• Like

Drew Richardson, ANU Medical School - Emergency Department Overcrowding

  • 430 views
Uploaded on

Drew Richardson presented this at Emergency Department Management Conference 2013. This conference focuses on improving access to care, clinical redesign, NEAT comliance, patient flow, point

Drew Richardson presented this at Emergency Department Management Conference 2013. This conference focuses on improving access to care, clinical redesign, NEAT comliance, patient flow, point

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
430
On Slideshare
0
From Embeds
0
Number of Embeds
3

Actions

Shares
Downloads
6
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. ED OVERCROWDING: An update on current research Case studies of possible solutions A/Prof Drew Richardson BMedSc MBBS(Hons) FACEM GradCertHE MD NRMA-ACT Road Safety Trust Chair of Road Trauma and Emergency Medicine Australian National University Medical School
  • 2. Declaration • This research was carried out whilst an employee of the Australian National University Medical School and was not separately funded • Views expressed are those of the author and do not necessarily reflect those of any of his employers • Overcrowding is my major research interest • The Unit has received research funding • Author has received travel/other expenses to speak • Author owns no related shares
  • 3. Objectives • Outline the history of research into ED overcrowding • Describe the major “landmark” studies in the field • Identify generally accepted research about the causes, effects, and possible solutions • Review research developments over the last two years in detail • Case studies from places reporting some recent success
  • 4. Overcrowding • Concept of overcrowding is almost as old as the concept of crowds • Wherever herd animals gather, the useful maximum number is sometimes exceeded unless there are external controls
  • 5. Overcrowding • Earliest descriptions of overcrowding in a healing setting date to biblical times • Hospital Overcrowding and adverse effects described since at least the mid nineteenth century
  • 6. Overcrowding • Studies reporting increased ED workload pre-date recognition of ED as a specialty • Multiple proposed solutions started almost 40 years ago • Emerged as a significant subject for research NEJM 1958 Jan 2; 258(1): 20-5 Can Med Assoc J 1974 May 4; 110(9): 1039-43
  • 7. • 1081 papers in international literature to Dec 31 2012 • Read all these abstracts so you don’t have to Medline: emergency AND (crowding OR overcrowding OR "access block") 0 20 40 60 80 100 120 140 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
  • 8. History • Overcrowding became a major issue in USA in late 1980s – Traditionally started in New York – Others lay claim • Scientific descriptions started in 1990s – General Medical Literature – Health Services Literature – Emergency Medicine Literature • Clear recognition that cause and solutions lay outside ED Gallagher EJ, Lynn SG. The etiology of medical gridlock: causes of emergency department overcrowding in New York City. J Emerg Med. 1990 Nov-Dec;8(6):785-90 Schneider S, Zwemer F, Doniger A, Dick R, Czapranski T, Davis E. Rochester, New York: a decade of emergency department overcrowding. Acad Emerg Med. 2001 Nov; 8(11):1044-50 Bindman AB, Grumbach K, Keane D, Rauch L, Luce JL. Consequences of Queuing for Care at a Public Hospital Emergency Department. JAMA. 1991 Aug 28;266(8):1091-6 Baker DW, Stevens CD, Brook RH. Patients who leave a public hospital emergency department without being seen by a physician. Causes and consequences. JAMA. 1991 Aug 28;66(8):1085-90 Kellermann AL, Hackman BB. Patient 'dumping' post-COBRA. Am J Public Health. 1990 Jul;80(7):864-7 Grumbach K, Keane D, Bindman A. Primary Care and Public Emergency Deaprtment Overcrowding. Am J Public Health. 1993 Mar;83:372-8 Andrulis DP, Kellermann A, Hintz EA, Hackman BB, Weslowski VB. Emergency departments and crowding in United States teaching hospitals. Ann Emerg Med. 1991 Richards JR, Navarro ML, Derlet RW. Survey of directors of emergency departments in California on overcrowding. West J Med. 2000 Jun;172(6):385-8
  • 9. History • Despite a lack of supporting evidence, unambiguously stated that overcrowding was a threat to patient safety • Early publications tended to start from this assumption then describe ways to fix it – Triage – Short stay Units – Multimodal interventions G Dickinson. Emergency department overcrowding. CMAJ. 1989 Feb 1;140(3): 270-1 Shah CP, Carr LM. Triage: a working solution to over crowding in the emergency department. Can Med Assoc J. 1974 May 4;110(9): 1039-43 Neville L, Rowand RS. Short stay unit solves emergency overcrowding. Dimens Health Serv. 1983 Feb;60(2): 26-7 Feferman I, Cornell C. How we solved the overcrowding problem in our emergency department. CMAJ. 1989 Feb 1;140(3): 273-6 Lynn SG, Kellermann AL. Critical decision making: managing the emergency department in an overcrowded hospital. Ann Emerg Med. 1991 Mar;20(3): 287-92 Cooke J, Finneran K. A clearing in the crowd: innovations in emergency services. Pap Ser United Hosp Fund N Y. 1994 Jan: 1-43
