ED Overcrowding

Introduction

• Overcrowding definition
  • The situation where ED function is impeded (either treatment rate or quality) primarily because the number of patients waiting to be seen, undergoing assessment and treatment or waiting for departure exceeds either the physical or the staffing capacity of the ED (ACEM)
• Access block definition
  • Excessive delay in accessing appropriate inpatient beds and proportion of patients with >8 hours total ED time
    • Quantified by proportion of admissions to the hospital, transfers to other hospitals and deaths that have a total ED time of greater than 8 hours

• Access block (aka ED boarding) is the greatest contributory factor to ED overcrowding in Australia
• Also been increase in demand on ED’s in both number and complexity of patients due to enlarging, ageing population and growth in diagnostic and therapeutic options
• This has not been matched by an increase in services, particularly outside office hours

Theory

• Queuing theory
  • Length of queue and waiting time is determined by the arrival rate, the treatment rate and the baulk rate (DNW – which is dependent on length of queue)
• Individual patient’s access to care is dependent upon:
  • Urgency (assuming correct triage category)
  • Number of similar patients already waiting ahead
  • Rate and strategy of treatment
• Treatment rate dependent upon:
  • Staffing
  • Occupancy
  • Resources
• On a daily basis, patient flow is significantly dependent on occupancy as even a small decrease in treatment rate has a cumulative effect with further increase in numbers waiting ahead of each new arrival

Causes of overcrowding

• Single most important factor is availability of inpatient beds
  • Depends on number of beds and bed management
• Discharge practice, patient complexity and admission practice at off-peak times all impact ED flow at peak times
• Absolutely is a marker as whole of hospital dysfunction requiring a whole of hospital response
• Overall ED demand continues to increased worldwide at rates well above population growth, reflecting changes in patient expectations and demographics
• Total ED time has considerably increased overall due to changes in diagnostic and therapeutic approaches
  • Increasing CT use for abdominal pain
• Partly mitigated by shorter, protocol-driven care of other conditions e.g. routine CT for minor head injury and immediate discharge
• Substitution of hospital admission with longer ED stays is also a likely contributor

Consequences of overcrowding

• Associated with reduced access to care, decreased quality measures and lesser outcomes
  • Applies to patients who experience delay in obtaining an inpatient bed and those who present to, or already in, an overcrowded ED
• Increased mortality seen in:
  • Patients who ‘board’ in ED due to access block
  • Admission from overcrowded ED
  • Discharges from overcrowded ED
  • Populations served by overcrowded ED’s
• Dose-response relationship exists and causality has been proven
• Increases total length of stay in hospital
• Increased DNW rates (with inherently high morbidity/mortality)
• Increased medical errors
• Can lead to ambulance diversion (an ineffective and unsafe practice)
• Increases medical negligence claims

Strategies

• Increasing hospital resources and provision of appropriate incentives has been shown to reduce overcrowding
• Increases in number and seniority of ED staff has been shown to improve process measures
• Physical rebuilding increases resources but changes in flow dynamics are still highly dependent on the rest of the hospital
  • e.g. Building bigger ED without improvements in access to inpatient beds just leads to a bigger ED boarding problem
• Analysis of flow and system design may improve efficient use of pre-existing resources
• Senior review early (e.g. at triage) and streaming through fast track are both effective but can prove expensive in terms of capital expenditure and increased staffing
• Mandated time targets + appropriate hospital-wide incentives are effective
  • 4-hour rule in WA and UK has not been associated with negative effect on quality, safety or use of tests
  • Early signs of positive benefit on mortality in these regions
  • Hospital commitment even without full achievement has been shown to improve ED function
• Full Capacity Protocols (FCP)
  • Distribute the overcrowding burden between ED and inpatient areas
  • No detrimental effects on patient care in Alberta
  • Proven to decrease ED LOS, reduce waiting times, reduce DNW rates, reduce patient mortality and increase patient satisfaction
  • Bed management meeting involving senior nursing staff, bed czar, senior physician and executive member to determine hospital census/safety and attribute Level
  • Should be used in tandem with other overcapacity measures
  • Must ensure patients not suitable for inpatient boarding are not sent to the wards
  • Must engage executive, senior nursing leaders and inpatient teams in this process or is doomed to fail
  • Potential issues
    • Concerns re: safety, cross-contamination, workload and inpatient crowding
    • Increased inpatient nursing workload
    • Crowding seen as ED problem NOT whole of hospital
    • Electronic medical record needs to have admission slots for inpatient boarding
    • Nursing ratios on wards may be exceeded and must be considered
    • Consideration of privacy screens, portable resuscitation/suction equipment, toileting facilities for transferred patients
    • Fire safety
    • Risk of victim of own success as other hospitals fail to manage overcapacity and you end up accepting all the ambulances
  • Must emphasise it is a matter of hallway vs. hallway and patients are likely better managed by the inpatient specialised nursing team in a ward hallway than the ED hallway
  • Nurse ratios in ED are unsafe in the first place in this setting
  • Example below:

• Discretionary, low acuity presentations contribute a significant number but insignificant workload in most ED’s
  • Do not need fixed capacity spaces and contribute minimally to occupancy issues
  • Do not meaningfully affect the care of critically unwell patients
  • Contribution to number waiting at any given time is high as low acuity
  • Use of GP’s in ED has not been shown to be beneficial
• Telephone advice services have not been shown to reduce ED workload in Australasia but the public like them
• ED fast-track
  • Efficiently manage low-complexity patients and improve overall wait time, staff and patient satisfaction
  • Contribution to improving occupancy rates is minimal
• Observational medicine is a useful adjunct to or alternative to inpatient care
• Multidisciplinary assessment and discharge is effective at reducing representation in the elderly
• Advanced chest pain protocols for rapid rule out
• Clearly defined turnaround KPI’s
• Support staff to perform work not requiring physician or nurse
• Consider the use of scribes
• Institutional processes
  • Institutional awareness as whole of hospital problem
  • Match resources to needs throughout the 24 hour cycle and 7 days a week
  • Smooth elective surgical timing (i.e. spread across week NOT just start of week)
  • Plan for emergency admissions as very predictable every day of the week
  • Eliminate lock-outs for patient transfers to the ward
  • Examine the discharge process for all patients and potential inefficiencies
  • Use discharge lounges
  • Full capacity protocols (see above)
  • Bed czar – Independent of hospital departments and reports to senior administrators
  • Direct admission orders
  • Cancel elective surgeries when hospital capacity is at maximum

Last Updated on October 6, 2021 by Andrew Crofton