ACEP TAsk ForCE rEPorT on BoArding

Emergency Department
Crowding: High-Impact Solutions
APril 2008
2
Emergency Department Crowding: High-Impact Solutions
Continuing Medical Education Credit
information
Release date: July 25 2008
Expiration date: July 2! 20""
Statement of Need
Many emergency de#artments in t$e %nited &tates are
critically o'ercro(ded and t$is $am#ers t$e deli'ery of $ig$)
*uality medical care+ T$e #rimary cause of o'ercro(ding is
,oarding-t$e #ractice of $olding #atients in t$e emergency
de#artment after t$ey $a'e ,een admitted to t$e $os#ital ,ecause
no in#atient ,eds are a'aila,le+ T$is #ractice often results in
#atients. lying on gurneys in emergency de#artment corridors
for $ours and e'en days ($ic$ affects not only t$eir care and
comfort ,ut also t$e #rimary (ork of t$e emergency de#artment
staff-taking care of emergency de#artment #atients+ /n August
2000 t$e American College of Emergency P$ysicians esta,lis$ed
a task force to de'elo# lo()cost or no)cost solutions to ,oarding+
T$e task force re#ort 1Emergency 2e#artment Cro(ding3 4ig$)
/m#act &olutions5 (as #u,lis$ed in A#ril 2008 to $el# emergency
#$ysicians sto# ,oarding in t$eir o(n $os#itals and ultimately
im#ro'e #atient care+
rom the !""# $odel of the Clinical
%ractice of Emergency $edicine
A##endi6 2+ 7t$er com#onents of t$e #ractice of
emergency medicine
Administration
$ethod of %articipation
T$is educational acti'ity consists of a "!)#age re#ort eig$t
#ost)test *uestions and four e'aluation *uestions and s$ould take
a##ro6imately 2 $ours to com#lete+ To com#lete t$is educational
acti'ity as designed t$e #artici#ant s$ould in order re'ie( t$e
learner o,8ecti'es read t$e re#ort and com#lete and su,mit
t$e online CME #ost)test including t$e e'aluation *uestions+
Partici#ants may su,mit t$e #ost)test at any time u# to 9 years
from t$e release date+ :o credit (ill ,e gi'en after t$at date+
T$irty days after su,mitting t$e #ost)test #artici#ants
(ill ,e asked to ans(er fi'e *uestions regarding $o( t$ey
$a'e im#lemented t$e recommendations and ($et$er t$e
recommendations $el#ed t$eir emergency de#artments eliminate
,oarding and im#ro'e #atient care+
&earner '()ecti*es
7n com#letion of t$is acti'ity you s$ould ,e a,le to3
"+ 2efine emergency de#artment cro(ding+
2+ 2iscuss causes of emergency de#artment cro(ding+
9+ 2escri,e t$e conse*uences of cro(ding+
!+ 2elineate actions t$at can $el# eliminate cro(ding+
+ccreditation Statement
T$e American College of Emergency P$ysicians ;ACEP< is
accredited ,y t$e Accreditation Council for Continuing Medical
Education ;ACCME< to #ro'ide continuing medical education
for #$ysicians+ ACEP designates t$is educational acti'ity for
a ma6imum of 2 AMA PRA Category 1 Credits=+ P$ysicians
s$ould only claim credit commensurate (it$ t$e e6tent of t$eir
#artici#ation in t$e acti'ity+ A##ro'ed ,y ACEP for 2 $ours of
ACEP Category / credits+
,arget +udience
T$is educational acti'ity $as ,een de'elo#ed for emergency
#$ysicians+
Contri(utors
-rent +splin. $D. $%H. +CE%. 2e#artment 4ead of
Emergency Medicine >egions 4os#ital &t+ Paul Minnesota?
Associate Professor and @ice C$air 2e#artment of Emergency
Medicine %ni'ersity of Minnesota Medical &c$ool Minnea#olis
Minnesota
rederic/ C0 -lum. $D. +CE%. Aest @irginia %ni'ersity
Morganto(n Aest @irginia
Ro(ert I0 -roida. $D. +CE%. C$ief 7#erating 7fficer
P$ysicians &#ecialty Btd+ >>C ;Emergency Medicine P$ysicians
Btd+<? President E2 Duality &olutions /nc+ Akron 7$io
10 Richard -u/ata. $D. Clinical Professor Emergency
Medicine Bos Angeles CountyE%ni'ersity of &out$ern California
Medical Center Bos Angeles? Medical 2irector Emergency
2e#artment &an Ca,riel @alley Medical Center &an Ca,riel
California+
$ichael -0 Hill. $D. +CE%. President and CE7
EMPAT4 Consulting >ic$mond California
Stephen R0 Hoffen(erg. $D. +CE%. President CarePoint
Medical Crou# 2en'er Colorado+
Sandra $0 Schneider. $D. +CE%. -oard &iaison. Professor
and C$air Emeritus 2e#artment of Emergency Medicine
%ni'ersity of >oc$ester >oc$ester :e( Fork
%eter 2iccellio. $D. +CE%. Chairman. Professor and @ice
C$airman 2e#artment of Emergency Medicine &tate %ni'ersity
of :e( Fork at &tony,rook &tony,rook :e( Fork
Shari 30 1elch. $D. +CE%. Duality /m#ro'ement Consultant
and Educator /ntermountain 4ealt$care %ta$ Emergency
P$ysicians %ni'ersity of %ta$ /nstitute for 4ealt$care
/m#ro'ement &alt Bake City %ta$
%u(lisher4s Notice
/n accordance (it$ ACCME &tandards and ACEP #olicy
all #ersons ($o are in a #osition to control t$e content of t$is
educational acti'ity must disclose to #artici#ants t$e e6istence of
significant financial interests in or relations$i#s (it$ manufacturers
of commercial #roducts t$at mig$t $a'e a direct interest in t$e
su,8ect matter including t$e s#onsor of t$is educational acti'ity if
a##lica,le+
T$e contri,utors to 1Emergency 2e#artment Cro(ding3
4ig$)/m#act &olutions5 $a'e disclosed t$e follo(ing interests or
relations$i#s3 2r+ 4ill is President and CE7 of EMPAT4 Consulting
an organiGation de'oted to im#ro'ing $os#ital o#erations+ 2r+
As#lin 2r+ Blum 2r+ Broida 2r+ Bukata 2r+ 4offen,erg 2r+
&c$neider 2r+ @iccellio and 2r+ Aelc$ $a'e no significant financial
interests or relations$i#s to disclose+
ACEP e6#ects t$at t$e relations$i#s contri,utors disclose
if any (ill not influence t$eir contri,utions+ ACEP also e6#ects
contri,utors to #resent information in an o,8ecti'e manner (it$out
endorsement or criticism of s#ecific #roducts or ser'ices+
ACEP makes e'ery effort to ensure t$at contri,utors to
