Transcript Slide 1

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
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
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/FactFile.html; AHRQ Nationwide Inpatient Sample & Thompson Healthcare Projected Inpatient
ED Becoming Hospital's Front Door
Service Line Break Down
Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/FactFile.html; AHRQ Nationwide Inpatient Sample & Thompson Healthcare Projected Inpatient
Aging Adult Population
www.princetoncme.com
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/FactFile.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
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
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-
Current* Workforce Shortage – Healthcare Professionals
* American Hospital Assoc. survey data Dec 2005
Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-
Shortage of On Call Specialists
Affecting nearly 75% of all hospitals
Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-
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*
* 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
% 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…
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
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
Surrogate
Markers of
Crowding
• 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)
Crowding Models
• NEDOCS (National ED Overcrowding Scale)
= Uses:
∑ niti/N
-BA) beds,
• EDWIN (ED Work Index)
a(BT#ED
total
#inpt beds, total #ED
= pts
sum
of
ESI
(trm/#ED
all on
• READI (Real-time Emergency= a(pts
Analysis
of
i) of
ED,
total
# pts
ininwaiting
patients
ventilator,
tx ∑active
nt
areas)
+longest
b(∑(ni) in ED /
Demand Indicators)
number
ofptattending
Using:
Total
#pts(hrs),
in
current
stay
reverse
ESI/#nurses)
+ ED,
physicians
hr (Na) x #
#tx
spaces,
total
# ptseach
inpatient
c(boarders/#ED
txED
areas)
• Work Score
= (Total
# pts
in
ED)/ #staff
Total
currently
available
tx pt
bays
arrivals,
pt
acuity,
boarding,
(hrs)
last
#ED
treatment
bays/hr
(Bplaced
T) – (BA
in) ED tx rm
• ED Occupancy Rate
Calculate: bed ratio,
Uses: ratio,
# attendings,
acuity
provider #
• EDCS (ED Crowding Scale)
staffed
beds, #value
critical
ratio,
demand
care pts, #total staffed
• Discrete Event Simulation
hospital beds, hospital
occupancy
• Queuing Theory
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:
Medicaid
SCHIP
Hospital and
“Back
End”
pts
use ED 2x more
Problem
often than uninsured
and 4x more than
insured*
– It Is an ED Problem
– Uninsured Are the Problem
– Non-Urgent & “Frequent Flier” Pts
Doesare
not fix boarding
problem
Problem
Highest ED utilization
Arrival
rate is very
– Build More Beds
is by NH pts (2nd by
46% pts who
predictable
by hrLWBS
per
infant <1 year old) **
– Pts Who LWBS Are Not Sick
immediate
dayneeded

medical attention,
– Arrival Pattern of Patients is Unpredictable
11% hospitalized in
next wk. “Too sick to
wait ” ***
* www.heritage.org 12/8/07; ** EDBA 2008 Data;  CDC/NCHS, *** Baker, 1991
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.
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.
Thank You