  • 10. History • First systematic research showed association with increased costs – Actually spending midnight in ED not associated with less ward LOS • First outcome study showed increased mortality in Spain – Weak methodology, weekly presentations, no correction for seasonal factors • First Review article listed 8 adverse effects but provided a reference for only one of them (ambulance diversion) Krochmal P, Riley TA. Increased health care costs associated with ED overcrowding. Am J Emerg Med. 1994 May;12(3):265-6 Miró O, Antonio MT, Jiménez S, De Dios A, Sánchez M, Borrás A, Millá J. Decreased health care quality associated with emergency department overcrowding. Eur J Emerg Med. 1999 Jun;6(2):105-7 Derlet RW, Richards JR. Overcrowding in the nation's emergency departments: complex causes and disturbing effects. Ann Emerg Med. 2000 Jan;35(1):63-8
  • 11. Systematic studies • New generation of researchers entered the field in 2000s • Systematically examined – Definitions (still needs work) – Causes – Effects • Process • Quality • Patient Outcome including mortality – Solutions • Fair to say that even with good data it has proven difficult to persuade our inpatient and administrative colleagues – Even if our children think we research “the bleeding obvious”
  • 12. Colleges needed no persuasion • “Crowding occurs when the identified need for emergency services exceeds available resources for patient care in the emergency department (ED), hospital, or both” • “Overcrowding is the 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 or the staffing capacity of the Emergency Department” • “Access Block is the situation where patients in the ED requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame. It is expressed as the proportion of patients requiring formal admission to hospital who have a total ED time greater than 8 hours” American College of Emergency Physicians. Crowding. Ann Emerg Med. 2006 Jun;47(6):585 Australasian College for Emergency Medicine. Policy document — standard terminology. Emerg Med (Aust) 2002; 14: 337-340 Australasian College for Emergency Medicine. Policy document — standard terminology. Emerg Med (Aust) 2002; 14: 337-340
  • 13. Anecdote or Data? • Old political rule: Use data to justify your position, but use anecdote to persuade • Emergency medicine started the 21st century with lots of anecdote but despite 10 years of overcrowding in some places, surprisingly little data • To us, the problem was obvious
  • 14. Anecdote or Data? Drive THRU BURGER PrincePrincePrincePrince • Hospital patients with broken hips or heart attacks similar to drive through customers • Need to sort out their medical needs (take the order) then provide definitive care (serve) • Short queue for each
  • 15. Anecdote or Data? Drive THRU BURGER PrincePrincePrincePrince • If the restaurant does not have sufficient ability to cook the meals, the person in the order window cannot do their job • The queue becomes a hazard
  • 16. Anecdote or Data? Drive THRU BURGER PrincePrincePrincePrince • They do not rent the block next door to give more queuing space • Would last 10m
  • 17. Anecdote or Data? Drive THRU BURGER PrincePrincePrincePrince • Such an approach would be waste of money, lead to longer queues, worse outcomes
  • 18. Anecdote or Data? Drive THRU BURGER PrincePrincePrincePrince • The solution is to fix the problems in the kitchen! • Unfortunately this anecdote and those like it were not sufficient to convince managers outside emergency medicine • Back to data
  • 19. Causes of Overcrowding - 1 • Increasing demand at the front door noted since 1950s • “Build it and they will come” – USA: 102.8M in 1999 to 136.1M in 2009 (32%) • 37.8/100 to 45.1/100 persons (19%) – Australia: 37% over decade 2000-01 to 2009-10 • 1.8% annual increase after population growth • Development of EM as a specialty has contributed to a positive attitude towards ER • Development of medical care in general increases demand • Population aging is important Shortliffe EC, Hamilton TS, Noroian EH. The emergency room and the changing pattern of medical care. N Engl J Med. 1958 Jan 2;258(1):20-5
  • 20. Causes of Overcrowding - 2 • Accepted by professional bodies that access to inpatient beds (“access block”) and resultant “boarders” causative • This research base started in 2003 – Clear statistical link between hospital occupancy and ED LOS • Subsequently confirmed in multiple studies around world • Mostly retrospective • Ever increasing sophistication Forster AJ, Stiell I, Wells G, Lee AJ, van Walraven C. The effect of hospital occupancy on emergency department length of stay and patient disposition. Acad Emerg Med. 2003 Feb;10(2):127-33 Dunn R. Reduced access block causes shorter emergency department waiting times: an historical control observational study. Emerg Med Australas. 2003 Jun;15(3):232-8 Fatovich DM, Nagree Y, Sprivulis P. Access block causes emergency department overcrowding and ambulance diversion in Perth, Western Australia. Emerg Med J. 2005 May;22(5):351-4 Fatovich DM, Hirsch RL. Entry overload, emergency department overcrowding, and ambulance bypass. Emerg Med J. 2003 Sep;20(5):406-9