College)s#onsored #rograms are kno(ledgea,le aut$orities
in t$eir fields+ Partici#ants are ne'ert$eless ad'ised t$at t$e
statements and o#inions e6#ressed in t$is #rogram are #ro'ided
as guidelines and s$ould not ,e construed as College #olicy
unless s#ecifically referred to as suc$+ T$e material contained
$erein is
not intended to esta,lis$ #olicy #rocedure or a standard of care+
T$e 'ie(s e6#ressed in t$is educational acti'ity are t$ose of t$e
contri,utors and not necessarily t$e o#inion or recommendations
of t$e American College of Emergency P$ysicians+ T$e College
disclaims any lia,ility or res#onsi,ility for t$e conse*uences of any
actions taken in reliance on t$ose statements or o#inions+
Co#yrig$t 2008 American College of Emergency P$ysicians+
All rig$ts reser'ed+ Printed in t$e %&A+ E6ce#t as #ermitted under
t$e %nited &tates Co#yrig$t Act of "H0I no #art of t$is #u,lication
may ,e re#roduced or distri,uted in any form or ,y any means
9
or stored in a data,ase or retrie'al system (it$out #rior (ritten
#ermission of t$e #u,lis$er+
ACEP BoArding TAsk ForCE MEMBErs And lEAdErs$iP
-oarding ,as/ orce $em(ers
Peter @iccellio M2 FACEP Chairman &andra
M+ &c$neider M2 FACEP Board Liaison Brent
As#lin M2 MP4 FACEP
Frederick Blum M2 FACEP
>o,ert /+ Broida M2 FACEP
A+ >ic$ard Bukata M2
Mic$ael B+ 4ill M2 FACEP
&te#$en 4offen,erg M2
FACEP &$ari J+ Aelc$ M2
FACEP
+CE% &eadership
Binda Ba(rence M2 FACEP President of ACEP (2007-
08) Brian Jeaton M2 FACEP President of ACEP (200-
07) 2ean Ailkerson J2 MBA CAE E!e"#ti$e %ire"tor
Marilyn E+ Bromley >: &taff Liaison
ConTEnTs
'*er*iew + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + 5
4ig$)/m#act &olutions + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + I
Additional &olutions + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
I 1&olutions5 T$at Are :ot Effecti'e + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
I
,he Impact of Emergency Department '*ercrowding
on %atient Care and Sur*i*al + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + 0
'*ercrowded Emergency Departments + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + 0
our 5uestions + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + 0
"+ Emergency 2e#artment Cro(ding3 A$at /s /tK + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + 0
2+ A$at Causes Cro(dingK + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + 8
9+ A$at Are t$e Conse*uences of Cro(dingK + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + 8
!+ A$at Can Be 2one to >educe Cro(dingK + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + "0
Internal Emergency Department +ctions and %rocesses
,hat 1ill Impro*e +ccess and low + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + "0
Hospital +ctions and %rocesses ,hat 1ill Impro*e +ccess and low + + + + + + + + + + + + + + + + + "2
References + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + "9
ACEP TAsk ForCE rEPorT on BoArding
Emergency Department Crowding:
High-Impact Solutions
T$e American College of Emergency P$ysicians ;ACEP< in August 2000 esta,)
lis$ed a task force to de'elo# t$ree to fi'e lo()cost or no)cost solutions to t$e #rac)
tice of 1,oarding5 or $olding #atients admitted to t$e $os#ital in t$e emergency
de) #artment ($ic$ is t$e #rimary cause of o'ercro(ding+ T$e task force (as
c$arged (it$ #ro#osing solutions to address t$e gro(ing crisis t$at is $arming t$e
#u,lic.s access to lifesa'ing emergency care+ For t$e #ur#oses of t$is re#ort a
,oarded #atient is defined as a #atient ($o remains in t$e emergency de#artment
after t$e decision to admit $im or $er to t$e $os#ital $as ,een made+
'2 ER2 I E1
Many emergency de#artments in t$e %nited
&tates are critically o'ercro(ded and una,le to re)
s#ond to day)to)day emergencies let alone disas)
ters and acts of terrorism+ Cro(ding is a crisis t$at
results from t$e #ractice of 1,oarding5 or $old)
ing emergency #atients ($o $a'e ,een admitted
to t$e $os#ital in t$e emergency
de#artment+ Cro(ding occurs
gency+ A$en am,ulances are di'erted critically ill
#atients must tra'el fart$er for care ($ic$ delays
t$eir treatment ($en seconds count+
Emergency de#artment cro(ding is an institu)
tional #ro,lem t$at goes (ell ,eyond t$e emer)
gency de#artment+ 7nly ($en all stake$olders
agree t$at t$e #ro,lem is systemic
and $os#ital)(ide can solutions ,e
($en no in#atient ,eds are a'ail)
a,le in t$e $os#ital not ,ecause of
too many #atients (it$ nonurgent
medical conditions seeking emer)
gency care+ T$e #ractice of ,oard)
ing endangers #atients and results
in delays in care and am,ulance
di'ersion+
A$en emergency #atients are
,oarded t$ey lie on gurneys or sit
in c$airs in t$e emergency de#art)
ment often filling e'ery a'aila,le
s#ace including t$e $all(ays+ T$is
$as a significant negati'e effect on
#atient safety comfort and satis)
faction+ /t also ties u# resources
rendering emergency staff un)
only ($en all
stake$olders agree
t$at t$e #ro,lem
is systemic and
$os#ital)(ide
can solutions ,e
im#lementedL
t$at (ill #rotect
e'eryone.s access
to emergency care+
im#lemented t$at (ill im#ro'e #a)
tient flo( from triage to disc$arge
and #rotect e'eryone.s access to
emergency care+
To ,egin to sol'e t$e #ro,lem
,oarding must at a minimum ,e
s#read t$roug$out t$e $os#ital ,y
mo'ing #atients out of t$e emer)
gency de#artment as soon as t$ey
are admitted+ T$is (ill #ro'ide a
decom#ression 'al'e to $el# alle'i)
ate t$e ,ottleneck caused ,y emer)
gency #atients (aiting for in#atient
,eds+ /n addition t$e $ealt$ care
industry must realign its
o#erations to meet #atients.
