Emergency Department Crowding: What Is It, Is It a Problem,

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Emergency Department Crowding What Is It, Is It
a Problem, How Do We Fix It?

• Jennifer Wiler MD, MBA

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Q Is Emergency Department Crowding Problem?
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Increasing ED Patient Volumes
1994-2004 Annual number of U.S. ED visits rose
by 18 (93M to 110M) ? EDs decreased 12
Hospital Ambulatory Medical Care Survey 9/06
www.CDC.gov
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ED Becoming Hospital's Front Door
of Inpatient Admissions from ED Is on the Rise
Source http//www.healthleadersmedia.com/content
/205614/topic/WS_HLM2_FFL/Fact-File.html AHRQ
Nationwide Inpatient Sample Thompson Healthcare
Projected Inpatient Database
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ED Becoming Hospital's Front Door
Service Line Break Down
Source http//www.healthleadersmedia.com/content
/205614/topic/WS_HLM2_FFL/Fact-File.html AHRQ
Nationwide Inpatient Sample Thompson Healthcare
Projected Inpatient Database
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Aging Adult Population
www.princetoncme.com
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Increasing with Chronic Conditions Obesity
2006 report - of pts 65 yo or older with
self-reported select chronic conditions during 2
yr period
Source http//www.healthleadersmedia.com/content
/205614/topic/WS_HLM2_FFL/Fact-File.html
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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
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Increasing Number Of Uninsured PatientsAnd --
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
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Physicians NOT Accepting Medicaid Patients is On
the Rise
Modern Physician 11/06
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Projected Workforce Shortage Physicians
Source http//www.healthleadersmedia.com/content
/205614/topic/WS_HLM2_FFL/Fact-File.html
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Current Workforce Shortage Healthcare
Professionals
American Hospital Assoc. survey data Dec 2005
Source http//www.healthleadersmedia.com/content
/205614/topic/WS_HLM2_FFL/Fact-File.html
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Shortage of On Call Specialists
Affecting nearly 75 of all hospitals
Source http//www.healthleadersmedia.com/content
/205614/topic/WS_HLM2_FFL/Fact-File.html
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EMTALA

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

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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)

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The Result Your ED Waiting Room Looks Like This
And It is Not Just Us...
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Missouri 13th Most Busy EDs in Nation
ED Visits By State Number of ED visits/1,000
people in 2005
Source http//www.healthleadersmedia.com/content
/205614/topic/WS_HLM2_FFL/Fact-File.html Kaiser
Family Foundation www.kaiserfamily foundation.org

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of Hospitals with ED At or Over Capacity
Source http//www.healthleadersmedia.com/content
/205614/topic/WS_HLM2_FFL/Fact-File.html
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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
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Many EDs Report Being On Diversion
500,000 Ambulance Diversions Qyr ? On average one
every minute
Source http//www.healthleadersmedia.com/content
/205614/topic/WS_HLM2_FFL/Fact-File.html
American Hospital Association, 2007 Survey of
Hospital Leaders
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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 430 p.)
• Washington Hospital Center at 286 capacity
• Shortages of" ED "capacity and intensive care
  beds will grow worse if Bush administration
  Medicaid changes are implementedthe 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)
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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
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Q Is Emergency Department Crowding a Problem?
A YES
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And It Is Not Just the USA

• Australia
• UK
• Korea
• Canada
• Greece

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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

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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.
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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, 200304. 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
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Q What Is Crowding?
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Crowding What Is It?

• You just know

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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
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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)
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
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
(Total pts in ED)/ Total ED treatment bays/hr
Uses attendings, staffed beds, critical
care pts, total staffed hospital beds, hospital
occupancy
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Q How Do We Fix ED Crowding?
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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
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How Do We Fix It?
Medicaid and SCHIP pts use ED 2x more often than
uninsured and 4x more than insured

• 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

Hospital Back End Problem
Does not fix boarding problem
Highest ED utilization is by NH pts (2nd by
infant lt1 year old)
Arrival rate is very predictable by hr per day ?
46 pts who LWBS needed immediate medical
attention, 11 hospitalized in next wk. Too sick
to wait
www.heritage.org 12/8/07 EDBA 2008 Data ?
CDC/NCHS, Baker, 1991
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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 dont have emergency todaycopay please
• Houston, Denver, Others
• http//abcnews.go.com/Video/playerIndex?id2561039
  affilkdnl
• UK Model (98 Disposed within 4 hrs)

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How Do We Fix ED Crowding?
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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

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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)

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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)

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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.

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Hospital Wide Actions

• 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.

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Thank You