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

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

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

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

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

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

• 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

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

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

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

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”

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

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

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

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

Anecdote or Data?

Drive

THRU

BURGER

PrincePrincePrincePrince

• They do not rent the

block next door to give

more queuing space

• Would last 10m

Anecdote or Data?

Drive

THRU

BURGER

PrincePrincePrincePrince

• Such an approach

would be waste of

money, lead to longer

queues, worse

outcomes

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

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

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

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 adultspresenting to US emergency departments: assumptions vs data.JAMA. 2008;300:1914-1924.

Rimsza ME, Butler RJ, Johnson WG. Impact of Medicaiddisenrollment 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

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.

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

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.

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?

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

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

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. 2011Jul; 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 formanagement 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

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

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 andpercutaneous 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-acquiredpneumonia. 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

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

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

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

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

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

Patient Outcome beyond the ED

• 2002: First study to show

effect of prolonged ED LOS

on subsequent (not total)

hospital LOS

• Dose-response curve

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. 2011Jul; 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

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 AustraliaMiró 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 andTrauma Mortality: Evidence from Houston, Texas. J Trauma. 2004 Dec;57(6):1260-5

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

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 impactof ambulance diversion on heart attack deaths.Inquiry. 2010;47(1):81-91

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

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

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

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

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

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]

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

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

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

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

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.

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

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

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

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

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%

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

Per

cen

tag

e o

f ti

me

(% o

f 5

wee

ks)

Before After

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