needs+ 4os#ital resources must ,e
a'aila,le 0 days
a,le to care for additional #atients from t$e (ait)
ing room or from an am,ulance+ T$ese ,oarded
#atients (ait sometimes for days for in#atient
,eds in a c$aotic and un#redicta,le en'ironment
($ere c$ildren mig$t (itness a resuscitation or an
elderly (oman mig$t (itness a #syc$iatric emer)
a (eek in sufficient *uantity+ &urgical #rocedures
and ot$er acti'ities suc$ as radiological
ser'ices and #$ysical t$era#y s$ould ,e
sc$eduled so t$at t$ese ser'ices are a'aila,le 0
days a (eek t$us eliminating t$e ,acklog of
emergency #atients and ensuring continuity of
care+
E M E r g E n C y d E PA r T M E n T C r o( d i n g 3 $ i g $ ) i M PA C T s o l u
T i o n s
High-Impact Solutions
T$e follo(ing solutions (ould $a'e significant
im#act on reducing ,oarding and im#ro'ing t$e
flo( of #atients t$roug$ emergency de#artments3
M $o*e emergency patients who ha*e (een
admitted to the hospital out of the emergency
department to inpatient areas. such as hallways.
conference rooms. and solaria ;see Full Ca#acity
Protocol at (( ( +$ os # i t al o' e r c r o(d ing+ c o m<+ /f
eac$ $os#ital unit (ould care for a small num,er
of additional #atients t$e ,urden of ,oarding
(ould ,e more e'enly s#read across t$e $os#ital
t$us freeing t$e emergency de#artment to
function effecti'ely (it$out unduly stressing t$e
in#atient units+
M Coordinate the discharge of hospital patients
(efore noon0 Research shows that timely
discharge of patients can significantly impro*e
the flow of patients through the emergency
department (y ma/ing more inpatient (eds
a*aila(le to emergency patients0 4o(e'er t$e
disc$arge #rocess $as ,ecome more com#le6
and disc$arging #atients ,y noon (ill re*uire
leaders$i# and a c$ange in culture and #rocess
t$at must in'ol'e #$ysicians nurses and staff
from am,ulances nursing $omes social (ork
care management #$armacy radiology la, and
$ousekee#ing+
M Coordinate the scheduling of electi*e patients
and surgical patients0 &tudies s$o( t$at t$e
une'en influ6 of electi'e surgical #atients
;$ea'iest early in t$e (eek< is a #rime contri,utor
to $os#itals e6ceeding t$eir ca#acity+
+dditional Solutions
/m#ro'ing t$e flo( of #atients t$roug$
emergency de#artments can sa'e time ,ut often
adds significant costs+ Met$ods of im#ro'ing
flo( suc$ as using scri,es adding nurses and
su##ort #ersonnel im#ro'ing turnaround time for
la, and N)ray ;including t$e use of #oint)of)care
testing< esta,lis$ing electronic records installing
registration kiosks and allo(ing nurses to order
tests at triage ;ad'ance triage< can decrease triage
to disc$arge time+ 4o(e'er t$e costs to im#lement
t$ese #rocedures often e6ceed t$e amount of
sa'ings t$ey generate+
T$e follo(ing are additional solutions t$at (ould
im#ro'e t$e flo( of emergency #atients along (it$
t$e #ros and cons of eac$3
M -edside Registration0 >egistering #atients at
t$e ,edside or eliminating triage altoget$er ;,y
#lacing #atients directly in ,eds< can decrease
(ait times from triage to emergency ,ed and
#ro'ide a small sa'ings in time de#ending on t$e
time currently de'oted to t$is #rocess+ 4o(e'er
more #ersonnel ty#ically are re*uired and
eliminating triage is #ossi,le only if em#ty ,eds
e6ist+
M ast ,rac/ 6nits0 Triaging #atients (it$
nonurgent medical conditions to a se#arate
area of t$e emergency de#artment for care a
#ractice kno(n as 1fast)tracking5 often
re*uires more #ersonnel ,ut also gi'es staff t$e
a,ility
to *uickly $andle lo()acuity #atients+ 4o(e'er
furt$er #artitioning t$e emergency de#artment
into se#arate units mig$t not ,e $el#ful and also
(ill create silos and o,stacles to #atient flo(+
M '(ser*ation 6nits0 4os#itals t$at $a'e
added o,ser'ation areas $a'e reduced
cro(ding
,ut not (it$out significant construction and
#ersonnel costs+
M %hysician ,riage0 /n'ol'ing a #$ysician in t$e
triage #rocess is a costly (ay to disc$arge
lo()acuity #atients *uickly ($ic$ de#ending
on t$e num,er of lo()acuity #atients mig$t ,e
$el#ful+ 4o(e'er referring #atients a(ay from
t$e emergency de#artment (ill re*uire ade*uate
o#tions for suc$ referrals+
M Cancelling electi*e surgeries0 T$is #ractice can
greatly reduce t$e demand for in#atient ,eds ,ut
t$e lost re'enue is not usually offset ,y t$e care
of additional emergency #atients+
7Solutions8 ,hat +re Not Effecti*e
&ome $os#itals $a'e e6#anded t$eir emergency
de#artments as a (ay to increase t$eir ca#acity
to care for #atients+ 4o(e'er t$is does not sol'e
o'ercro(ding+ Ait$ less #ressure on t$e system
t$e $os#ital mig$t sim#ly e6#and into t$e additional
s#ace increasing rat$er t$an decreasing t$e
num,er of admitted #atients ($o are ,oarded+
A more effecti'e solution (ould ,e to add an
o,ser'ation area+
/n addition s#ecified areas for disc$arged
#atients on in#atient floors tend not to ,e used ,y
t$e in#atient nurses e6ce#t ($en t$e full ca#acity
#rotocol #laces stress on t$eir #arts of t$e system+
&ome $os#itals em#loy $os#italists to coordinate
#atient care+ %sing $os#ital),ased #$ysicians suc$
as $os#italists and intensi'ists $as ,een s$o(n to
decrease $os#ital lengt$s of stay ,ut not emergency
de#artment (aiting times+
Am,ulance di'ersion is used ,y many emergency
de#artments ,ut it is increasingly e'ident t$at in
most circumstances it sim#ly doesn.t (ork+ Also
a gro(ing amount of researc$ su,stantiates t$e
$arm to #atients ($ose care is delayed ,ecause
of ,eing di'erted to $os#itals fart$er a(ay+ T$e
researc$ suggests t$e #ractice is ,ot$ unsafe and
ineffecti'e and s$ould ,e a,andoned as an o#tion
for addressing t$e #ro,lems of $os#ital cro(ding+
