1. Hospital Capacity and Emergency Department Diversion: Four Community Case Studies AHA Survey Results April 2004

2. 1 Executive Summary u This report includes the findings from the second of two studies initiated by the American Hospital Association (AHA) on emergency department (ED) capacity constraints and ambulance diversions. 1 u This study seeks to look specifically at communities hospital capacity and how it changes by day and time of day to get a better understanding of the multiple factors that are leading to ED diversions. u 28 hospitals in 4 communities were asked to track inpatient and ED capacity as well as ED diversions at various times over a three day period. u Over 50 percent of hospitals in each community reported that their EDs were at or over capacity. u All communities experienced some level of ambulance diversion, though hours on diversion varied by community. u This study illustrates the difficulty hospitals face in anticipating and responding to changing demand. 1 Times when hospital emergency departments cannot accept all or specific types of patients by ambulance.

3. 2 Executive Summary (continued) u While lack of critical care beds was the most common reason for diversion, the specific causes of diversion varied by community and by hospital at specific points in time. u Other factors that led to diversion included: ED overcrowding Staff shortages Closure of other facilities u RN vacancy rates by community were generally higher in the ED than in the facility as a whole and hospitals with the highest rates of diversion had higher RN vacancy rates. u Hospitals reporting being at or over capacity in the ED had longer waiting and boarding times. u Average occupancy based on a midnight census fails to reflect volume fluctuations by day and time of day.

4. 3 Background & Purpose u In 2002, the AHA conducted a national survey of hospitals to get a better understanding of the growing problem of emergency room capacity constraints and ED diversions. This national study found that: Nearly 80 percent of urban hospitals described their EDs as "at" or "over" capacity 1 More than half of urban hospitals reported time on diversion 1 u This current study, the AHA Daily ED and Hospital Capacity Survey, is a follow-on study to the national survey conducted in 2002. The purpose of this study is to look specifically at communities hospital capacity to get a better understanding of the multiple factors that are leading to ED diversions. Specifically, this study seeks to: Show how the traditional midnight census fails to capture the variability in hospital activity Determine where back-ups tend to occur within the hospital Explore how diversion situations develop across a community 1 Findings from Emergency Department Overload: A Growing Crisis, April 2002

5. 4 Study Approach: Survey Design u AHA Daily ED and Hospital Capacity Survey involved hospital staff tracking ED and hospital volume over a three day period at three times of day: 11 a.m. 6 p.m. Midnight u Survey questions probed the following areas: Annual ED and inpatient volume and capacity data Current RN vacancy rates Point-in-time Measures: Number of staffed ED treatment areas, ED census, number of ED patients waiting to be seen, number of ED boarders 1, hospital inpatient census Daily Measures: ED Diversion tracking by frequency and type, RN hours worked, average waiting times, average boarding times Hospital perceptions of ED capacity issues 1 Admitted patients waiting in the ED for an inpatient bed

6. 5 u The sites for this study were selected from those cities identified during the 2002 national survey as having significant levels of ED diversions. u Urban areas were chosen to allow information collection from the entire community (no more than 10 hospitals). u Cities were selected where at least one hospital had reported being over capacity or on diversion for > 20% of time u Of the cities from the first survey meeting these criteria, we selected four from different geographic regions across the US: Louisville, Kentucky Portland, Oregon Harrisburg, Pennsylvania El Paso, Texas Study Approach: Site Selection

7. 6 u AHA invited all hospitals in all four communities to participate in this three day survey of ED and hospital capacity. u The survey was pilot-tested in three Harrisburg hospitals in November 2002. Revisions were made to the survey instrument based on participant feedback. u The survey was fielded in all hospitals in the remaining three communities in late January 2003. u The surveys were distributed to hospital contacts prior to the survey period. In addition, The Lewin Group reviewed survey content with each hospital via conference call prior to the survey period. u After completion of survey period, hospital contacts returned survey results via fax and mail to The Lewin Group for analysis. u The Lewin Group entered all survey data into a database and analyzed them to identify patterns and trends. Hospitals were asked to clarify any data that were unclear. u Data Limitations: Small sample – only 28 hospitals studied. Limited timeframe – three days in Nov. (pilot) and three days in Jan. Missing data – not all hospitals responded to all questions. Study Approach: Methods & Analysis

8. 7 Findings

9. 8 The majority of hospitals in each community reported being at or over capacity. Percentage of Hospitals At or Over Capacity in Their Emergency Departments By Community

10. 9 One third of hospitals were on diversion for more than 20% of the three day period. Percentage of Hospitals By Time on Diversion

11. 10 Harrisburg exhibited the most severe diversion problem. Average Percent of Time on Diversion During 3-Day Period By Community

12. 11 Lack of critical care capacity and ED overcrowding were the most common reasons for diversion. Reasons for Diversion By Community Percent of Diversions by Reason Capacity constraints elsewhere in the hospitalparticularly in critical care unitscan lead to back-ups in the ED.

