Impact of Critical Bed Status on Emergency Department Patient Flow and Overcrowding (original) (raw)
Related papers
CJEM, 2010
ABSTRACTObjective:Patients in the emergency department (ED) who have been admitted to hospital (inpatient “boarders”) are associated with ED overcrowding. They are also a symptom of a hospital-wide imbalance between demand and supply of resources. We analyzed the trends of inpatient admissions, ED boarding volumes, lengths of stay and bed resources of 3 major admitting services at our teaching institution.Methods:We used hospital databases from Jan. 1, 2004, to Dec. 31, 2007, to analyze ED visits that resulted in admission to hospital.Results:During the study period, 21 986 ED patients were admitted to hospital. The percentage of cancer-related admissions to the oncology admitting service decreased from 48% in 2004 to 24% in 2007, and admissions to general internal medicine (GIM) increased nearly 2-fold, from 28% in 2004 to 54% in 2007. In addition, GIM admitted about 10% more myocardial infarction and heart failure patients than did cardiology. General internal medicine constituted...
Journal of Critical Care, 2010
Rationale: Emergency department (ED) patients in need of an intensive care unit (ICU) admission are very sick. Reducing the length of time to get these patients into ICU beds is associated with improved outcomes. Objective: To reduce the ED length of stay for patients requiring admission to the medical ICU or coronary care unit through the implementation of the "active bed management" (ABM) intervention. Methods: A pre-post study design compared data from November 2006 to February 2007 with those from those same months in the prior year at Johns Hopkins Bayview Medical Center in Baltimore. The ABM intervention was carried out by hospitalist physicians and involved: (i) making triage decisions for patients to be admitted and facilitating their transfer from ED to the appropriate care setting and (ii) having proactive management of Department of Medicine resources, which included twice-daily ICU bed management rounds and regular visits to the ED to assess flow. Measurement: Throughput time for patients presenting to the ED requiring ICU admission was analyzed. Main Results: The ED census was higher during the intervention period as compared with the control period, 17 573 versus 16 148 patients. Throughput from ED to coronary care unit and medical ICU beds was reduced by 99 (±14) minutes (from 353 minutes in the control period to 254 minutes in the 4 months after the initiation of ABM, P b .0001). Staffing, length of stay, case mix index, ICU transfer rates, and ICU death rates were stable across the 2 periods, all P = not significant. Conclusion: Conscientious management of hospital beds, in this case by hospitalist physicians providing ABM, can have a positive and substantial impact on the ED throughput of critically ill patients admitted to ICU beds. This efficiency is likely to positively have impacted on patient satisfaction and safety.
2010
ABSTRACT 1 Departments of Emergency Medicine and Health Policy, George Washington University, Washington 2 King Abdulaziz University, Jeddah Emergency department crowding A worldwide problem with evidence-based, but underused solutions Emergency department (ED) crowding is an increasing public health crisis in the U.S. and around the world. A burgeoning literature has found associations between ED crowding and negative outcomes, such as poor quality care, medical errors, inpatient complications, and higher mor-tality rates [1, 2]. A recent report detailed increased crowding across 16 countries, including Germany. Similar to many oth-er industrialized countries, ED visit vol-ume and crowding are both increasing in Germany [3]. Recent surveys in Germany have found increases in ED visits by 4% in 2006 and 8% in 2007, with an estimat-ed 12 million visits in 2007; however, there are no official national statistics on Ger-man ED visits [3]. Across the world, ED crowding has worsened for several reasons. First and most important, people increasing-ly chose EDs over other settings because of the convenience and the 24-7 compre-hensive care provided. In many countries, the outpatient care system makes patients wait and is poorly designed to care for acutely ill patients [4]. For these reasons, increases in ED visit volume have out-paced population growth in the U.S., Can-ada, and France [3]. EDs themselves have also become more congested as lengths of stays have increased with higher rates of laboratory testing, advanced imaging, and intravenous fluid and medication ad-ministration [5]. Particularly in the U.S., there have been dramatic increases in the use of CT scans in the ED [6]. Finally, ED crowding is worsened by ED board-ing, where admitted patients spend pro-longed periods of time in the ED before being moved to inpatient beds. Based on local reports, boarding seems to be a ma-jor theme across many countries' hospi-tals [3]. In some parts of the world, econom-ics favor higher ED crowding [7]. Be-cause caring for an acutely ill patient is much more time-and resource-intensive than a well visit, physicians increasing-ly refer their patients to the ED for work-ups. Patients also realize that comprehen-sive ED care is often superior to evalua-tion in a doctor's office for acute prob-lems. Furthermore, outpatient physi-cians increasingly are not available at off-hours when patients' acute care needs re-quire attention. For many hospitals, there are few incentives to reduce ED crowding. Having a crowded ED may paradoxical-ly benefit hospital finances. For example, in U.S. hospitals, patients who use the ED are more likely to be uninsured