E M E r g E n C y d E PA r T M E n T C r o( d i n g 3 $ i g $ ) i M PA C T s o l u
T i o n s
&ome systems t$at $a'e eliminated di'ersion as
an o#tion $a'e not seen a (orsening of cro(ding+
,he Impact of Emergency Department
'*ercrowding on %atient Care and Sur*i*al
T$e ne(s media $a'e gi'en great attention to
t$e cro(ding 1crisis5 in emergency de#artments
as if t$is (ere a recent de'elo#ment+ 4o(e'er as
far ,ack as "H80 after sustained and unsol'a,le
#ro,lems (it$ cro(ding t$e first state(ide
conference on cro(ding (as $eld in :e( Fork City
in'ol'ing t$e :e( Fork c$a#ter of ACEP Emergency
Medical &er'ices t$e :e( Fork &tate 2e#artment
of 4ealt$ and legislators+ At t$at time t$e issue
(as clearly delineated ,ut no clear solutions (ere
fort$coming+ &ince t$en $os#ital and emergency
de#artment o'ercro(ding $a'e $ad cyclical media
attention al,eit (it$ 'ery little done to fi6 t$e
#ro,lem+
4o( did emergency de#artments get so
o'ercro(dedK
4os#itals in t$e "HI0s (ere in large #art #laces
for electi'e admissions of #atients ;or sc$eduled
surgeries< (it$ only a small #ercentage of #atients
,eing unsc$eduled or 1emergent5 ;seeking care
for medical emergencies<+ 4os#itals also ty#ically
$ad su,stantial ca#acity to allo( for system)
(ide inefficiencies+ 2uring t$is time $os#itals
o#erated #rimarily as H to 5 Monday t$roug$ Friday
,usinesses (it$ skeleton cre(s on e'enings nig$ts
and (eekends+
Fast)for(ard to 2008 ($ere dramatic c$anges
$a'e occurred in t$e $ealt$ care system+ T$e
num,er of emergency 'isits $as clim,ed
dramatically and most emergency 'isits and
$os#ital admissions are unsc$eduled+ T$e #atient
#o#ulation also is muc$ sicker+ At t$e same time
t$e route of entry into t$e $os#ital $as s$ifted
(it$ t$e ma8ority of #atients entering t$roug$ t$e
emergency de#artment and (it$ most coming in
t$e afternoons and e'enings+
2es#ite t$is significant s$ift $os#itals $a'e not
ada#ted to t$e c$anges and continue to function
as H to 5 Monday t$roug$ Friday institutions (it$
skeleton cre(s on e'enings nig$ts and (eekends+
T$is $as resulted in a mismatc$ of resources 'ersus
needs generating serious lack of ca#acity issues
($ic$ #er$a#s e6#lains in #art ($y $ig$er deat$
rates for strokes and $eart attacks occur among
#atients admitted on (eekends 'ersus (eekdays+
/n addition contrary to t$e con'entional
(isdom t$at emergency #atient 'olume is $ig$ly
un#redicta,le t$e num,er of admissions #er day
no( can ,e #redicted (it$ remarka,le accuracy+
4o(e'er $os#itals still do not antici#ate and
#re#are for t$e ne6t day.s 'olume and admission
t$roug$ t$e emergency de#artment+
&o $o( does t$e institutional structure create
ca#acity issues ,y designK A classic e6am#le is
t$e coordination of surgical #rocedures ($ic$
are not sc$eduled smoot$ly t$roug$out t$e (eek
,ut rat$er are front)loaded on Mondays t$roug$
Aednesdays+
A$yK 7ften ,ecause of critical follo(u# care
demands+ For e6am#le an ort$o#edist kno(s
t$at a #atient undergoing $i# re#lacement is
critically de#endent u#on #$ysical t$era#y in t$e
days immediately follo(ing surgery to #re'ent
life)t$reatening #osto#erati'e com#lications and
to o#timiGe reco'ery of functional ca#acity+ &o if
t$e $os#ital.s #$ysical t$era#y staff is small or
none6istent on (eekends t$e ort$o#edist $as little
c$oice ,ut to sc$edule as muc$ surgery as #ossi,le
at t$e ,eginning of t$e (eek+
4o( can t$is #ro,lem ,e sol'edK &im#ly ,y
e6#anding ca#acity ,eyond t$e H to 5 (eekday
sc$edule+ As #roof in #oint ($en an institution in
Massac$usetts ($ic$ $ad struggled (it$ ca#acity
issues for years c$anged to a smoot$ surgical
sc$edule t$eir ca#acity issues disa##eared+
'*ercrowded Emergency Departments
As #art of t$e #ro,lem)sol'ing #rocess it is
im#ortant to distinguis$ ($at cro(ding means in
t$e emergency de#artment 'ersus t$e in#atient
units of most $os#itals+ /n#atient units ($en t$eir
normal #atient ,eds are full are considered 1full5
and t$us not 1ca#a,le5 of taking more #atients+
Emergency de#artments are considered 1full5
($en all t$eir rooms are full all t$eir $all(ay
stretc$ers are full and all t$eir c$airs are full+ T$us
t$ere is a striking contrast ,et(een t$e emergency
de#artment and t$e in#atient units in t$eir
res#ecti'e 'ie(s of ($at constitutes 1at ca#acity5
or ,eing cro(ded+
our 5uestions
T$e ans(ers to four *uestions (ill #ro'ide insig$t
into t$e causes of and solutions to cro(ding+
9:; Emergency Department Crowding: 1hat Is It<
@arious studies $a'e de'elo#ed definitions of
cro(ding ,ut in its sim#lest form it e6ists ($en
t$ere is no s#ace left to meet t$e timely needs of t$e
ne6t #atient ($o needs emergency care+ /f t$e care
of urgent #ro,lems is delayed due to congestion
t$en cro(ding e6ists+
9!; 1hat Causes Crowding< >ecently t$ere $as
,een greater understanding of ($y ,oarding-
t$e #ractice of $olding admitted #atients in t$e
emergency de#artment ($en t$ere is no 1#ro#er5
s#ace for t$em in t$e institution-is t$e #rimary
cause of o'ercro(ding+ 7'er t$e years t$e reasons
for cro(ding $a'e included seasonal illnesses and
'isits ,y t$e #oor and uninsured ($o $a'e no($ere
else to turn e6ce#t t$e 1safety net5 #ro'ided ,y
emergency de#artments+ T$is latter trend $as
resulted from t$e Emergency Medical Treatment
and Ba,or Act ;EMTABA< ($ic$ re*uires $os#ital
emergency de#artments to medically screen and
sta,iliGe all #atients (it$ medical emergencies
regardless of t$eir a,ility to #ay+
Muc$ of t$e researc$ a,out 1unnecessary5
'isits (as #u,lis$ed in t$e "H80s and early
"HH0s and consisted of retros#ecti'e re'ie(s of
t$e
final diagnoses of emergency #atients not t$eir