  • 21. Causes of Overcrowding - 3 • Politicians and funders tended to blame “non- urgent patients”, “GP-type patients”, “uninsured” – Language and reasoning varied but everywhere • Research response also happened around the world • Retrospective studies of load • Some prospective studies of telephone advice lines, low- acuity services • Low acuity patients do not block ambulances from unloading Nagree Y, Ercleve TN, Sprivulis PC. After-hours general practice clinics are unlikely to reduce low acuity patient attendances to metropolitan Perth emergency departments. Aust Health Rev. 2004 Dec 13;28(3):285-91 Dent AW, Phillips GA, Chenhall AJ, McGregor LR. The heaviest repeat users of an inner city emergency department are not general practice patients. Emerg Med (Fremantle). 2003 Aug;15(4):322-9 Sprivulis P. Estimation of the general practice workload of a metropolitan teaching hospital emergency department. Emerg Med (Fremantle). 2003;15:32-37 Sprivulis P, Grainger S, Nagree Y. Ambulance diversion is not associated with low acuity patients attending Perth metropolitan emergency departments. Emerg Med Australas. 2005 Feb;17(1):11-5 Canadian Health Services Research Foundation. Myth: Emergency room overcrowding is caused by non-urgent cases. J Health Serv Res Policy. 2010 Jul;15(3):188-9 Schull MJ, Kiss A, Szalai JP. The effect of low-complexity patients on emergency department waiting times. Ann Emerg Med. 2007;49:257-264 Newton MF, Keirns CC, Cunningham R, et al. Uninsured adults presenting to US emergency departments: assumptions vs data. JAMA. 2008;300:1914-1924. Rimsza ME, Butler RJ, Johnson WG. Impact of Medicaid disenrollment on health care use and cost. Pediatrics. 2007;119: e1026-1032 Munro J, Nicholl J, O'Cathain A, Knowles E. Impact of NHS Direct on demand for immediate care : observational study. BMJ. 2000;321:150–153 Dunt D, Wilson R, Day SE, et al. Impact of telephone triage on emergency after hours GP Medicare usage: a time-series analysis. Aust New Zealand Health Policy. 2007;4:21
  • 22. Causes of Overcrowding - Recent • More prospective studies on the effects of closing inpatient beds – Not good for ED • Ever more complex models used in analysis – Admission practice in off-peak times does impact results at peaks – Distinct “Choke points” found in large hospitals around discharge timing from the wards – Hospital Occupancy and complexity as measured by admissions important – Same patterns across broad groups of hospitals Crilly J, Keijzers G, Krahn D, Steele M, Green D, Freeman J. The impact of a temporary medical ward closure on emergency department and hospital service delivery outcomes. Qual Manag Health Care. 2011 Oct-Dec;20(4):322-33 Luo W, Cao J, Gallagher M, Wiles J. Estimating the intensity of ward admission and its effect on emergency department access block. Stat Med. 2012 Nov 21. doi: 10.1002/sim.5684 Khanna S, Boyle J, Good N, Lind J. Unravelling relationships: Hospital occupancy levels, discharge timing and emergency department access block. Emerg Med Australas. 2012 Oct;24(5):510-7 Rathlev NK, Obendorfer D, White LF, Rebholz C, Magauran B, Baker W, Ulrich A, Fisher L, Olshaker J. Time series analysis of emergency department length of stay per 8-hour shift. West J Emerg Med. 2012 May;13(2):163-8 Wiler JL, Handel DA, Ginde AA, Aronsky D, Genes NG, Hackman JL, Hilton JA, Hwang U, Kamali M, Pines JM, Powell E, Sattarian M, Fu R. Predictors of patient length of stay in 9 emergency departments. Am J Emerg Med. 2012 Nov;30(9):1860-4.
  • 23. Causes of Overcrowding - Recent • Sep and Dec 2012 Annals of EM • 424 hospitals: Throughput performance measures highly dependent on “exogenous variables” – Seeking a way to adjust measures for hospital and outside factors – Concluded no simple way exists – Volume, casemix, age, teaching etc • 8 years of National Ambulatory Medical Care Surveys – Visits up 1.9% per annum (15%) – Occupancy up 3.1% per annum (27%) – Increase driven by practice intensity • Doing more for each patient
  • 24. Causes of Overcrowding - Recent • Boarding still contributes to crowding, but is no longer getting worse the way it was a decade ago • In this US series growth is in practice intensity – Older and sicker? – Substituting admissions? – Doing too much? • Most growth in imaging • Most contribution simple tests and treatment • Much more research to be done Pitts SR, Pines JM, Handrigan MT, Kellermann AL. National trends in emergency department occupancy, 2001 to 2008: effect of inpatient admissions versus emergency department practice intensity. Ann Emerg Med. 2012 Dec;60(6):679-686.
  • 25. Consequences of Overcrowding • As noted, in 2000 it was accepted as a given that ED overcrowding was bad, but no evidence base • The next generation of researchers set about seeking any relationship between overcrowding and undesirable outcomes • Broadly this came to 3 different approaches: • Is a crowded ED a functional place? Process • Is a crowded ED a safe place ? Quality • What happens to patients in a crowded ED? Outcome • Subdivided by: – What happens to those who board / have access block? – What happens to those who come to a crowded ED?
