 Minor units NHS Walk-in centers : 81 in 2004 EP qualified : 2500 Triage : non systematic Nursing staff protest against overcrowding at the Mid-Western Regional Hospital ED in Limerick EDs were infamous for their ‘‘corridors of shame’’: patients lying on trolleys for more 12 hours waiting for admission to the hospital and reception areas crowded with patients waiting 6 to 8 hours to see a physician. The overwhelming reason for prolonged waits and overcrowding in Irish EDs is not the duplication of work inherent in the referral process but it is because of a lack of acute hospital capacity. 14.2 million (1998) to 16.5 million(2008) visits in AED (ED) 31 % growth in > 65 yo 36 % of total hospital admission > 440,000 people live in Care Home

UK the 4 hours target ‘‘From October, 2001, Regional Directors are required to inform Ministers of all trolley waits of over 12 hours (from time to admission to reaching a hospital bed) as they occur, essentially making this violation the sign of a failed institution.’’ In 2000, the Labour government announced that ‘‘…by 2004, no one should be waiting more than four -hours in accident and emergency (ED) from arrival to admission,transfer or discharge … ED based Clinical Decision Unit (CDU) as alternatives to emergency hospitalization BMJ 2005;330:1188–9 A 75-yo, arriving by ambulance, during the night and requiring admission has 51 % risk staying in AED > 8 h

FRANCE Population : 65 millions (2,2 M Paris, 11,5 M Ile de France) French Society of EM (SFMU) www.sfmu.org 630 ED in France (96 Paris Ile de France) 14 M visits (+4 % /y) > 3 M (+ 6,3%) in Paris + 50 % of ED visits in 10 years Age: 10 % > 75 years old ; 30 % child SAMU: 1,4 M Emergency calls (+ 3 %) Paris Specialty of EM 2004 Dispatching center (SAMU) : 105 631 ED, 96 (Paris ) 435 EMS(SMUR) > 100. 000 IMCU/year (+5%) EP : > 3000 Triage : yes Voilà maintenant une dizaine de jours que les médecins et paramédicaux du service des urgences de l’hôpital de Rambouillet sont en grève. S’ils poursuivent cependant leur travail, ils veulent dénoncer le manque de personnel dans le service, ce qui conduit la totalité des employés à avoir un recours abusif aux heures supplémentaires, « non payées ou récupérées en ce qui concerne les infirmières », affirme Frédéric Mandel, urgentiste.Cela amènerait les médecins à travailler l’équivalent de 15 mois dans l’année. Le service a décidé depuis le 1er avril de refuser les heures supplémentaires, non obligatoires, pour dénoncer ce manque de personnel. Conséquence : l’hôpital doit avoir recours à des intérimaires à un coût « exorbitant », ce qui représente « un non-sens », dénonce Frédéric Mandel. Number of ED visits in France/ year (reference = 100 in 1996)

ED Overcrowding in France Input: overall increase in patient volume Ignorance of GP’use : 4,7 times/year General Practitioners: 285 GP’s /1000 inhab in 2025 Free –of- charge service ( apparently) Throughput: Elderly patients (> 80 yo) with chronic diseases Perceive a need for hospital bed. Working time directive “35 hours” law (48 h EP) Shortage of nursing staff Output: lack of beds 17 % admission rate Lack of nursing home < 15 beds/1000 hab 2012 : Grenoble, Roubaix, Rambouillet, Tenon (Paris), Marseille… France on strike (again ?!) included patients were young, male, witha low level of education, and employed. As in the literature,most patients decided to go to the ED directlywithout prior contact with their GP and pain perceivedby the patient, need of access to diagnostic investigations,and difficulty in accessing ambulatory healthcareservices were the most common reasons provided bypatients for attending the ED [12-14,29-31]. Carasco V. Activity of French Emergency Departments in 2004: study and results. Etude DRESS N° 524; 2006

Nederlandse Vereniging van Spoedeisende Hulp Artsen (NVSHA) Netherlands population of 17 million 102 hospitals 11 Trauma centres Nederlandse Vereniging van Spoedeisende Hulp Artsen (NVSHA) Netherlands Society of Emergency Physicians (NSEP) 33 No national census of ED visits Annual patient volume in the ED: 12,000 to 50,000 Estimates range 1,9 to 2,2 million visits/year Average growth rate 2 to 4 % ED crowding is not a big issue in the Netherlands as a gatekeeper to secondary care. the GP acts As a rule, patients need a referral from their GP to use hospital services. Maximum LOS is counted in hours rather than days, LWBS rare