sym#toms+ 7nce t$e diagnoses (ere kno(n
researc$ers concluded t$e 'isits did not constitute
emergencies and (ere unnecessary+ Based on t$is
researc$ t$ere (as a gro(ing sense t$at many
emergency #atients (ere seeking
emergency care fri'olously gi'ing
t$ose (it$ real emergencies as muc$ as t$ose (it$
minor #ro,lems+
T$e critical *uestion to ask regarding
1unnecessary5 'isits is3 12o nonemergent #atients
interfere (it$ t$e care of urgent #atientsK5 >ecent
studies closely e6amined t$e effect of nonemergent
#atients on t$e care of critically ill #atients and
concluded t$e im#act essentially is none6istent+
4o( do EMTABA t$e #oor and t$e safety
net role of emergency de#artments contri,ute
to cro(dingK EMTABA re*uires #atients to ,e
medically e'aluated and if t$ere is a medical
emergency to #ro'ide ($ate'er treatment is
re*uired to sta,iliGe t$em regardless of t$eir a,ility
to #ay+ T$us EMTABA concerns as (ell as issues
related to t$e #oor and t$e uninsured are issues
of finance not cro(ding+ :o e'idence su##orts
or refutes t$e effects of t$ese issues on cro(ding
ot$er t$an t$e (ell)documented increase in serious
medical #ro,lems in #atients ($o $a'e no $ealt$
insurance+
2o seasonal 'ariations contri,ute to cro(dingK
More #atients do seek emergency care during a
flu e#idemic+ 4o(e'er t$is is a #ro,lem t$at is
layered on to# of a c$ronic day)
to)day mont$)to)mont$ issue (it$
rise to attem#ts to restrict 'isits
increase co)#ays institute #$one
screening #rior to 'isit and ot$er
inter'entions+
4o(e'er many #eo#le
e6#erience t$e sym#toms of a
medical emergency ,ut after a
medical e6amination and diagnostic
testing it is determined t$ey do not
$a'e medical emergencies+ T$ese
T$e clearest cause
of cro(ding is t$e
,oarding of
admitted #atients+
cro(ding+ Cro(ding is a year)
round #$enomenon not a transient
#ro,lem caused ,y seasonal
'ariation+
A num,er of recent studies s$o(
a direct and strong correlation
,et(een t$e num,er of admitted
#atients ,eing ,oarded in t$e
emergency de#artment and
cro(ding making it clear ,eyond
'isits s$ould not ,e classified as unnecessary+ Just
as a 1s#ot5 on t$e lung mig$t mean not$ing or
indicate a malignancy a c$ild (it$ a fe'er mig$t
$a'e a sim#le cold or se'ere se#sis or meningitis+
A 1sim#le sore t$roat5 mig$t ,e 'iral or re#resent
im#ending air(ay o,struction from e#iglottitis?
($at t$e #atient e6#eriences is t$e same3 a sore
t$roat+
2uring t$e "HH0s ACEP ,egan to ad'ocate for a
national 1#rudent lay#erson standard5 ($ic$ ,ases
$ealt$ care co'erage on a #atient.s sym#toms
not $is or $er final diagnosis since t$e general
#u,lic s$ould not ,e e6#ected to self)diagnose
t$eir medical conditions+ /n a study ,y FranasGek
"
#atients (ere asked at triage to assess ($et$er
t$eir #ro,lem (as critical urgent or routine+ 7f
t$e #atients ($om t$e #$ysician determined to ,e
critical 25O ,elie'ed t$eir #ro,lem (as routine+
7t$er studies $a'e s$o(n t$at ,arriers to care
;#$one screening increasing co)#ays etc+< affect
*uestion t$at t$is is t$e num,er one cause of
o'ercro(ding+ /n s$ort it is not t$e emergency
de#artment t$at is causing t$e cro(ding+ /t is t$e
$os#ital t$at is una,le to accommodate more
in#atients+
9=; 1hat +re the Conse>uences of Crowding< A
(ealt$ of researc$ demonstrates t$e se'ere
conse*uences of emergency de#artment cro(ding
on #atients and #$ysicians+ Among t$e findings are
t$e follo(ing3
M Sic/ people wait too long to recei*e emergency
care0 T$e Centers for 2isease Control and
Pre'ention ;C2C< found for #atients 8udged ,y
t$e triage nurse to ,e critical more t$an "0O
(aited more t$an " $our to see a #$ysician in
t$e emergency de#artment+
2
T$is is a critical
#ro,lem ,ecause many illnesses are time
de#endent and early inter'ention gi'es rise to
,etter outcomes+ Bate diagnoses mig$t ,e too
late (it$ #ermanent conse*uences of disa,ility
or deat$+
9
Aaiting times can ,e reduced ,y
reducing access ,lock+
!
M Anot$er study e6amined t$e com#lication rate
among #atients (it$ acute coronary syndrome
;AC&< and found a significant increase in serious
com#lications ;a##ro6imately IO 'ersus 9O
incidence of deat$ cardiac arrest $eart failure
late M/ @Tac$ or @Fi, &@T ,radycardia stroke
or $y#otension< in #atients seeking emergency
care during times of cro(ding+
5
M -oarding increases the total length of stay in the
hospital. further worsening access to emergency
care0 &e'eral studies document a total $os#ital
lengt$ of stay to ,e a full day longer among
#atients ,oarded in t$e emergency de#artment
'ersus #atients (it$ similar illnesses #rom#tly
#laced in t$e in#atient units+
I )8
M -oarding increases wal/outs+ T$e longer #eo#le
(ait t$e greater t$e likeli$ood t$ey (ill lea'e
#rior to recei'ing care+
H
%nfortunately t$e
#ercentage of #atients (it$ serious illness differs
little ,et(een #atients ($o left and t$ose ($o
(aited for care+ A num,er of t$ese (alkouts
su,se*uently re*uire admission+
"0
M '*ercrowding increases medical errors0 A
num,er of articles document t$e increase in
medical errors associated (it$ ,oarding and
cro(ding+
""
Many of t$ese are errors of omission
and not commission since t$e emergency staff
must simultaneously care for in#atients and
focus on t$e ne( emergencies coming in t$e
door+
"2
According to t$e Joint Commission
50O of sentinel e'ents causing serious in8ury or
deat$ occur in t$e emergency de#artment and
a##ro6imately one t$ird of t$ese are related to
cro(ding+
"9
M '*ercrowding causes deaths0 T$e emergency
medicine community $as long ,een a(are of t$e
dangers of cro(ding and delays in care+ &e'eral