  • 26. Process • Perhaps surprising that little immediate followup to the 1994 study linking overcrowding with costs • First published report statistically linking access block with ED function (mean wait) – Nov 2000 • Followed by a series of confirmatory studies Richardson DB. Quantifying the effects of access block. Annual Scientific Meeting of the Australasian College for Emergency Medicine, Canberra, November 2000. Emerg Med Australas. 2001 Mar; 13(1): A10
  • 27. Process – Statistical Links Demonstrated • Access Block – Ambulance Bypass • Divert Status – Ambulance delay for chest pain • NEDOCS – LWBS • Access Block – Waiting Times • Subjective overcrowding – Waiting Time • Boarding Hours – Multiple flow measures • Boarder Burden – Median LOS discharged ED • Largely retrospective studies Fatovich DM, Nagree Y, Sprivulis P. Access block causes emergency department overcrowding and ambulance diversion in Perth, Western Australia. Emerg Med J. 2005 May;22(5): 351-4 Schull MJ, Morrison LJ, Vermeulen M, Redelmeier DA. Emergency department overcrowding and ambulance transport delays for patients with chest pain. CMAJ 2003; 168: 277-283 Weiss SJ, Ernst AA, Derlet R, King R, Bair A, Nick TG. Relationship between the National ED Overcrowding Scale and the number of patients who leave without being seen in an academic ED. Am J Emerg Med. 2005 May;23(3): 288-94 Dunn R. Reduced access block causes shorter emergency department waiting times: An historical control observational study. Emerg Med (Aust). 2003 Jun;15(3): 232-8 Vieth TL, Rhodes KV. The effect of crowding on access and quality in an academic ED. Am J Emerg Med. 2006 Nov;24(7): 787-94 Timm NL, Ho ML, Luria JW. Pediatric emergency department overcrowding and impact on patient flow outcomes. Acad Emerg Med. 2008 Sep;15(9): 832-7 White BA, Biddinger PD, Chang Y, Grabowski B, Carignan S, Brown DF. Boarding inpatients in the emergency department increases discharged patient length of stay. J Emerg Med. 2013 Jan;44(1):230-5
  • 28. Individual Quality • Large studies linked delay in reaching an inpatient bed with: – Defined adverse events in various groups (all, ICU, >65) – Delay to provision of home medications – Worse adherence to AMI guidelines – Pneumonia in intubated patients Chalfin DB, Trzeciak S, Likourezos A, et al; DELAY-ED study group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007 Jun; 35(6): 1477-83 Liu SW, Thomas SH, Gordon JA, Hamedani AG, Weissman JS. A pilot study examining undesirable events among emergency department-boarded patients awaiting inpatient beds. Ann Emerg Med. 2009 Sep; 54(3): 381-5 Liu SW, Chang Y, Weissman JS, Griffey, RT, Thomas J, Nergui S, Hamedani AG, Camargo, CA, Singer S. An Empirical Assessment of Boarding and Quality of Care: Delays in Care Among Chest Pain, Pneumonia, and Cellulitis Patients. Acad Emerg Med 2011. doi: 10.1111/j.1553-2712.2011.01082.x Ackroyd-Stolarz S, Read Guernsey J, Mackinnon NJ, Kovacs G. The association between a prolonged stay in the emergency department and adverse events in older patients admitted to hospital: a retrospective cohort study. BMJ Qual Saf. 2011 Jul; 20(7): 564-9 Diercks DB, Roe MT, Chen AY, Peacock WF, Kirk JD, Pollack CV Jr, Gibler WB, Smith SC Jr, Ohman M, Peterson ED. Prolonged emergency department stays of non-STsegment- elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/American Heart Association Guidelines for management and increased adverse events. Ann Emerg Med. 2007 Nov; 50(5): 489-96 Carr BG, Kaye AJ, Wiebe DJ, et al. Emergency department length of stay: a major risk factor for pneumonia in intubated blunt trauma patients. J Trauma 2007 Jul; 63(1): 9-12
  • 29. Overall Quality • Worse pain care in – Hip fracture – Severe pain – Back pain – Sickle Cell Crisis – Children with long bone fractures • Lesser patient satisfaction in admitted patients • Greater risk of missed AMI Hwang U, Richardson LD, Sonuyi TO, Morrison RS. The effect of emergency department crowding on the management of pain in older adults with hip fracture. J Am Geriatr Soc. 2006 Feb;54(2):270-5 Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008 Jan;51(1):1-5 Hwang U, Richardson L, Livote E, et al. Emergency department crowding and decreased quality of pain care. Acad Emerg Med. 2008 Dec;15(12):1258-65 Pines JM, Shofer FS, Isserman JA, Abbuhl SB, Mills AM. The effect of emergency department crowding on analgesia in patients with back pain in two hospitals. Acad Emerg Med. 2010 Mar;17(3):276-83 Shenoi R, Ma L, Syblik D, Yusuf S. Emergency department crowding and analgesic delay in pediatric sickle cell pain crises. Pediatr Emerg Care. 2011 Oct;27(10):911-7 Sills MR, Fairclough DL, Ranade D, Mitchell MS, Kahn MG. Emergency department crowding is associated with decreased quality of analgesia delivery for children with pain related to acute, isolated, long-bone fractures. Acad Emerg Med. 2011 Dec;18(12):1330-8 Pines JM, Iyer S, Disbot M, et al. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med. 2008 Sep;15(9):825-31 Schull MJ, Vermeulen MJ, Stukel TA. The risk of missed diagnosis of acute myocardial infarction associated with emergency department volume. Ann Emerg Med. 2006 Dec;48(6):647-55