13. 12 This study illustrates the difficulty of anticipating and responding to changes in demand. u One hospital had 2.6 patients per critical care bed at one point--nearly three times the demand of a day earlier. u At 11:00 AM Monday, one hospital had a ratio of five patients per staffed ED treatment area 1 ; at the same time Tuesday this ratio was one. u At one point Louisville had 65 patients boarding across its nine hospitals. u One hospitals general acute care occupancy ranged from a low of 55% to a high of 106% during the three day period. 1 Number of patients in staffed treatment areas and in ED waiting room divided by number of staffed treatment areas.

14. 13 Across the communities, over half of admissions were unscheduled. A high proportion of unscheduled admissions limits the ability to alter the pattern of scheduled admissions to smooth demand. Percent Unscheduled Admissions By Community

15. 14 In three communities, RN vacancy rates are higher in the ED than in the ICU. RN Vacancy Rates By Community RN Vacancy Rate

16. 15 High diversion rates appear to be associated with high RN vacancy rates. Average RN Vacancy Rates By Hospital Diversion Category Vacancy Rate

17. 16 Capacity constraints were associated with longer waiting times for patients… Average Waiting Time (in minutes) By Assessed Capacity Level Minutes

18. 17 …and longer ED boarding times. Average Boarding Time (in hours) By Assessed Capacity Level Hours

19. 18 The percentage of patients who left without being seen was not related to perceived capacity levels. Average Percentage of Patients Who Left Without Being Seen By Assessed Capacity Level Percent of Total Patients

20. 19 Hospitals cited a number of underlying factors as contributing to ED diversions. u Bed closures Pressures to be efficient have led to less stand-by capacity to accommodate spikes in demand in inpatient units; when inpatient units are full, back-ups occur in the ED as patient boarders occupy treatment space Closures of psychiatric beds have been a particular concern in Harrisburg where large numbers of psychiatric boarders frequently lead to ED diversion u Large indigent populationin El Paso, large immigrant population crossing the border for carefor whom the ED is a guaranteed access point for care u Population growth has led to increased demand for ED services u Lack of community resources for Medicaid patients leads to increased use of the ED for primary care u Lack of physicians in certain areas leads to higher use of the ED for routine care

21. 20 u Creating a community-wide diversion committee to coordinate ED capacity and patient flow u Improving communication both within and among hospitals u Increasing the threshold for diversion – continuing to accept patients in instances when hospitals would have been on diversion in the past u Expanding non-urgent care capacity u Expanding inpatient capacityparticularly critical care or telemetry u Conducting utilization review to ensure patients are transferred efficiently from critical to acute care to hospital discharge to ensure availability of beds for new patients Study suggests operational changes and community collaboration can ensure resources are used most efficiently and provide some relief. But these efforts may need to be combined with increased capacity in the ED and inpatient units. Hospitals and communities reported taking a number of actions to reduce ED diversions.

22. 21 Portland and Harrisburg reported improvement in the diversion situation since last year. Percent of Hospitals that Noted Diversion Increased, Decreased, or Stayed the Same, 2001 vs. 2002 Percent of Hospitals

23. 22 Conclusions u Capacity constraints and ambulance diversions continue to be concerns of the hospitals in the communities studied. u No two communities are alike in terms of the specific factors that drive these concerns. u Even within a hospital the specific capacity issue leading to diversion differed across the period studied. u The midnight census as a marker of hospital capacity overlooks daily fluctuations in demand and supply. u Perceptions of being at or over capacity in the emergency room appear to correlate with longer ED patient and boarder wait times, but not with the number of patients leaving EDs without being seen. u Hospitals in the sample with more time on diversion also reported higher RN vacancy rates in ICUs. u Study suggests operational changes and community collaboration can provide some relief, but may need to be combined with increased capacity in the ED and inpatient units.