recent studies looking at large data,ases t$at
com#are mortality rates in #atients seeking
emergency care during times of cro(ding 'ersus
times of no cro(ding conclude t$at t$e rate of
deat$ is $ig$er during times of cro(ding+ T$is
effect ;$aGard ratio for deat$ of a##ro6imately
"+9<
"!)"I
offers a target larger t$an t$ose of ot$er
initiati'es gi'en great im#ortance suc$ as t$e
administration of anti,iotics for #neumonia
#atients (it$in ! $ours ($ic$ no( is a
#erformance measure ,y ($ic$ $os#itals are
#aid+ Com#liance (it$ t$is initiati'e is estimated
to reduce t$e num,er #er "00 ($o (ould $a'e
died to H9+ Cro(ding studies estimate t$at deat$s
(ould ,e reduced from "00 to ,et(een 05 and
89+ T$ese are su,stantial num,ers and a##ly to a
'ery large #o#ulation+ As suc$ cro(ding a##ears
to ,e a far more im#ortant issue to resol'e+
M C$alfin and colleagues ;2000< looked at outcomes
for intensi'e care unit ;/C%< #atients su,8ected to
a delay of more t$an I $ours in transfer to an /C%
and found increased $os#ital lengt$ of stay ;0
'ersus I days< and $ig$er mortality rates ;"0+0O
'ersus 8+!O< for t$ese #atients+
"0
M Crowding causes am(ulance di*ersion0
According to t$e C2C a##ro6imately 50O of
emergency de#artments e6#erience cro(ding
and one t$ird of $os#itals $a'e e6#erienced
am,ulance di'ersion+
"8
:inety #ercent of
emergency de#artment directors re#ort cro(ding
as a recurrent #ro,lem
"H
and ot$er studies $a'e
re#orted am,ulance di'ersion in u# to 50O of
emergency de#artments+
20
&uc$ cro(ding and
di'ersion $a'e raised an alarm regarding t$e
a,ility of t$e $ealt$ care system to res#ond to
catastro#$e+
2"
M /nterestingly t$ere is scant e'idence t$at
am,ulance di'ersion actually (orks
22
alt$oug$
e'idence e6ists for delayed care in t$e face of
am,ulance di'ersion+
29
/n t$is regard study
aut$or :ic$oll demonstrated an increased
mortality rate (it$ #rolonged trans#ort times+
2!
M /t is clear t$at am,ulance di'ersion is dri'en
,y t$e ,oarding of admitted #atients and is not
ot$er(ise related to issues of staffing or s#ace
(it$in t$e emergency de#artment itself+
25
M -oarding of inpatients interferes with the
patient-centered care model0 Many $os#itals are
ado#ting #atient)centered care ($ic$ means
t$at continuity teams care for #atients during
t$eir stay+ /ntuiti'ely if #atients s#end a #ortion
of t$eir stay in t$e emergency de#artment
rat$er t$an on an a##ro#riate floor continuity is
im#ossi,le+
M Crowding increases medical negligence claims.
which increases health care costs for e*eryone0
T$e fre*uency of medical lia,ility la(suits filed
against emergency #$ysicians is increased
,y a factor of fi'e sim#ly ,ased on ($et$er a
#atient (aits more t$an rat$er t$an less t$an 90
minutes to ,e seen ,y a #$ysician+
"0
"0
Most im#ortantly #atient care is (orsened ,y
,oarding+ E'idence),ased researc$ demonstrates
t$at ,oarding results in t$e follo(ing3
M 2elays in care
M Am,ulance di'ersion
M /ncreased $os#ital lengt$s of stay
M Medical errors
M /ncreased #atient mortality
M Financial losses to $os#ital and #$ysician
M Medical negligence claims
9?; 1hat Can -e Done to Reduce Crowding<
T$is section is di'ided into actions and #rocesses
to sol'e o'ercro(ding (it$in and ,eyond t$e
emergency de#artment+ Because cro(ding is a
$os#ital #ro,lem t$e greatest gains (ill occur ,y
(orking on flo(s (it$in t$e $os#ital+ /m#ro'ing
flo( t$roug$ t$e emergency de#artment can sa'e
small amounts of time ,ut often adds significant
cost+ T$at ,eing said emergency de#artment
#rocesses can ,e im#ro'ed ,ut are likely to $a'e
little effect on cro(ding unless matc$ed (it$
successful in#atient flo( initiati'es+
Internal Emergency Department +ctions
and %rocesses ,hat 1ill Impro*e +ccess
and low
M -edside registration is a fundamental conce#t of
#rocess im#ro'ement ($ic$ seeks to streamline
and increase efficiency ($ere'er #ossi,le+ Many
emergency de#artments (ill triage t$en register
and finally #lace #atients in ,eds+ @irtually all
emergency #atients $a'e some (aiting time
during ($ic$ t$ey could ,e registered at t$e
,edside eliminating t$e need to (ait in line to
register+ /n ado#ting ,edside registration t$ere
(ill ,e a need for #atients to $a'e a 1*uick reg5
i+e+ a ,asic *uick set of identifiers to register
t$em into t$e $os#ital.s com#uter system+ T$e
com#lete registration can t$en ,e accom#lis$ed
at t$e ,edside+
M &imit triage to what is crucial and (ypass triage
altogether when (eds are a*aila(le0 Many
emergency de#artments $a'e a triage #rocess
t$at a##lies to all #atients regardless of illness or
in8ury se'erity+ As a result a line forms at triage
defeating t$e 'ery #ur#ose of triage ($ic$ is
to ra#idly sort out ($ic$ #atients need ($at
and ($ere+ 4ere are some e6am#les of (ays to
streamline triage3
- Patients ($o look (ell (it$ o,'ious lo()
risk #ro,lems suc$ as s#rains and lacerations
s$ould ,e sent directly to t$e area ($ere t$ey
(ill recei'e care ;e+g+ a fast track area< (it$out
delaying triage ,y o,taining 'ital signs andE
or ot$er information t$at rarely results in a
c$ange at triage+ Patients ($o a##ear critically
ill or in8ured s$ould ,e sent directly to t$e
a##ro#riate area (it$out delay+ T$us triage can
focus more time on t$ose #atients ($o re*uire
more e'aluation and 8udgment to determine t$e
se'erity of t$eir medical conditions+
- /f emergency ,eds are a'aila,le allo( t$e
#atient to ,y#ass triage and go directly to t$e
(aiting ,ed+ A$en t$ere are staff and s#ace
to see ne( #atients t$ere is no 'alue added in
delaying care at triage+
M De*elop a fast trac/ for treating simple fractures.