  • 30. Overall Quality • Delay to thrombolysis in AMI • Delay to antibiotics in CA pneumonia • Adverse events in AMI • Delay to surgery in #NOF Schull MJ, Vermeulen MJ, Slaughter G, et al. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med. 2004 Dec;44(6): 577-85 Pines JM, Hollander JE, Localio AR, Metlay JP. The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med. 2006 Aug;13(8):873-8 Fee C, Weber EJ, Maak CA, Bacchetti P. Effect of emergency department crowding on time to antibiotics in patients admitted with community acquired pneumonia. Ann Emerg Med. 2007 Nov;50(5):501-9, 509.e1 Pines JM, Localio AR, Hollander JE, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia. Ann Emerg Med. 2007 Nov;50(5):510-6 Fishman PE, Shofer FS, Robey JL, Zogby KE, Reilly PM, Branas CC, Pines JM, Hollander JE. The impact of trauma activations on the care of emergency department patients with potential acute coronary syndromes. Ann Emerg Med. 2006 Oct;48(4):347-53 Richardson DB, McMahon K. Emergency Department Access Block Occupancy Predicts Delay to Surgery in Patients with Fractured Neck of Femur. Emerg Med Australas. 2009 Aug; 21(4): 304-308
  • 31. Overall Quality • Delay to resuscitation • Violence towards ED staff • Defined complications in boarders • Contamination of Blood cultures • Time to antibiotics in febrile neonates • Quality and timeliness (but not equity) in paediatric asthma • Preventable Medical Errors (National ED Safety Study) Hong KJ, Shin SD, Song KJ, Cha WC, Cho JS. Association between ED crowding and delay in resuscitation effort. Am J Emerg Med. 2012 Nov 15 Medley DB, Morris JE, Stone CK, Song J, Delmas T, Thakrar K. An association between occupancy rates in the emergency department and rates of violence toward staff. J Emerg Med. 2012 Oct;43(4):736-44. Zhou JC, Pan KH, Zhou DY, Zheng SW, Zhu JQ, Xu QP, Wang CL. High hospital occupancy is associated with increased risk for patients boarding in the emergency department. Am J Med. 2012 Apr;125(4):416.e1-7 Lee CC, Lee NY, Chuang MC, Chen PL, Chang CM, Ko WC. The impact of overcrowding on the bacterial contamination of blood cultures in the ED. Am J Emerg Med. 2012 Jul;30(6):839-45 Kennebeck SS, Timm NL, Kurowski EM, Byczkowski TL, Reeves SD. The association of emergency department crowding and time to antibiotics in febrile neonates. Acad Emerg Med. 2011 Dec;18(12):1380-5. Sills MR, Fairclough D, Ranade D, Kahn MG. Emergency department crowding is associated with decreased quality of care for children with acute asthma. Ann Emerg Med. 2011 Mar; 57(3): 191-200.e1-7 Epstein SK, Huckins DS, Liu SW, Pallin DJ, Sullivan AF, Lipton RI, Camargo CA Jr. Emergency department crowding and risk of preventable medical errors. Intern Emerg Med. 2012 Apr; 7(2): 173-80
  • 32. Overall Quality - Recent Literature • So many to choose from • Acting on IOM research priorities • Quality defined by timeliness of therapy in asthma, fracture • 9 overcrowding measures • Large statistical adjustment • Best overcrowding measures – Total patient care hours – Arrivals last 6 hours • Retrospective, limited input variables (no boarding) • Simple measures often best Sills MR, Fairclough D, Ranade D, Kahn MG. Emergency department crowding is associated with decreased quality of care for children. Pediatr Emerg Care. 2011 Sep; 27(9): 837-45
  • 33. 2006: Institute of Medicine Report • Marked the widespread acceptance outside the EM community that there is a problem • Multiple recommendations • Improved efficiency and flow • Coordination and accountability • Increased resources • Pay attention to Children – Research agenda
  • 34. Correlation or Causation? • Demonstrating causality is generally agreed to require the Bradford-Hill criteria: • Strength of association • Consistency • Specificity • Temporality • A dose–response relationship • Biological plausibility • Coherence • Reversibility • Consideration of alternative explanations Hill AB. The environment and disease: association or causation? Proc R Soc Med 1965; 58: 295-300
  • 35. Patient Outcomes • Self evident to EPs that after the presenting emergency condition has been identified and managed, prolonged care in the ED is not in the best interests of the patient • Boarding or Access Block represents restricted access to timely urgent care, which delays definitive therapy, prolongs hospital stay and increases complications • ED staff equipped to provide acute care are not the most appropriate providers to inpatients • An ED working at 200% of its capacity is likely to provide a lesser standard of care than a ward never exceeding 100% • Less self-evident to outsiders
  • 36. Patient Outcome beyond the ED • 2002: First study to show effect of prolonged ED LOS on subsequent (not total) hospital LOS • Dose-response curve
