Emergency Department Crowding: What Is It, Is It a

Problem, & How Do We Fix It?

Jennifer Wiler MD, MBA

Q: Is Emergency Department Crowding Problem?

Increasing ED Patient Volumes

“Hospital Ambulatory Medical Care Survey” 9/06 www.CDC.gov

1994-2004: Annual number of U.S. ED visits rose by 18% (93M to 110M) EDs decreased 12%

ED Becoming Hospital's Front Door

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html; AHRQ Nationwide Inpatient Sample & Thompson Healthcare Projected Inpatient Database

% of Inpatient Admissions from ED Is on the Rise

ED Becoming Hospital's Front Door

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html; AHRQ Nationwide Inpatient Sample & Thompson Healthcare Projected Inpatient Database

Service Line Break Down

Aging Adult Population

www.princetoncme.com

2006 report - % of pts 65 yo or older with self-reported select chronic conditions during 2 yr period

Increasing # with Chronic Conditions & Obesity

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html;

Kaiser Family Foundation www.statehealth.org

Number of Uninsured in Missouri = 14th Highest In USA

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html; Kaiser Family Foundation www.statehealth.org

Increasing Number Of Uninsured Patients…And -- Federal Safety Net Spending Not Kept Pace

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html; Kaiser Family Foundation www.statehealth.org

Physicians NOT Accepting Medicaid Patients is On the Rise

Modern Physician 11/06

Projected Workforce Shortage – Physicians

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html;

Current* Workforce Shortage – Healthcare Professionals

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html;

* American Hospital Assoc. survey data Dec 2005

Shortage of On Call Specialists

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html

Affecting nearly 75% of all hospitals

EMTALA …

• 1986 Consolidated Omnibus Budget Reconciliation Act (COBRA)– a.k.a. Federally Mandated

Uncompensated Care

“Back End” Issues

• Increased Elective Surgery Cases ($$)

• Decreased Hospital Capacity– Mental Health In Pt Beds

• At Inpt Capacity – Dec staffing, dec specialty bed availability, inc census

= Increased BOARDING (variable definitions)

The Result …Your ED Waiting Room Looks Like This

And It is Not Just Us...

Missouri 13th Most Busy ED’s in Nation*

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html; Kaiser Family Foundation www.kaiserfamily foundation.org

* ED Visits By State: Number of ED visits/1,000 people in 2005

% of Hospitals with ED At or Over Capacity

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html

“I mean, people have access to healthcare in America. After all, you

just go to an emergency room.”

President Bush Cleveland Ohio June 10, 2007

Many ED’s Report Being On Diversion…

Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html; American Hospital Association, 2007 Survey of Hospital Leaders

500,000 Ambulance Diversions Qyr On average one every minute

EDs Have No Surge Capacity

• Hospital Emergency Surge Capacity: Not Ready For The “Predictable Surprise”– 34 hospitals in New York City, Washington,

Los Angeles, Chicago, Houston, Denver, and Minneapolis (March 25, 2008 at 4:30 p.)

– Washington Hospital Center at 286% capacity

– “Shortages of" ED "capacity and intensive care beds will grow worse if Bush administration Medicaid changes are implemented…the Department of Health and Human Services "has issued three Medicaid regulations that will reduce federal funds to public and teaching hospitals by tens of billions of dollars over the next five years," which could further exacerbate the situation.

Chairman Rep. Henry A. Waxman (D-CA)

IOM 2006: “Hospital Based Emergency Care – At The Breaking Point”

• Many EDs and trauma centers are overcrowded.

• Emergency care is highly fragmented.

• The emergency care system is ill-prepared to handle a major disaster.

• EMS and EDs are not well equipped to handle pediatric care.

www.iom.edu

Q: Is Emergency Department Crowding a Problem?

A: YES

And It Is Not Just the USA

• Australia

• UK

• Korea

• Canada

• Greece

ED Crowding/Boarding Effects

• Prolonged Pt Wait Times

• Inc Pt Dissatisfaction/ Inc Pt Complaints

• Dec Staff Satisfaction (Inc turnover, Inc cost)

• Decreased Physician Productivity

• Increased Pt Violence Against Physicians

ED Crowding/Boarding: Worse Outcomes

• Adverse Outcomes– Significant increase in serious complications (~6 vs.3%) ACS pts during

crowding1

– Overcrowding causes deaths.2

• High occupancy est. to cause 13 pt deaths/yr

– Overcrowding increases errors & complications.

• 50% sentinel events causing serious injury/death occur in ED ~1/3rd related to crowding3

• Reduced Quality – Inc door to needle time4

– Worse treatment of pain5

• Impaired Access (Diversion & LWBS)• Pts who LWBS 2x likely to report worsened health problems6

1 Pines JM, Hollander JE. the emergency department to the intensive care unit. Crit Care Med. 2007; 35(6):1477-1483. 3 Joint Commission. Sentinel Event Alert, June 17, 2002; http://www.jointcommission.org/sentinelevents/ statistics. Accessed 4 June 2007.); 4 Schull 2004; 5 Hwang, 2006; 6 Bindman, 1991.

