ED Overcrowding Isra Al-LawatiIsra Al-Lawati

R3R3

Outline

Objective IntroductionDefinitionMarkers of Overcrowding Source of Crowding in ED SolutionsSummery

Objective

Familiarize you with crowding concept

Tackle major cause of crowding in our departments compered to international causes

Explore the most efficient solutions

Introduction

Emergency department (ED) overcrowding significant problem

Major barrier to receiving timely emergency care

Increased health care costs

Raised stress levels among staff and patients

Adversely affecting patient outcome.

Forecasting Models of Emergency DepartmentCrowding

Lisa M. Schweigler, MD, MPH, MS, Jeffrey S. Desmond, MD, Melissa L. McCarthy, ScD,ACADEMIC EMERGENCY MEDICINE 2009

EffectsAdverse Outcomes

Patient Mortality

Reduced QualityTransport DelaysTreatment Delays

Impaired AccessAmbulance DiversionPatient Elopement

Provider LossesFinancial Effects

History

Described in 1980s

Aging population

Rising infectious disease rates e.g. AIDS

Substance abuse

Psychiatric illness

Effects of poverty on health

Hospital bed and staffing shortages

CAEP - canadian association of emergency physicians: - emergency department overcrowding - position statement 2003

Early 1990s strategies to address overcrowding were developed little or no action

Easier and cheaper to House the ED wide acceptable

Late 1990s problem peaked

Aging population

Fewer hospital beds and fewer Eds

Raising patient volumes and acuities

CAEP - canadian association of emergency physicians: - emergency department overcrowding - position statement 2003

Kellermann AL. Crisis in the emergency department. N Engl J Med 2006 Sep 28;355(13):1300–1303.

ED visits 26%, # ED 9% 198000 closed bed

Definitions

The ACEP Crowding Resources Task Force

“A situation in which the identified need for emergency services outstrips available resources in the ED”

More patients than staffed ED treatment beds

Waiting times exceed a reasonable period.

Pts being monitored in non-treatment areas (eg, hallways)

Inability to appropriately triage Pt

www.acep.org/workarea/downloadasset.aspx?id=8872

Canadian Association of Emergency Physicians

“Situation in which demand for service exceeds the ability to provide care within a reasonable time, causing physicians and nurses to be unable to provide quality care.”

Monitoring waiting times & time to be seen by the ED physician

Time to be seen by a consultant

Time to admitted patient to an inpatient bed.

Australian collage of emergency Medicine (ACEM)

“Situation where emergency department function is impeded primarily because the number of patients waiting to be seen, undergoing assessment and treatment, or waiting for departure exceeds either the physical bed and/or staffing capacity of the emergency department”

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

ED crowding is a system problem not an ED problem

Measure of health system performance

Examine ED crowding in the context of the entire delivery system by using reliable methods to understand, measure, and monitor system capacity

Markers of Overcrowding

Inability to offload ambulance patients and a resultant loss of capacity in the local emergency response in the community.

Inability to place critically unwell patients in an appropriate treatment space when required.

Patients undergoing clinical management in a non-treatment area.

Admitted patients receiving a lesser standard of care than that applying in their destination unit.

Reasons

1. Macro level – This perspective examines the forces of the national and regional levels that drive ED crowding, such as the federal and state government health programs, and other regulatory bodies.

2. Micro level – This perspective examines the forces that affect EDs on a local and institutional level.

Micro Level

Conceptual model of ED crowding:

• Input: any condition, event, or system characteristic that contributes to the demand for ED services.

Sources and aspects of patient inflow

• Throughput: the processes of care within the ED

• Output: The movement of pt out of the ED to another care site

180. ‐ 173 42(2): 2003; Med. Emerg. Ann crowding. department emergency of model conceptual A al. et KV, Rhodes DJ, Magid BR, Asplin 1

Input 3 general categories of care delivered in the ED

(1) emergency care

• Seriously ill and injured patients may be increasing.

• Referral of patients with emergency conditions.

(2) unscheduled urgent care

• Lack of capacity for unscheduled care in the ambulatory care system

• Desire for immediate care

(3) safety net care

• Vulnerable populations (eg, Medicaid beneficiaries,the uninsured)

Non-Urgent Visits• Low-acuity ED PT.

– Present even in hospitals with dedicated fast-track systems.

– Reasoning:• Insufficient access or/ and Untimely access to PC.

Account for a small portion of total ED volume. Account for a small portion of total ED volume.

Frequent Flyers

4 or more annual visits to the ED 8-14 % total ED visits

Non-urgent complaints

Chronic illness, drug seeking patients, malingers

29% of these visits might have been

appropriate for primary care.

Hoot & Aronsky Systematic Review of Emergency Department Crowding Volume 52 NO2 : August 2008 Annals of Emergency Medicine

Throughput

Identifies patient length of stay in the ED as a contributing factor .

Highlights the need to look internally at ED care processes & modify them a to improve efficiency and effectiveness.

2 Phases

phase I : triage, room placement, and the initial provider evaluation

Phase II: diagnostic testing and ED treatment ( Majority time)

Output

Inefficient disposition of ED patients

board admitted pt ED’s capacity to care for new patients

Boarding of inpatients in the ED cited as the most important determinant of overcrowding & ambulance diversion.

Boarding consume nursing & physician resources and delay evaluation of new patients.

Inpatient Boarding:

1/2 of American ED’s have extending boarding times.

A point-prevalence study 22 % ED pts were boarded patients.

Factors ?!!

•Andrulis DP, Kellermann A, Hintz EA, et al. Emergency departments and crowding in United States teaching hospitals. Ann Emerg Med. 1991;20:980-986.

•Schneider SM, Gallery ME, Schafermeyer R, et al. Emergency department crowding: a point in time. Ann Emerg Med. 2003;42:167-172.

Once Discharge :

The availability of timely follow-up appointments in the ambulatory care system once again may create capacity problems

Time spent by ED providers arranging appropriate follow-up

If outpatient follow-up care cannot be made, EP are more likely to admit patients to the hospital

180. ‐ 173 42(2): 2003; Med. Emerg. Ann crowding. department emergency of model conceptual A al. et KV, Rhodes DJ, Magid BR, Asplin 1

Solutions

Acknowledge it a SYSTEM problem.

Look in each component and find modifiable factors

Increased Resources

Ways that have been shown to effectively decrease ED stays:

• Permanent increase in ED physician staffing.

length of stay by 35 minutes

• Activation of reserve personnel during peak times. e.g. : Influenza Season

Rondeau KV, Francescutti LH. Emergency department overcrowding: the impact of resource scarcity on physician job satisfaction. J Healthc Manag. 2005;50:327-340.

• 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.

• Acute medical Unit • Reduce Boarding time

• Point-of-care Laboratory Testing

• Shown to decrease length of stay by 41 minutes.

• Fast Tracks

Improve waiting time but Not the crowding

• Improve Bed Access and Management

Most promising interventions in terms of permanently reducing ED Crowding

• Additional Solutions Bedside Registration

Physician Triage

Cancelling Elective Surgeries

“NOT” Effective Solutions

Ambulance Diversion

ED Expansion

Employ hospitalists to coordinate patient care

American College of Emergency Physicians. Emergency Department Crowding: High-Impact Solutions. April 2008.

Summary

Crowding Is not the Volume its Available recourse

It’s a System problem not ED

Conceptual model

Conjoint efforts to solve the problem

Thank You

??