  • 37. Patient Outcome beyond the ED • Same result when correcting for age, time of day, casemix • Same result in ICU patients • Adverse events in over 65 • Adverse events in AMI • Pneumonia in trauma patients • Defined adverse events in boarders • Again mostly retrospective but confounders addressed with multivariate techniques Liew D, Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust. 2003 Nov 17; 179(10): 524-6 Chalfin DB, Trzeciak S, Likourezos A, et al; DELAY-ED study group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007 Jun; 35(6): 1477-83 Ackroyd-Stolarz S, Read Guernsey J, Mackinnon NJ, Kovacs G. The association between a prolonged stay in the emergency department and adverse events in older patients admitted to hospital: a retrospective cohort study. BMJ Qual Saf. 2011 Jul; 20(7): 564-9 Diercks DB, Roe MT, Chen AY, Peacock WF, Kirk JD, Pollack CV Jr, Gibler WB, Smith SC Jr, Ohman M, Peterson ED. Prolonged emergency department stays of non-STsegment- elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/American Heart Association Guidelines for management and increased adverse events. Ann Emerg Med. 2007 Nov; 50(5): 489-96 Carr BG, Kaye AJ, Wiebe DJ, et al. Emergency department length of stay: a major risk factor for pneumonia in intubated blunt trauma patients. J Trauma 2007 Jul; 63(1) :9-12 Zhou JC, Pan KH, Zhou DY, Zheng SW, Zhu JQ, Xu QP, Wang CL. High hospital occupancy is associated with increased risk for patients boarding in the emergency department. Am J Med. 2012 Apr; 125(4): 416.e1-7 Fishman PE, Shofer FS, Robey JL, Zogby KE, Reilly PM, Branas CC, Pines JM, Hollander JE. The impact of trauma activations on the care of emergency department patients with potential acute coronary syndromes. Ann Emerg Med. 2006 Oct; 48(4): 347-53
  • 38. Overall Outcome beyond the ED • Medical care strives to produce best patient outcomes rather than simply best measures of process or documented quality • Mortality is the unequivocal outcome for which research seeking any link with ED overcrowding is critical • Death after ED presentation is multifactorial and rare so large series are required • First published study from Spain was poorly controlled but found an excess of deaths • Second published study from Houston was underpowered but found a trend towards excess trauma mortality • Third & fourth studies were well designed from Australia Miró O, Antonio MT, Jiménez S, De Dios A, Sánchez M, Borrás A, Millá J. Decreased health care quality associated with emergency department overcrowding. Eur J Emerg Med. 1999 Jun;6(2):105-7 Begley CE, Chang Y, Wood RC, Weltge A. Emergency Department Diversion and Trauma Mortality: Evidence from Houston, Texas. J Trauma. 2004 Dec;57(6):1260-5
  • 39. 2006: Overcrowding and Mortality • Two studies from different places with totally different methodological approaches – One retrospective matched cohort in a single ED over 3 years – One multivariate 3-hospital study of admissions through ED • Both found around 30% increase in short term mortality from presenting to a crowded ED or crowded hospital
  • 40. Overcrowding and Mortality • Major studies have reported a relationship between overcrowding or delay in ED and increased mortality – Intensive care patients – Sepsis and pneumonia patients – All patients discharged from ED • In places with ambulance diversion during overcrowding – Hospital mortality lower as ambulances are turned away – Citywide AMI mortality higher • Two neutral findings – Suggested these are settings where overcrowding so severe that no adequate control periods Chalfin DB, Trzeciak S, Likourezos A, et al; DELAY-ED study group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007 Jun;35(6):1477-8357 Hong YC, Chou MH, Liu EH, et al. The effect of prolonged ED stay on outcome in patients with necrotising fasciitis. Am J Emerg Med. 2009 May;27(4):385-90 Jo S, Kim K, Lee JH, Rhee JE, Kim YJ, Suh GJ, Jin YH. Emergency department crowding is associated with 28-day mortality in community-acquired pneumonia patients. J Infect. 2012 Mar;64(3):268-75 Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ. 2011 Jun 1; 342:d2983 Shenoi RP, Ma L, Jones J, Frost M, Seo M, Begley CE. Ambulance diversion as a proxy for emergency department crowding: the effect on pediatric mortality in a metropolitan area. Acad Emerg Med. 2009 Feb;16(2):116-23 Fatovich D. M. Effect of ambulance diversion on patient mortality: How access block can save your life. Med J Aust. 2005 Dec 5-19;183(11/12):672–673 Yankovic N, Glied S, Green LV, GramsM. The impact of ambulance diversion on heart attack deaths. Inquiry. 2010;47(1):81-91
  • 41. Recent Work - 1 • 3 yr of admissions in academic ED • Stratified by boarding interval • Adjusted for measures of severity and comorbidity • Hospital with an overcapacity protocol: low-risk boarders could be moved to ward hallways • 41256 patients Singer AJ, Thode HC Jr, Viccellio P, et al. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011; 18: 1324-1329
  • 42. Recent Work - 2 • Highly significant dose-response relationship between boarding duration and ICU admission, mortality and inpatient LOS • Overcapacity protocol is a theoretical weakness but the data is compelling
  • 43. Recent Work - 2 • Case-crossover study of Medicare patients with AMI from 4 Californian counties – All Medicare claims – All ambulance diversion logs – 6 years (2000-2006) – No AMI specific transport policies • Each case linked to closest ED by mailing address • EDs acted as their own controls • Adjustments for demographics, comorbidities, hospitals • 13860 AMIs, 149 EDs Shen Y, Hsia RY. Association Between Ambulance Diversion and Survival Among Patients With Acute Myocardial Infarction. JAMA. 2011; 305(23): 2440-2447
