1. Eric REVUE, MD Prehospital and Emergency Department Dreux (France)
  Emergency Department crowding and solutions The French perspective. Review of literature
ED crowding is a universal and international problem.
The causes of crowding are many.
EP and ED directors reported overcrowding as a problem resulting in patients in hallways, full occupancy of ED beds and long waits occurring several times a week.
Overcrowding has many other effects including frustration for patients and ED personnel, lesser patient satisfaction and greater risk for poor outcome.
Our study covers the causes, significance and dangers of overcrowding in France and focuses on specific solutions.
Def: Crowding typically involves patients being monitored in non treatment areas (eg, hallways) and awaiting ED treatment beds or inpatient beds. Crowding may also involve an inability to appropriately triage patients, with large numbers of patients in the ED waiting area of any triage assessment category.(ANNALS OF EMERGENCY MEDICINE 42:2 AUGUST 2003)
In Paris, ED overcrowding should be defined as a period when ambulances are diverted to nearby hospitals when all critical care beds in the ED are occupied, patients are occupying hallway spaces.
Eric REVUE, MD
Prehospital and Emergency Department
Dreux (France)
6 th European Congress on Emergency Medicine
12 th Annual Meeting of SweSEM
October 2010

2. Organization for Economic Cooperation and Development (OECD)
France ED in 2010
Pop: 65 Millions inhabitants (2,2 M Paris, 11,5 M Ile de France)
630 Emergency Departments in France (96 Paris IDF)
14 Millions visits (+4 % / year) > 1 Million pediatrics
> 3 Millions (+ 6,3%) in Paris IDF(800 Short Stay Unit beds)
+ 50 % of ED visits in 10 years ( )
> 17 % admit hospital
81 % discharge from ED
2 % transfer to another hospital
+ 3 % emergency call SAMU (112) 1,4 Million in Paris IDF
A recent report by the Organization for Economic Cooperation and Development (OECD), indicates that France ranks high on most measures of health status and is well above the OECD average on a range of key indicators.
However, health professionals staffing emergency departments of public hospitals in France, complain of deteriorating working conditions due to overcrowding.
> Intensive care Mobile Unit (SMUR)/year in 2008 (+ 4%)
> 300 visits in ED /1000
>100 patients/day
(10 % > 75 year old 30 % child)
Organization for Economic Cooperation and Development (OECD)
France = 1 rst Health System in the world (WHO)…
Number of ED visits in France/ year (reference = 100 in 1996)

3. Causes of 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
Facilities and rapid access to immediate care
Nearby hospital,
Free –of- charge service ( apparently)
Throughput:
Patient : need of X ray or quick laboratory tests ? delays +++
Elderly patients (> 80 yo) with chronic diseases visit ED > 50 % admit
Perceive a need for hospital bed.
shortage of on-call specialty consultant or lack of availability
Working Time Directive for ED personnel and the French “35 hours” law (48 h EP)
Shortage of nursing staff
Output: lack of beds
for patients admitted to the hospital
Lack of nursing home < 15 beds/1000 hab (> 75 years old)
Input:
GP:
The French consult their doctors more often (average 4,7/year,they can visit several general practitioners), are admitted to the hospital more often, and purchase more prescription drugs. Patients have a free choice of doctor, and do not need a referral from a general practitioner in order to consult a specialist.
Doctors benefit from total freedom to choose where they wish to practice, and geographical disparities in the distribution of doctors have existed for a long time.
Population of GP in France is still decrease ( < 3 GP/ 1000 patients) with an increasing number of female doctors.
Throughput: ED complain about the implementation of the EU Working Time Directive for physicians and the enforcement of the French “35 hours law” for other members of staff increased staff pressure.
Lack of sufficient personnel has been cited as one of the causes of the high mortality observed in the particularly hot summer of 2003 or winter epidemics.
+ 40 % of elderly patients > 80 years old in 2007 in ED (+ 10 % in Paris and Ile de France 2000 – 2004) and > 50 % are admit through the ED.
Out Put: The primary determinants of ED overcrowding are not related to patient throughput inside the ED but actually originate outside the ED.
Of these, the two most important determinants of ED overcrowding pertaining to the critically ill are an increasing volume of high-acuity patients presenting to the ED and insufficient inpatient capacity.

4. Why/What patients are waiting in French ED?
TRIAGE = 5 %
ER = 17 %
Emergency Physician = 13 %
Laboratory X Ray
= 25 %
Diagnosis = 12 %
In 2003, a national survey on overcrowding in French ED focused on different use of Emergencies:
facilities and rapid access to immediate care, nearby hospital,
apparently free –of- charge service,
ignorance of GP’use,
need of X ray or quick laboratory tests,
perceive a need for hospital bed.
Crowding was associated with increased door-to-needle time for patients with suspected myocardial infarction .
High ED occupancy levels were associated with delayed pain assessment.
The length of stay is rising with the waiting times for laboratory tests or R rays (25 %) or waiting for a bed (13%).
In French ED the average length of stay for discharged patient is > 4 h sometimes > 24h
Specialist = 5%
Treatment = 4,5 %
Bed = 13 %
Papers = 4,6 %
> 25 % Length of stay > 4h (> 24 h )
Transport = 1,6 %