lacerations. sore throats. etc0 >emo'ing #atients
($o can ,e fast tracked from t$e mainstream of
#atients $el#s to o#en s#ace and allo( resources
to ,e directed to(ard sicker #atients facilitating
t$e care of all #atients+ Fast track areas s$ould ,e
staffed consistently and a##ro#riately+
M $inimi@e silos within the department0 Alt$oug$
t$e 'alue of fast tracks is (ell esta,lis$ed
su,di'iding t$e emergency de#artment can
create o,stacles to flo(+ As muc$ as #ossi,le
ma6imiGe t$e use of s#ace and increase t$e flo(
of #atients ,y using ,eds for all #ur#oses+
M Expand the practice of o(ser*ation medicine0
Particularly in t$e face of ca#acity limitations
dri'en ,y t$e ,oarding of admitted #atients
treatment of #atients ($o could #ossi,ly a'oid
admission 'ia e6tended o,ser'ation diagnosis
and treatment in t$e emergency de#artment
(ill $el# decrease ca#acity needs+ 7ne area
of great #otential for emergency #$ysicians
is t$e esta,lis$ment of ad'anced c$est #ain
#rotocols to im#ro'e t$e diagnostic #rocess for
t$ose #atients (it$ $ig$er risk and to disc$arge
#atients (it$ minimal risk+ :ote t$at t$e #ractice
of o,ser'ation medicine or esta,lis$ment of
#rotocols to rule out AC& in t$e emergency
de#artment does not re*uire t$at a #articular
s#ace ,e se*uestered for suc$ a #ractice
alt$oug$ t$at mig$t ,e ideal+ 7'erall t$e greater
t$e ca#acity issue t$e more t$e emergency
de#artment t$e $os#ital and t$e #atients are
ser'ed ,y esta,lis$ing suc$ #rotocols in t$e
emergency de#artment ,y reducing t$e num,er
of #atients ($o (ill need $os#italiGation+ T$e
o,ser'ation unit s$ould ,e under t$e control
of t$e emergency de#artment to ma6imiGe its
effecti'eness+
M Esta(lish clearly defined turnaround-time
9,+,; goals in t$e emergency de#artment for
admitted and disc$arged #atients and commit
as a de#artment to identifying and correcting all
o,stacles to t$e realiGation of t$ese TAT goals
M Carefully e*aluate staffing needs0 Alt$oug$ many
staffing models e6ist t$e same #rinci#les a##ly+
7ld staffing #atterns are dri'en ,y t$e *uestion3
14o( fe( resources can / #ossi,ly get ,y (it$K5
As t$e emergency de#artment $as e'ol'ed sicker
#atients more com#re$ensi'e (orku#s and
e6#ansion of o,ser'ation medicine $a'e dri'en
a reconsideration of staffing needs+ T$e sim#lest
measure of staffing is ($et$er #atients. needs
can ,e met in a timely fas$ion+ &uc$ measures
as door)to)ECC time door)to)anti,iotics and
door)to)#ain medication can ,e used as a #ro6y
for ade*uate staffing+ T$e tem#oral distri,ution
of staff s$ould matc$ t$e flo( of #atients in t$e
emergency de#artment+ As a roug$ rule in order
to #ro'ide reasona,ly timely care no nurse
s$ould ,e managing more t$an four #atients
simultaneously+ For t$e sicker #atients a nurse
s$ould care for no more t$an t(o #atients+ Also
consider t$e ty#es and distri,ution of staff+
Emergency de#artments tend to ,e to#)$ea'y
(it$ #$ysicians and nurses (it$ inade*uate
su##ort staff+ Any (ork t$at can ,e done ,y
someone ot$er t$an a #$ysician or nurse s$ould
,e s$ifted to su##ort staff+
M 6se scri(es for documentation0 T$e a'erage
emergency #$ysician s#ends no less t$an H0
to "20 minutes in 8 $ours on documentation+
T$e use of scri,es can reduce or eliminate t$is
task for #$ysicians allo(ing t$em to see more
#atients in a timely manner+ Ait$ a##ro#riate
attention to #ro#er documentation a scri,e
#rogram (ill easily #ay for itself+ T$e use of
scri,es for nurses is unstudied alt$oug$ fe(
(ould *uestion t$e ,urden of documentation
,orne ,y t$e nursing staff+
M Decrease ,+, associated with ancillary ser*ices0
Effecti'e ser'ice for #atients means ra#id TAT for
la, and radiology tests+ Consider t$at for an
emergency de#artment t$at sees 200 #atients #er
day decreasing t$e mean emergency de#artment
lengt$ of stay ,y 0+2 minutes #er #atient e*uates
to $a'ing an e6tra ,ed+ &mall im#ro'ements
in $ig$)'olume ser'ices can $a'e a significant
im#act on emergency de#artment ca#acity+
M Close the waiting room0 2o not send #atients to
t$e (aiting room after triage e'en if t$ere is no
,ed for t$e #atient in t$e clinical s#ace+ Bring all
#atients (aiting to ,e seen into t$e emergency
de#artment+ T$ese #atients can ,e (atc$ed and
re#rioritiGed and (ill get into ,eds more *uickly
for e6amination+ 7nly #atients ($o must remain
in ,ed s$ould 1o(n5 t$eir ,eds during t$eir
stay+
M 6se protocols and order sets for uniformity and
to ensure all needed tests and inter'entions occur
at t$e earliest #ossi,le #oint in t$e #atient.s stay+
M Consider use of an electronic medical record
9E$R;0 Carefully consider t$e 'alue added from
an EM> 'ersus t$e additional staff time re*uired
to enter information+ /f #a#er records are used
in t$e emergency de#artment a local scanning
solution can ser'e as t$e EM> so t$at c$arts from
#rior 'isits are a'aila,le+ Alt$oug$ em#$asis
is #laced on t$e ,enefits of $a'ing an EM>
su,stantial time is di'erted from t$e #atient.s
,edside to t$e com#uter+ Consider e6#anded use
of scri,es to ensure t$at #$ysicians and nurses
are functioning effecti'ely+
M Define response times for (oth initiation and
completion of consultations0 Measure t$ese
times as an institutional #olicy and identify
mec$anisms to decrease TAT for #$ysicians on
call+
M Implement triage protocols0 /nitiation of
#rotocols at triage $as ,een s$o(n to facilitate
more timely #ost)triage care+ 4o(e'er use of
#rotocols must ,e done in suc$ a (ay as not to
usur# t$e #rimary #ur#ose of triage3 To identify
t$ose in greatest need of timely treatment+
M +ssign a physician to triage0 /n de#artments
(it$ o'er($elming ca#acity issues #lacing a
#$ysician at triage can streamline t$e disc$arge
of minor #atients and $el# initiate care for sicker
#atients+ /n general t$is re*uires an additional
#$ysician to staff t$e emergency de#artment
and consideration of t$e cost in'ol'ed s$ould