SWEDEN Population : 9 millions 3 regions – 21 districts 34 EM Society Swesem (Svensk Förening for Akutsjukvard) and Nordic Society for Disaster Medicine) www.swesem.org Specialty of EM since 2005 Specificity No prehospital EMS Number of ED : 90 Numerous regional primary care 800 new doctors/year Triage : yes ED crowding in Sweden : not a major problem the number of inpatients beds is the lowest in the OECD listings : 2.1 acute beds / 1,000 inhabitants Large societal emphasis on prevention Extensive GP network that handles one million patient visits per two million inhabitants/month ,but when patients feel the need for medical attention, they are first encouraged to look for more information over the Web or telephone before seeking care. The goal of the system : to establish a ‘‘dialogue’’with each patient before he visits the ED << Swedish health care authorities objective : 80% discharge rate at 4 h. In Sweden, like in Norway, Denmark and Finland,ED patients are usually sorted into medical specialties by a triage nurse, and then managed by physicians from the respective specialties, most often internal medicine, surgery and orthopedic surgery. We believe that introducing more EM specialists would simplify and increase the flexibility of the ED organization andt hat this in turn would probably enhance patient throughput. Average LOS ≈ 4 h (2h waiting for the 1st EP) 65 % In Sweden, like in Norway, Denmark and Finland, ED patients are usually sorted into medical specialties by a triage nurse, and managed by physicians from the respective specialties ( internal medicine, surgery , orthopedic surgery )

Thanks to Philip Anderson Denmark Danish Society for Emergency Medicine (DASEM, founded 2006) www.akutmedicin.org 32 Patients discouraged to seek ED care without contacting GP ⁄ prehospital care GPs manage patients by phone, refer patients to GP office or ED, send mobile GP to the home. Ambulances have physicians with the option to treat and release patients. Thanks to Philip Anderson

Finland Dispatch Center refers patients to GPs or hospitals ED Population: 20,000 to 200,000 Finnish Society for Emergency Medicine Dispatch Center refers patients to GPs or hospitals ED Primary care EDs operate during off hours only Triage systems 4 categories (ABCD): immediate to 2 hours No ambulance diversion > 890,000 ED visits (2008) specialist care 142,000 primary care 50 % discharged home Mean boarding time 4-8 h (Helsinki University Central Hospital) Overcrowding is due to decreasing number of beds in hospitals

Beds , beds, beds ….my kingdom for a bed ! Increased Hospital Occupancy Beds , beds, beds ….my kingdom for a bed ! - 45 % - 49 % UK : 1960 -2003 USA: 1960 - 2003 N beds/1000 habitants - 45 % - 30 % hospital bed shortage, especially ICU and telemetry beds.3,5,14,15 Canada: 1960 – 2002 France : 1974 – 2003 ICU and telemetry beds (IRL : 3 beds/1000 the lower of EU)

Increasing Patient Acuity IT : 20,000 deaths SP: 141 deaths PO 1300 deaths F : 20,000 deaths 70,000 deaths (EU) Our index mixes age over 70 years, body core temperature above 39°C and admission after ED visit or death in the ED,which are variables rapidly available after patient referral.Finally, EDs appear valuable centres of control to alert for heatrelatedprehospital excess of mortality while deaths do not Critical Care Vol 10 No 6 Claessens et al.necessarily occur in the ED. How emergency departments might alert for prehospital heat-related excess mortality? Claessens Critical Care Vol 10 No 6

Patient Self-Referral Germany, Ireland, Italy, Netherlands, Norway, Portugal, Spain, Switzerland and the UK, the general practitioner (GP) acts as a gatekeeper to health services whose role is primary health carer. 57% of ED visits are primary care = NHS (UK), SAMU (F) Lee A, Lau F, Hazlett CB, et al. Measuring the inappropriate utilization of accident and emergency services? Int J Health Care Qual Assur. 1999; 12:287-92.

Input: Anticipation of delivery of care to patients (Sweden) Protocols ED /Medicine wards (EU) Coordination GP /Hospital/ Walk in Center (Netherlands, Denmark, Sweden) Shortcut : direct entrance through ED (France MI) Throughput: Bed’s management : nurse or physician (Spain, Sweden) “temporary emergencies beds unit” (UK, France) Requisition of beds (Barcelona, Spain) Multidisciplinary ED with internist FastTrack (Italy, France) Alternatives : hospitalization “at home” (Spain, UK) Short track for elderly patients (Spain, France, Italy ..) Interdisciplinary geriatric palliative care team (Spain,..) Solutions ? 39  

Conclusions : overcrowding in Europe 7 Increased complexity and acuity of patients presenting to the ED. Overall increase in patient volume. Managed care problems. Lack of beds for patients admitted to the hospital. Delays in service provided by radiology, laboratory, etc.. Shortage of nursing or administrative support staff. Shortage of on-call specialty consultants or lack of availability. The problem of crowding in the ED is one that affects both Europe and the U.S. The ED is the gateway to the hospital; problems arising there have the potential to affect the entire hospital. Because ED crowding has different regional causes, any potential solutions must be tailored to regional variations. These differences suggest that while a universal solution is not necessarily practical, we can look at various policies that have had a positive impact on crowding and implement similar solutions across countries, tailored to the needs of individual regions.