1. Overcrowding in the ED: is there a difference in the causes between US/Europe and GCC countries? Eric REVUE, MD Emergency Department and prehospital EMS Chartres (France) Chair of the EuSEM website Heikki NIKKANEN,MD Emergency Department Boston (USA)

2. >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o Emergency Department ED visits Admission Nursing Home Direct Admissions Return home Return Home Ideal world

3. >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o Admissions No beds ! No beds at the Inn >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o >->o « Real Life » Urgent (and non-Urgent) ED visits Emergency Department Return at home ? Return at Home

5. Beds, beds, beds ….my kingdom for a bed ! France : 1974 – 2003 N beds/1000 habitants UK : 1960 -2003 Canada: 1960 – 2002 USA: 1960 - 2003 - 30 % - 49 % - 45 % Increased Hospital Occupancy

6. Overcrowding in US

7. The People

8. Where are we now? 130M ED visits 4% of US health care expenditure 3700 EDs (down 11%) Visit rate 43 / 100 P Non-urgent cases low Out of hours visits high

9. Emergency Department Visits in the Past 12 Months SOURCE: CDC/NCHS, Health, United States, 2012, Figure 20. Data from the National Health Interview Survey.

10. One or More Emergency Department Visits in the Past 12 Months SOURCE: CDC/NCHS, Health, United States, 2012, Figure 21. Data from the National Health Interview Survey.

11. Mean wait time to see a physician in an ED, average annual, 2008–2010 SOURCE: CDC/NCHS, Health, United States, 2012, Figure 25. Data from the National Hospital Ambulatory Medical Care Survey, Emergency Department Component.

12. Emergency Department Visits with Plain Radiography or Advanced Imaging Scans NOTE: CT is computed tomography; MRI is magnetic resonance imaging. SOURCE: CDC/NCHS, Health, United States, 2012, Figure 26. Data from the National Hospital Ambulatory Medical Care Survey, Emergency Department Component.

13. Median LOS by disposition

14. Discharge Status of ED Visits, Average Annual, 2009–2010 NOTE: A small percentage of visits result in death. SOURCE: CDC/NCHS, Health, United States, 2012, Figure 27. Data from the National Hospital Ambulatory Medical Care Survey, Emergency Department Component.

17. Age Distribution of the U.S. Population, by Sex: 1950 MaleFemale Millions

18. Age Distribution of the U.S. Population, by Sex: 2000 Millions MaleFemale = Year 1950

19. Age Distribution of the U.S. Population, by Sex: 2050 MaleFemale Millions = Year 2000

20. Overcrowding in Europe

21. 14 European ED and overcrowding University 82 % Regional 85 % District 77 % General 66 % Private 26 % ( AUT,BEL,CYP, GER,MAT,POL,SPA) Jayaprakash et al. Western Journal of Emergency Medicine Volume X, no. 4 : November 2009

23. Source : Hope

24. 33 Netherlands population of 17 million 102 hospitals 11 Trauma centres the GP acts As a rule, patients need a referral from their GP to use hospital services. Maximum LOS : in hours rather than days LWBS rare ED crowding is not a big issue No national census of ED visits Mean 12,000 to 50,000 patients/year ≈1,9 to 2,2 million visits/year Average growth rate 2 to 4 %

25. 34 SWEDEN Population : 9 millions 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 Average LOS ≈ 4 h (2h waiting for the 1 st EP) 65 % Objective : 80% discharge rate at 4 h. ED crowding : not a major problem

26. 32 Denmark Thanks to Philip Anderson ED crowding : not a major problem, but…

27. Finland Dispatch Center refers patients to GPs or hospitals ED Primary care EDs operate during off hours only No ambulance diversion Population: 20,000 to 200,000 > 890,000 ED visits (2008) specialist care 142,000 primary care 50 % discharged home Mean boarding time 4-8 h Overcrowding is due to decreasing number of beds in hospitals