  • 44. Recent Work - 2 • When hospital on diversion >12h per day, less AMI patients admitted to hospitals with a catheter lab (78% vs 87%) • Diversion >12hr associated with 3% increase in mortality at 30 days, persisting for at least 1 year • Unable to separate ambulance, ED and hospital effects, but ambulance diversion is bad for patients
  • 45. Recent Work - 3 • 995979 admissions through ED to 187 hospitals – California, 2007 • Crowding defined as days of top quartile of ambulance diversion for that hospital • Model included demographics, day of week, time of year, comorbidities Effect of Emergency Department Crowding on Outcomes of Admitted Patients. Sun BC, Hsia RY, Weiss RE, Zingmond D, Liang LJ, Han W, McCreath H, Asch SM. Ann Emerg Med. 2012 Dec 5. doi:pii: S0196-0644(12)01699-X
  • 46. Recent Work - 3 • Results highly significant • 5% greater chance of inpatient death [300 deaths] • 0.8% longer hospital stay [6200 bed-days] • 1.1% increased costs [$17M]
  • 47. The Debate is over • Finally now accepted that ED and hospital crowding do cause harm to patients • Strength of association • Consistency • Specificity • Temporality • A dose–response relationship • Biological plausibility • Coherence • Reversibility • Consideration of alternative explanations Hill AB. The environment and disease: association or causation? Proc R Soc Med 1965; 58: 295-300
  • 48. One mortality reversibility study • A randomised controlled trial of overcrowding unlikely • One report of reversibility of the mortality effect so far • Requires a well documented system which improves its overcrowding status in a short period • State of Western Australia done that • Access block from 40% to 10% in 3 tertiary hospitals • Mortality reduced from 1.12% to 0.98% in same period • This is an encouraging first report – Too many variables and changes in hospitals’ practice to be certain it is causative – Documentation is ongoing – a more definitive result is expected Geelhoed GC, de Klerk NH. Emergency department overcrowding, mortality and the 4-hour rule in Western Australia. Med J Aust. 2012 Feb 6;196:122-6
  • 49. Cures for Overcrowding? • Three basic approaches – Mitigating the bad effects and decreasing ED LOS (ED internal) – Cutting occupancy with particular groups (ED collaborative) – Whole of hospital change • There is sufficient before-after jurisdiction-wide evidence that it can be changed medium term – Reversibility of flow issues demonstrated – Not specific interventions, but financial incentives & resources – Sustainability much less clear in long term Weber EJ, Mason S, Carter A, Hew RL. Emptying the corridors of shame: organizational lessons from England's 4-hour emergency throughput target. Ann Emerg Med. 2011 Feb; 57(2): 79-88.e1 Ben-Tovim DI, Dougherty ML, O’Connell TJ, McGrath KM. Patient journeys: the process of clinical redesign. Med. J. Aust. 2008; 188 (6 Suppl): S14–17 Richardson DB, Kelly A-M, Kerr D. Prevalence of Access Block in Australia 2004-8. Emerg Med Australas. 2009 Dec; 21(6): 472- 478 Geelhoed GC, de Klerk NH. Emergency department overcrowding, mortality and the 4-hour rule in Western Australia. Med J Aust. 2012 Feb 6;196:122-6
  • 50. Multiple successful approaches • Small, mostly before-after studies with publication bias – We report what works • Local process changes, staff • Streaming • Early Senior input • Joint with radiology/pathology • Overcapacity protocols • Top-down incentives • Only intervention consistently reported as not working is telephone advice lines Shetty A, Gunja N, Byth K, Vukasovic M. Senior Streaming Assessment Further Evaluation after Triage zone: a novel model of care encompassing various emergency department throughput measures. Emerg Med Australas. 2012 Aug; 24(4): 374-82 Huang EP, Liu SS, Fang CC, Chou HC, Wang CH, Yen ZS, Chen SC. The impact of adding clinical assistants on patient waiting time in a crowded emergency department. Emerg Med J. 2012 Nov 22 Sterner SE, Coco T, Monroe KW, King WD, Losek JD. A new after-hours clinic model provides cost-saving, faster care compared with a pediatric emergency department. Pediatr Emerg Care. 2012 Nov;28(11):1162-5 Jang JY, Shin SD, Lee EJ, Park CB, Song KJ, Singer AJ. Use of a Comprehensive Metabolic Panel Point-of-Care Test to Reduce Length of Stay in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2012 Aug 15 Khanna S, Boyle J, Good N, Lind J. Early discharge and its effect on ED length of stay and access block. Stud Health Technol Inform. 2012;178:92-8 Birkhahn RH, Wen W, Datillo PA, Briggs WM, Parekh A, Arkun A, Byrd B, Gaeta TJ. Improving patient flow in acute coronary syndromes in the face of hospital crowding. J Emerg Med. 2012 Aug;43(2):356-65 Graber DJ, Ardagh MW, O’Donovan P, St George I. A telephone advice line does not decrease the number of presentations to Christchurch Emergency Department, but does decrease the number of phone callers seeking advice. 2003 Jul 11;116(1177):U495