or have government insurance and are less attrac-tive than pre-screened direct admissions which are more likely to have private in-surance, which pays higher rates. There-fore, many hospitals focus efforts on elec-tive cases rather than ensuring their EDs are efficient. In the U.S. and other parts of the world, the incentive to address ED crowding has started to change. Crowding measures such as ED length of stay are planned for U.S. public reporting; therefore, in the fu-ture, hospitals may have to compete on ED efficiency. Many U.S. EDs are already reporting waiting times on public bill-boards as a way to compete for paying pa-tients. Some countries are far ahead of the U.S. in reducing crowding and have man-dated limitations on ED lengths of stay. For example, from 2004–2005, the UK phased in a requirement that 98% of pa-tients leave the ED within 4 h [8]. More recently, New Zealand, Canada, and parts of Australia have created similar time lim-its for ED care ranging from 4–8 h. These time limits reduce crowding, but have al-so been criticized for unintended conse-quences, such as forcing dispositions that may occur in the final minutes before the time limit expires. In the UK, systems adapted to time limits, where patients re-quiring more prolonged work-ups were moved to different areas of the hospital, such as observation units. Just recently, the UK lifted the 4-h restriction on ED length of stay [9]. For hospitals that focus efforts on re-ducing ED crowding, there are many test-ed hospital-based solutions primarily fo-cusing on two areas: F improving throughput within the ED and F reducing the "access block" by focus-ing on eliminating the boarding of admitted patients.
Improving Emergency Department flow through optimized bed utilization
BMJ Quality Improvement Reports, 2016
Over the last decade, patient volumes in the emergency department (ED) have grown disproportionately compared to the increase in staffing and resources at the Toronto Western Hospital, an academic tertiary care centre in Toronto, Canada. The resultant congestion has spilled over to the ED waiting room, where medically undifferentiated and potentially unstable patients must wait until a bed becomes available. The aim of this quality improvement project was to decrease the 90th percentile of wait time between triage and bed assignment (time-to-bed) by half, from 120 to 60 minutes, for our highest acuity patients. We engaged key stakeholders to identify barriers and potential strategies to achieve optimal flow of patients into the ED. We first identified multiple flowinterrupting challenges, including operational bottlenecks and cultural issues. We then generated change ideas to address two main underlying causes of ED congestion: unnecessary patient utilization of ED beds and communication breakdown causing bed turnaround delays. We subsequently performed seven tests of change through sequential plan-do-study-act (PDSA) cycles. The most significant gains were made by improving communication strategies: small gains were achieved through the optimization of in-house digital information management systems, while significant improvements were achieved through the implementation of a low-tech direct contact mechanism (a two-way radio or walkie-talkie). In the postintervention phase, time-to-bed for the 90th percentile of high-acuity patients decreased from 120 minutes to 66 minutes, with special cause variation showing a significant shift in the weekly measurements.
Effects of Emergency Department Expansion on Emergency Department Patient Flow
Academic Emergency Medicine, 2014
Objectives: Emergency department (ED) crowding is an increasing problem associated with adverse patient outcomes. ED expansion is one method advocated to reduce ED crowding. The objective of this analysis was to determine the effect of ED expansion on measures of ED crowding. Methods: This was a retrospective study using administrative data from two 11-month periods before and after the expansion of an ED from 33 to 53 adult beds in an academic medical center. ED volume, staffing, and hospital admission and occupancy data were obtained either from the electronic health record (EHR) or from administrative records. The primary outcome was the rate of patients who left without being treated (LWBT), and the secondary outcome was total ED boarding time for admitted patients. A multivariable robust linear regression model was used to determine whether ED expansion was associated with the outcome measures. Results: The mean (AESD) daily adult volume was 128 (AE14) patients before expansion and 145 (AE17) patients after. The percentage of patients who LWBT was unchanged: 9.0% before expansion versus 8.3% after expansion (difference = 0.6%, 95% confidence interval [CI] =-0.16% to 1.4%). Total ED boarding time increased from 160 to 180 hours/day (difference = 20 hours, 95% CI = 8 to 32 hours). After daily ED volume, low-acuity area volume, daily wait time, daily boarding hours, and nurse staffing were adjusted for, the percentage of patients who LWBT was not independently associated with ED expansion (p = 0.053). After ED admissions, ED intensive care unit (ICU) admissions, elective surgical admissions, hospital occupancy rate, ICU occupancy rate, and number of operational ICU beds were adjusted for, the increase in ED boarding hours was independently associated with the ED expansion (p = 0.005). Conclusions: An increase in ED bed capacity was associated with no significant change in the percentage of patients who LWBT, but had an unintended consequence of an increase in ED boarding hours. ED expansion alone does not appear to be an adequate solution to ED crowding.
