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

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

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 Med 2006 Sep 28;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 1.Bohan JS. Emergency Care: A System in Crisis. JWatch Emergency Med. 2006; 1-1 2.Burt CW, McCaig LF, Valverde RH. Analysis of ambulance transports and diversions among US emergency departments. Ann Emerg Med. 2006; 47:317-326 3. Hoot NR, Aronsky D. Systematic Review of Emergency Department Crowding. Ann Emerg Med. 2008; 52: 126-136. 4.Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006; 355: 1300–1303 5.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. 6.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. 7.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.