  • 51. New Literature - Systematic Reviews • Now so much work that we have seen the rise of the systematic review (6 in 2012) • Mostly fairly critical of the methodologies used • Appear to work – Triage Liaison Physician – Triage nurse ordering – Rapid Assessment/Fasttrack • Appear not to work – Primary care professionals in ED • Insufficient evidence – Overcapacity protocols Rowe BH, Guo X, Villa-Roel C, Schull M, Holroyd B, Bullard M, Vandermeer B, Ospina M, Innes G. The role of triage liaison physicians on mitigating overcrowding in emergency departments: a systematic review. Acad Emerg Med. 2011 Feb;18(2):111-20 Rowe BH, Villa-Roel C, Guo X, Bullard MJ, Ospina M, Vandermeer B, Innes G, Schull MJ, Holroyd BR. The role of triage nurse ordering on mitigating overcrowding in emergency departments: a systematic review. Acad Emerg Med. 2011 Dec;18(12):1349-57 Villa-Roel C, Guo X, Holroyd BR, Innes G, Wong L, Ospina M, Schull M, Vandermeer B, Bullard MJ, Rowe BH. The role of full capacity protocols on mitigating overcrowding in EDs. Am J Emerg Med. 2012 Mar;30(3):412-20 Oredsson S, Jonsson H, Rognes J, Lind L, Göransson KE, Ehrenberg A, Asplund K, Castrén M, Farrohknia N. A systematic review of triage-related interventions to improve patient flow in emergency departments. Scand J Trauma Resusc Emerg Med. 2011 Jul 19;19:43 Bullard MJ, Villa-Roel C, Guo X, Holroyd BR, Innes G, Schull MJ, Vandermeer B, Ospina M, Rowe BH. The role of a rapid assessment zone/pod on reducing overcrowding in emergency departments: a systematic review. Emerg Med J. 2012 May;29(5):372-8 Khangura JK, Flodgren G, Perera R, Rowe BH, Shepperd S. Primary care professionals providing non-urgent care in hospital emergency departments. Cochrane Database Syst Rev. 2012 Nov 14;11:CD002097.
  • 52. This is about to change: Case Studies • The biggest news in the field of overcrowding cures in 2012 was the series of abstracts from Alberta • Canadian Emergency Medicine meeting, International conference on Emergency Medicine, Society for Academic Emergency Medicine (prize winning) • Cannot really call it equivalent to peer-reviewed study until it is published, but this is the most exciting work
  • 53. Access Block in Alberta • Many flow projects and capacity expansions: 2005 - 2008 • A multi-million dollar system-wide acute access program (GRIDLOCC – 2007 / 2008) failed to improve hospital access or reduce ED boarding times • For > a decade, ED and hospital access block increasing • Dec 2010: Implementation of the Alberta Overcapacity Plan • 14 Teaching Hospitals across Alberta simultaneously • >650,000 patients /year • Results mean that the evidence based reviws are likely to change their views shortly
  • 54. 5 Philosophical tenets of a successful OCP • The same care standards apply throughout the hospital, from patient arrival to discharge • Overcrowding (access block) is addressed by the entire system • Best outcomes and efficiencies occur when patients are matched to the right unit and team ASAP • All units have important care missions and require reasonable access to their resources in order to provide acceptable care and meet performance targets • Hallways are undesirable locations for patient care
  • 55. New Unpublished Data • The Canberra hospital attempted to introduce an overcapacity protocol modelled on Alberta in 2013 – Sending patients to “overcapacity” spaces (corridors) not accepted • Revised to an overcapacity protocol which sent admitted patients to registered hospital beds when these beds were closed out-of-hours – Criteria of ED overcrowding, 10+ inpatients waiting for beds, and 3+ from same hospital division (med, surg, cancer, etc) • Second component of ED cost centre charging wards for admitted patients from 2 hours after admission • This enabled ED to staff the overcapacity inpatient beds until they were reopened by ward staff in the morning
  • 56. New Unpublished Data • Not a big change but historical controls suggest that 4 more patients per day and going into winter normally associated with worse crowds 5 weeks before 3/6/13 5 weeks after 3/6/13 Daily 183.8 187.9 Ward Admit 44.6 44.4 EMU 20.6 20.8 DNW 7.7% 7.8% Mean Occupancy 28.6 27.5 Mean Waiting Beds 7.95 6.72 NEAT for admissions 21.2% 22.5%
  • 57. New Unpublished Data • Dramatic difference in distribution of the number waiting for beds • In 5 weeks before, 8.1% of time (68:23) over 13 • In 5 weeks after, 0.8% of time (6:43) over 13 – A 90% drop (P<0.001) • Subgroup analysis: performance better through briefer severe overcrowding periods • Activated 6 times in 5w – ED safety valve, hospital incentive Bed Waiting Occupancy 0 2 4 6 8 10 12 14 0 5 10 15 20 Occupancy with patients waiting for beds Percentageoftime(%of5weeks) Before After
  • 58. SUMMARY • Now a large evidence base from overcrowding research • Overcrowding in the ED is a whole of hospital problem with a major contribution from inpatient flow issues • Overcrowding is bad for ED function • Overcrowding causes bad outcomes including mortality • It can be addressed although probably not eliminated • Ample examples of local changes, some data quality issues • Good examples of whole-of-system change which has improved ED function without detriment to outcomes • Good studies showing reversibility of the adverse effects are the next frontier