5. Overcrowding in French ED
French Health Care System : coordination
hospital care/ ambulatory care ?
Health care/social care ?
TRIAGE
Resuscitation Room
< 5 %
Med/trauma
Med/
Trauma
Med/Trauma
Pediatrics
FAST
TRACK
60 %
17 %
NHSA
global increase in occasional use by the population may explain this heavier ER activity.
Many of the visits for minor reasons may appear inappropriate.
If frequent ER use has been described mainly in elderly adults, this phenomenon is also common in children.
In 2002 ,a national study with 150 French ED, population of young men (< 15 years old) represented 29 % of non urgent visits.
TRIAGE :
In France, triage is done more over to detect cases in need of priority care.
The French law cannot allow ED to deny emergency care to selected patients on the basis of chief symptoms and vital signs.
THROUGHPUT:
Periods of emergency department saturation are increasingly common in many parts of France, and overcrowding frequently results in rationed access to in-hospital beds , particularly acute beds in Paris.
The ED runs very efficiently with only a few patients in the waiting room queue until the inpatient hospital beds are full.
At this point, admissions cannot be moved out of the ED, witch decreases the number of available beds, utilizes a great deal of nursing and ancillary satff time, and invariably, when the saturation point is hit, waiting times go up and ED crowding should require.
Crowding in the ED is a multifactorial problem:
Recent hospital and ED closures
Nursing shortage
Complex work up for higher acuity patients
Delays in laboratory and radiology studies
Lack of availability of inpatients beds with prolonged patient boarding …
Patients who arrived at French ED during crowded periods waited 30 minutes longer for an ED bed.
Lack of physical inpatient beds
Inflexible nurses to patient staffing ratios
Delays cleaning rooms after patient discharge
Overreliance on ICU or telemetry beds
Delays in discharging hospitalized patients to post- acute care facilities

6. Solutions Literature Results on ED visits
Walk in Centers
Salisbury 2002,2003,2007
10 – 43 % if 24h/day , close ED ,protocols, triage
GP “gate keeper” “SOS Doctors”
Franco 1997,
Hurley 1989,Piehls 2000
10- 40%
SAMU NHS Direct
Munro 2000
Impact on LOS ?
Pay ED visit
Reed 2005, Rice 2004, Bunn 2005
- 20 – 30 % ?
Triage to GP
Schull and al 2007
LOS ?
Manchester Triage
Cheung 2002, Subash 2004
LOS +++ if nurse + EP
Fast Track
Darrab 2006, Cooke 2003
LOS – 20 %, LWBS ?
Nurse Pract, senior
Muphy 1997, Gerbeaux 2000
Xray,cost % lab
Point of care testing
Kendall 1998,Murray 1999
LOS idem
Geriat Mobile Unit
Roussel 2005, Chermak 2002
LOS admit+ 20%
Computerize
MEAH
LOS, quality of care
Beds Admission
Bellou 2005, SFMU 2003
- 25 % of beds
Short Cuts
(End of life..)
Billault 2004
Direct admission
Many experiments have been conducted aimed at redirecting these patients to some primary care facility like GP’s house.
WIC, GP’s house: moving non urgent patients out of the ED and into the (GP’house,,family Dr) does not decrease the ED overcrowding
Triage:
In put factors: visits by patients with non urgent complaints were not associated with the most severe crowding at large hospitals.
Fast Track: Non urgent patient coming to the ED are approximately 10 % of total patients.
One approach is “fast tracking,” which involves referring patients with non acute problems to the GP’s house that are adjacent to the emergency department.
Using emergency departments for less acute conditions may contribute to overcrowding.
They are high in cost and the patients could have been seen at a lower level facility.
Contrasting with US observations, nationality is habitually found in France (particularly in Paris and other big French cities) to be related to access to primary care independently of socioeconomic level. These latter people labeled "chronic patients”, "heavy users” or "repeaters”, are often considered to make undue use of ER facilities by consulting ordinarily for non-emergency problems. However, these patients often perceive a need for immediate care and their social origin casts doubts about their ability to use alternative services.
In put: Fast track: referring patients with non acute problems to immediate or prompt care at sites that are adjacent to the emergency department.
However, many facilities lack the resources to do this.
Referring non acute patients to off-site, non–emergency department settings is an alternative approach but often requires deferring care for at least 1 day.
Geriatric: “Rapid Geriatric Assessment Team”.
For many elderly, the Ed remains a critical point to access to more complete managed care. Intervention of multidisciplinary networks such as home health care programs aimed at detecting crisis factors and establishing early prevention of crisis states, may improve unfavorable medical and social conditions and reduce hospitalization in geriatric patients.
alternatives to complete hospitalization, such as day care surgery or treating patients in their homes (known as “hospitalization at home” in France).
In each case, the extension of capacity must be authorized. Authorization is granted in return for closing down acute beds, with a theoretical exchange rate of one place for two beds, which may be adjusted at the regional level to take account of existing bed numbers.
In spite of the incentives available, the development of alternatives to complete hospitalization remains limited by international standards.
Current policies concerning elderly people and disabled people have two aims: increasing the capacity of admission to institutions to meet growing demand and developing “lighter” forms of care (such as family placements and assistance with care in the home), which promote better integration and autonomy and are also much cheaper to provide.
The real deal is to improve availability of inpatient beds.
NEDOC (National ED Overcrowding Study) ?
EDWIN (ED Work Index) ?