Turkish journal of emergency medicine, 2014
Objectives In this study, we aimed to determine the causes of overcrowding in the Emergency Department (ED) and make recommendations to help reduce length of stay (LOS) of patients in the ED. Methods We analyzed the medical data of patients admitted to our ER in a one-year period. Demographic characteristics, LOS, revisit frequency, and consultation status of the patients were determined. Results A total of 163,951 patients were admitted to our ED between January 1, 2013, and December 31, 2013. In this period 1,210 patients revisited the ED within 24 hours. A total of 38,579 patients had their treatment in the observation room (OR) of the ED and mean LOS was found to be 164.1 minutes. Cardiology was the most frequently consulted specialty. Mean arrival time of the consultants in ED was 64 minutes. Conclusions Similar to EDs in other parts of the world, prolonged length of stay in the ED, delayed laboratory and imaging tests, delay of consultants, and lack of sufficient inpatient beds are the most important causes of overcrowding in the ED. Some drastic measures must be taken to minimize errors and increase satisfaction ratio.
Turkish Journal of Emergency Medicine, 2014
Objectives In this study, we aimed to determine the causes of overcrowding in the Emergency Department (ED) and make recommendations to help reduce length of stay (LOS) of patients in the ED. Methods We analyzed the medical data of patients admitted to our ER in a one-year period. Demographic characteristics, LOS, revisit frequency, and consultation status of the patients were determined. Results A total of 163,951 patients were admitted to our ED between January 1, 2013, and December 31, 2013. In this period 1,210 patients revisited the ED within 24 hours. A total of 38,579 patients had their treatment in the observation room (OR) of the ED and mean LOS was found to be 164.1 minutes. Cardiology was the most frequently consulted specialty. Mean arrival time of the consultants in ED was 64 minutes. Conclusions Similar to EDs in other parts of the world, prolonged length of stay in the ED, delayed laboratory and imaging tests, delay of consultants, and lack of sufficient inpatient beds are the most important causes of overcrowding in the ED. Some drastic measures must be taken to minimize errors and increase satisfaction ratio.
2019
Objective: To determine factors associated with overcrowding in the Emergency Department (ED) and make suggestions in the light of current data. Material and Methods: In a 3-year period, the number of patients admitted to our ED, number of forensic examination cases, number of patients who died, waiting times and Length of Stay (LOS) in the ED, consultation arrival times, length of laboratory result times, number of patients followed up in ED observation room and hospitalized to a ward were recorded. Findings were compared according to years. Results: Number of patients admitted to the ED did not significantly differ among years. LOS in the ED and the number of patients followed-up in the ED observation room increased significantly when compared according to years. Number of consultations also tended to increase. Even though the number of patients admitted to the red zone increases, when compared to 2016, mortality rate was significantly lower in 2017 and 2018. Conclusion: Rapid tra...
REASONS FOR DELAY IN INPATIENT ADMISSION AT AN EMERGENCY DEPARTMENT REVIEW OF LITERATURE
SOURCE Published by Journal Ayub Medical Coll Abbottabed in 2008 and I found it at There has been quite a number of works on the reason for patient delay in the Emergency Department. Many of these studies have ascribed the delay in Emergency Department to overcrowding as rightly referenced by the authors, as in Derlet R, et al (1) Andrulis DP et al (2). However many of the literatures showed that factors responsible for overcrowding was indirectly responsible for delay in Emergency Department. Such include insufficient emergency department or inpatient beds, delays while waiting for the laboratory tests (3). Previous studies did not separate the delay into before and after admission to inpatient ward was advised. This attempts to clearly depict the stage at which the delay sets in and hence would be easier to design a solution for the specific factor. None of the articles cited is less than 10years old. However by 2004 when the study was done and 2008 when it was published most of the articles were current under 3 years old. As a matter of fact, there has been a number of newer studies on overcrowding and other sources of delay to impatient admissions (4, 5). The review used the Vancouver referencing and the references were quite authoritative.
Emergency department and hospital crowding: causes, consequences, and cures
Clinical and Experimental Emergency Medicine, 2019
Overcrowding with associated delays in patient care is a problem faced by emergency departments (EDs) worldwide. ED overcrowding can be the result of poor ED department design and prolonged throughput due to staffing, ancillary service performance, and flow processes. As such, the problem may be addressed by process improvements within the ED. A broad body of literature demonstrates that ED overcrowding can be a function of hospital capacity rather than an ED specific issue. Lack of institutional capacity leads to boarding in the ED with resultant ED crowding. This is a problem not solvable by the ED and must be addressed as an institution-wide problem. This paper discusses the causes of ED overcrowding, provides a brief overview of the drastic consequences, and discusses possible cures that have been successfully implemented.