ED Crowding/Boarding: More Costly

• Boarding Increases the Total Hospital LOS1

– Est inc cost $6.8M over 3 yrs

– Worsening access

• Boarding Increases Walkouts2

– Lost hospital revenue $204/pt

• Increased Ambulance Diversion3

• Increases Medical Negligence Claims4

1 Krochmal P, Riley TA. Increased health care costs associated with ED overcrowding. Am J Emerg Med 1994; 12(3):265-266.; Richardson B. The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay. Med J Aust. 2002; 177(9):492-495.; Liew D, Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust. 2003; 179(10):524-526.2 Richardson DB, Bryant M. Confirmation of Association between overcrowding and adverse events in patients who do not wait to be seen. Acad Emerg Med. 2004; 11(5):462.3 . 3 Burt CW, McCaig LF. Staffing, Capacity, and Ambulance Diversion in Emergency Departments: United States, 2003–04. Advance data from vital and health statistics; no. 376. Hyattsville, MD: National Center for Health Statistics. 2006. 4 ED Crowding: High Impact Solutions www.acep.com

Q: What Is Crowding?

Crowding – What Is It?

You just know…

Crowding – What Is It?

• No Consensus on Definition– Staff do not agree (Reeder, 2003)

– Ambulance Diversion

– LWTC (LWBS)

– Boarding

• ACEP “Crowding occurs when the identified need for emergency services exceeds available resources for patient care in the ED, hospital, or both.”

“…measure flow - not crowding” (Asplin, 2006)

Surrogate Markers of Crowding

Crowding Models

• NEDOCS (National ED Overcrowding Scale)• EDWIN (ED Work Index)• READI (Real-time Emergency Analysis of

Demand Indicators)• Work Score• ED Occupancy Rate • EDCS (ED Crowding Scale)• Discrete Event Simulation• Queuing Theory

= ∑ niti/Na(BT-BA)

= sum of ESI (ti) of all active patients (ni) in ED / number of attending physicians each hr (Na) x # currently available tx bays (BT) – (BA)

= (Total # pts in ED)/ Total #ED treatment bays/hr

= a(pts in waiting rm/#ED tx ∑ nt areas) + b(∑ reverse ESI/#nurses) + c(boarders/#ED tx areas)

Using: Total #pts in ED, #tx spaces, patient arrivals, pt acuity, #staff

Calculate: bed ratio, acuity ratio, provider ratio, demand value

Uses: # attendings, # staffed beds, # critical care pts, #total staffed hospital beds, hospital occupancy

Uses: total #ED beds, #inpt beds, total #ED pts in ED, total # pts on ventilator, longest current pt stay (hrs), total # pts in ED boarding, (hrs) last pt placed in ED tx rm

Q: How Do We Fix ED Crowding?

TJC

• Implemented a new leadership standard

“Managing Patient Flow”, which mandates

that hospitals, “… develop and implement

plans to identify and mitigate impediments

to efficient patient flow throughout the

hospital”.TJC January 2005

How Do We Fix It?

• Myths:– It Is an ED Problem– Uninsured Are the Problem– Non-Urgent & “Frequent Flier” Pts are

Problem– Build More Beds– Pts Who LWBS Are Not Sick– Arrival Pattern of Patients is Unpredictable

Medicaid and SCHIP pts use ED 2x more often than uninsured and 4x more than insured*

Hospital “Back End” Problem

* www.heritage.org 12/8/07; ** EDBA 2008 Data; CDC/NCHS, *** Baker, 1991

Does not fix boarding problem

Highest ED utilization is by NH pts (2nd by infant <1 year old) **

46% pts who LWBS needed immediate medical attention, 11% hospitalized in next wk. “Too sick to wait ” ***

Arrival rate is very predictable by hr per day

ED Crowding Solutions

• ED Operational Improvements

• Regionalized IT healthcare networks (RHIO)

• Increase State Subsidies for Uncompensated care

• Access to Emergency Medical Service Act (HR 882; S 1003)

• Liability Protection for EMTALA Providers

• Deferral of Care

– “You don’t have emergency today…copay please”

– Houston, Denver, Others

– http://abcnews.go.com/Video/playerIndex?id=2561039&affil=kdnl

• UK Model (98% Disposed within 4 hrs)

How Do We Fix ED Crowding?

High Impact, Low Cost Solutions

• Move Admitted Pts Out of ED to Inpatient Areas

– i.e. Hallways, Conference Rms, etc.

• DC of Inpts before Noon

• Coordinate Scheduling of Elective & Surgical Pts

Others Solutions – ED Based

• Bedside Registration

• Limit triage to what is crucial & bypass triage altogether when beds are available

• Close the waiting room

• Physician Triage

• Use protocols and order sets

• Observation Units

• Fast Track Units

• Minimize silos within the ED

• Use scribes for documentation

• Electronic medical record (EMR)

Others Solutions – ED Based

• Establish clearly defined turn-around-time (TAT) goals

• Decrease turnaround times associated with ancillary services

• Define response times for both initiation & completion of consultations

• Monitor individual practitioners in the ED

• Deferred care of nonurgent patients

• Expand the size of the ED

• Staff to Match Volume (Inc staffing during times of increased volume/demand)

Hospital Wide Actions

• Cancelling elective surgeries

• Creation of an institutional awareness of the dangers associated with ED crowding due to boarding of emergency patients.

• Match resources to needs.

• Move toward a 24/7 operational culture.

• Coordinate the scheduling of elective patients and surgical cases.

• Address delays in moving emergency patients admitted to the hospital caused by nursing reports.

• Have all inpatient services managed by hospitalists, and have all ICUs managed by intensivists.

• Use discharge lounges for patients awaiting discharge.

• Hire a “bed czar” unit.

• Consider the use of a generic admission order set initiated by the ED.

• Establish hospital-wide protocols for addressing capacity issues in the emergency department & implement an alert system when the hospital is over capacity.

• Cancel elective admissions when hospital capacity is at maximum.

Hospital Wide Actions

Thank You