7. Beds , beds, beds ….my kingdom for a bed !
- 30 %
- 49 %
France : 1974 – 2003
UK :
- 45 %
- 45 %
Lack of patient bed availability has been identified as a major contributor to ED crowding.
Canada : 14 Millions of visits/year (2004)
UK:increase number of ED visits > 1% since 1990 (-49 %)
USA: > 14 % ED visits ( ) 100 millions per year
France : decreasing number of beds from 1987 to %/year = 30 %
Canada: 1960 – 2002
USA:
N beds/1000 habitants
Source: WHO

8. Triage Dispatch phone call Centre
Decrease LOS
Possible
To explore
Fast track
Walk in Centre
Nurse Practitioner
Primary Care
Point of care testing
Copayment
Senior EP in ED
Short cuts
(ACS, End of life…)
Organization
in the ED
Triage in ED
Triage before admit
Computer
Triage Dispatch phone call Centre
Number of beds

9. French Society of Emergency Medicine (2005)
Bed’s management : nurse or physician
Anticipation of delivery of care to patients
Protocols ED /Medicine wards
“temporary emergencies beds unit”
Avoid requisition of beds
Coordination GP /Hospital/ Walk in Center
Channels for elderly patients
Shortcut : direct entrance through ED
Interdisciplinary geriatric palliative care team
Multidisciplinary ED with internist
Alternatives : hospitalization “at home”
However, when French hospitals are perpetually functioning at greater than 90% of their inpatient capacity, they are ill equipped to handle surges in the number of admissions. Inadequate inpatient capacity for a patient population with increasing severity of illness forces the ED to serve as a holding area for admitted patients. The term ‘boarding’ refers to patients who are admitted to the hospital but who remain in the ED, sometimes for more than 24 hours, because of the lack of available beds
In 2005, the French Society of Emergency Medicine (SFMU) published different measures to improve and to solve overcrowding in ED.

10. LOS : 1h 50 mn 3h 30 admit Hospitalization “at home”
40000 visits (2009)
LOS :
1h 50 mn
3h 30 admit
The Victor Joussellin’s Hospital experience:.
With a progressive increase in the number of visits to the ED and inpatient hospital occupancy of 100% on most days, we have an almost daily bed crisis.
Our General urban hospital (500 beds). The median number of daily patients in the ED is 150 (40000/year), that does not include maternity and pediatric cases which are managed in separate casualty departments.
The mean ED LOS is 4h .The percentage of transfers from the ED to others hospitals is < 1 %.
Mortality rate is < 0,1 % Admission rate from the ED is 25 %. We don’t have hallway patients beds.
> 70 % of elderly patients (> 75 years old) are admit , only few patients were discharged to home.
In our ED we have introduced a new Policy aimed at performing hospital medical admissions. We assigned an admission team of nurses manager to be responsible for admission/discharge decisions. The team implemented validated disease management guidelines and protocols.
We also maximised the use of the emergency department observation unit (11 beds) by:
(1) using it as a short stay observation ward for common medical emergencies (eg, chest pain observation unit with the necessary monitoring);
(2) extending the length of stay to a maximum of 48 hours;
(3) allowing its use for certain procedures such as blood transfusions.
We observed the change in the total medical admission rate and admission rates for selected common medical conditions.
Throughput:
Output: To improve ED output, a nurse bed manager was delegate to the admission of inpatients from ED.
The nurse bed manager/coordinator had more responsibility and authority over patient disposition, even when patients belonged to another specific clinical department.
If the hospital is full and cannot admit the patient in a surgical or medicine department, the admission is in the Observation Short Unit or in the polyvalent Medicine department.
Medical short stay unit for geriatric patients in ED is useful for decision to admit patients.
The ability to move patients with a DTA out of ED depends on the ability of the hospital to accommodate patients to make room available
Short cuts

11. Overcrowding in France depends on
Conclusions
No “miracle recipe” ! But ……
Overcrowding in France depends on
Organization of the ED …and of the hospital !!!
Organization of the throughput and NOT the input
Development of GP’s houses ? May be
Fast Track
Short cuts ! (ACS, Stroke, ICU, palliative care….)
The ability of the hospital to the beds management = beds manager play a key role in the ED of operational capacity and control
Mobile Geriatric Unit in the ED
Protocols senior houses and geriatric unit
Alternatives to the admission ? Home care ?
Short stay Unit capacity
Polyvalent Medicine department close to ED with LOS < 5 days
Computerize model

12. Thank you for your attention
I could resume the situation of “real life” ED overcrowding in France in this picture: an EP on call and phone to his colleagues in other region hospital with grand’ ma 85 years old waiting for a bed ….
Many factors contribute to inpatient boarding in the ED in France.
Thank you for your attention