28. Germany 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

29. SPAIN Population : 40 millions 17 regions 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

30. ITALY Population : 60 millions 20 regions 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.

31. 27 GREECE 1·5 million immigrants visit the national hospitals have no medical insurance. Greece spends € 25 billion each year on medical services Doctors shouldn’t work > 48h/week… They work 60-70 h/week (10 shifts/month) Overcrowding is related to non-urgent cases and inappropriate visits. Eur J Emerg Med.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.imichali iclau H. (www.thelancet.com Vol 378 July 23, 2011)www.thelancet.com

32. UK the 4 hours target BMJ 2005;330:1188–9 by 2004, no one should be waiting more than four -hours in AED from arrival to admission,transfer or discharge

33. ED Overcrowding … and working conditions in France Input: overall increase in patient volume Ignorance of GP’use : 4,7 times/year General Practitioners: 3 GP’s /1000 inhab in 2025 Facilities and rapid access to immediate care 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 Carasco V. Activity of French Emergency Departments in 2004: study and results. Etude DRESS N° 524; 2006 2012 : Grenoble, Roubaix, Rambouillet, Tenon (Paris), Marseille…

34. GCC Countries GCC population ≈ 43.2 million Saudi Arabia 27.4 million United Arab Emirates 7.5 million Kuwait 2.7 million Oman 2.7 million Qatar 1.7 million Bahrain 1.2 million

35. Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates Number of Hospitals in GCC: – Government: 346 – Private 129 Number of Beds in GCC: – Government: 55,956 – Private: 10,605 Number of Physicians in GCC: – Government: 38,941 – Private: 10,916 Source: GCC Statistical Data Ending Year 2000

36. Non Urgent visits ? not having a regular healthcare provider (63%) being able to receive care on the same day (62%) convenience of and access to medical care 24/7 (62%) 2/3 Level 5 1/3 Level 4 believed their conditions were more urgent than their triage nurse rating. Patients' perspective on factors affecting utilization of primary health care centers in Riyadh, Saudi Arabia. Saeed AASaeed AA1, Mohamed BA. Saudi Med J. 2002 Oct;23(10):1237-42.Mohamed BA

37. FTA with improvements in WTs and LOS can have a large impact on the vulnerable LWBS population Impact of Fast Track Area on non Urgent patients in UAE ?

38. Can a change in policy reduce emergency hospital admissions? Kuwait experience (1) admission avoidance team of ED doctors (2) implementation of disease management guidelines (3) maximising the use of an ED observation unit.

39. 39 Overcrowding : solutions ?

40. 1 – Too many Patients « check in » 2 – Not enough « check out » 3 – Not enough resources OVERCROWDING PROCESS Asplin BR, et al. Ann Emerg Med 2003

41. INPUT TRIAGE INPUT TRIAGE THROUGHPUT LABORATORY RADIOLOGY SPECIALISTS THROUGHPUT LABORATORY RADIOLOGY SPECIALISTS OUTPUT (Med /Surgical Ward) OUTPUT (Med /Surgical Ward) > ?? % 5 % 80 % Admission rate : 10-20 % Level 5 non URGENT Level 2,3,4 Level 1 CRITICAL ILLNESS 70- 80 % 3 CRUCIAL POINTS IN ED

42. OUTPUT (Med /Surgical Ward) OUTPUT (Med /Surgical Ward) non URGENT Level 2,3,4 Level 1 VITAL DISTRESS 70- 80 % GP Primary Care GP Primary Care POC CT in ED POC CT in ED Bed Management Bed Management Fast Track ( EU, US, GCC) Fast Track ( EU, US, GCC) Coordination GP /Hospital/ Walk in Center (Netherlands, Denmark, Sweden) TEMPORARY BED UNIT Internist Geriatric, Palliative Team (Spain, France) Internist Geriatric, Palliative Team (Spain, France)

43. Accelerate « check out !! » Powell ES, et al. J Emerg Med. 2012

44. Accelerate Check out ! Powell ES, et al. J Emerg Med. 2012

45. 7 Conclusions : differences on overcrowding causes in US, Europe, GCC countries 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