,e factored into t$e decision to institute t$is
#ractice+ As #re'iously noted t$e #rimary triage
function s$ould not ,e usur#ed+
M $onitor indi*idual practitioners in the
emergency department (it$ regard to o'erall
TAT num,ers and ty#es of tests ordered and
#ercentage of #atients admitted+ &uc$ data can
,e used to identify #$ysician #ractices t$at need
closer monitoring andEor im#ro'ement+
M Deferred care of nonurgent patients0 Alt$oug$
#racticed in some areas t$ere are fe( data
to su##ort t$e safety of deferring nonurgent
#atients to ot$er facilities+ P$ysicians re#ort t$at
in order to determine t$at a #atient is nonurgent
t$ey $a'e to do enoug$ of an e'aluation to make
a diagnosis+ 7nce t$e diagnosis is made t$en
($at.s t$e #oint of deferralEreferralK :ote also
t$e researc$ ;cited #re'iously< t$at nonurgent
#atients are :7T creating delays for urgent
#atients needing to ,e seen+ T$is #rocess of
deferral of care s$ould not ,e considered (it$out
first ensuring certain follo(u# for t$e #atient+
M Expand the si@e of the emergency department0
4a'ing a##ro#riate s#ace and staff to matc$ t$e
'olume of emergency #atients is critical to #ro#er
functioning of t$e emergency de#artment+ Ait$
t$e ra#id gro(t$ of emergency #atient 'olume
#$ysical e6#ansion mig$t ,e necessary+ :ote
t$at s#ace increases eit$er ,y increasing t$e
#$ysical s#ace or ,y decreasing a'erage TAT+
Process im#ro'ement is su,stantially c$ea#er
and #ro,a,ly more effecti'e in t$e long run t$an
s#ace e6#ansion+ /f t$e need for s#ace is dri'en
,y ,oarding of admitted #atients increasing t$e
s#ace is likely to sim#ly increase t$e amount of
,oarding and t$us ,e self)defeating+
M +m(ulance di*ersion0 Alt$oug$ am,ulance
di'ersion does not (ork to ease cro(ding and
mig$t result in (orsening of care t$e act of
1going on di'ersion5 is an effecti'e (ay to notify
t$e $os#ital staff mem,ers and t$e community
of t$e crisis conditions+
M %ro*ide additional staff during times of increased
*olume0 T$is may ,e accom#lis$ed ,y using
on)call #$ysicians and nurses or ,y sc$eduling
s$orter s$ifts (it$ t$e e6#ectation t$at staff can
,e asked to come in " to 2 $ours early or stay "
to 2 $ours late as ca#acity demands+ T$e trigger
in suc$ a system s$ould clearly ,e defined ,y
o,8ecti'e criteria rat$er t$an left to inter#retation+
M Ha*e a clear understanding of the financial
power of the emergency department and
its im#act on t$e o'erall fiscal $ealt$ of t$e
institution+ All stake$olders s$ould $a'e a clear
understanding of t$e ,enefits of a (ell)run
emergency de#artment and t$e institutional
damage from a #oorly functioning emergency
de#artment+
Hospital +ctions and %rocesses ,hat 1ill
Impro*e +ccess and low
M Create institutional awareness of the dangers
associated with emergency department
crowding due to (oarding of emergency
patients0 &olutions can ,e found ($en t$ere is a
$os#ital)(ide cultural a(areness t$at cro(ding
is a #ro,lem to ,e s$ared and sol'ed t$roug$ t$e
efforts of t$e entire institution+
M $atch resources to needs0 &taffing s$ould
matc$ t$e needs of #atients+ 7ften t$e e'enings
re#resent t$e time of greatest acti'ity for ,ot$
disc$arging and admitting $os#ital #atients
($ic$ mig$t not ,e matc$ed ,y nursing staff
$ousekee#ing or ot$er needed ser'ices+ Also
(eekends tend to ,e understaffed ($en matc$ed
against #atient needs+
M $o*e toward a !?A# operational culture0
Aeekends are dangerous at $os#itals so again
matc$ resources to #atient needs+ E6amine
#atient disc$arges on (eekends ($ic$ tend to
,e lo(er due to co'ering #$ysicians ($o do not
kno( t$e #atient and t$e lack of ot$er resources
on (eekends ;e+g+ stress testing<+ /m#lement
#rocesses to im#ro'e care and facilitate
disc$arges on (eekends+ E6#and ser'ices and
staff ($ere needed+
M Coordinate the scheduling of electi*e patients
and surgical cases0 &tudies demonstrate
t$at t$e une'en influ6 of electi'e surgical
#atients ;#rimarily earlier in t$e (eek< is a
#rime contri,utor to e6ceeding ca#acity in t$e
emergency de#artment+
M +ddress delays in mo*ing emergency patients
admitted to the hospital caused (y waiting
for nursing reports0 /t is #aramount for
communication to occur ($en nursing s$ifts
c$ange and different staff take o'er #atient care+
4o(e'er 1lock)outs5 in terms of ($en a #atient
re#ort can ,e #ro'ided or a #atient admitted to
t$e in#atient unit must ,e eliminated+
M Examine the discharge process and measure all
reasons for delays in discharge of the patient0 2o
not assume t$e cause is kno(n (it$out actually
measuring it+ T$e disc$arge #rocess $as ,ecome
dramatically more com#le6+ T$e roles and timely
functions of #$ysicians nurses and staff from
am,ulances nursing $omes social ser'ice care
management #$armacy radiology la, ot$er
ancillary ser'ices and $ousekee#ing all affect
t$e disc$arge #rocess and s$ould ,e e6amined+
/dentify t$e #arts of t$e disc$arge #rocess
t$at can ,e initiated early on in antici#ation of
disc$arge+ T$e institution must ,e committed to
taking actions on t$e findings and im#ro'ing t$e
timeliness of t$e disc$arge #rocess+ &#ecifically
t$e institution must successfully ma6imiGe timely
disc$arge to im#ro'e ,ed a'aila,ility for t$ose in
need+ 7ne #ractice re#orted as an /nstitute for
4ealt$care /m#ro'ement initiati'e is t$e use of
a disc$arge ($ite,oard+ A small ($ite,oard at
t$e $ead of eac$ #atient ,ed outlines ($at $as
to take #lace ,efore t$e #atient is disc$arged
;e+g+ #$ysical t$era#y consultation dietary
consultation etc+< T$is #ractice informs t$e
family t$e #atients and t$e staff of ($at needs
to $a##en and t$ey ,ecome t$e dri'ers for eac$
#rocess+
M Ha*e all inpatient ser*ices managed (y
hospitalists. and ha*e all IC6s managed (y
intensi*ists0 T$is results in ,ot$ care and s$orter
lengt$s of stay+
M 6se discharge lounges for patients awaiting
discharge0 Consider mo'ing t$e entire in#atient
disc$arge #rocess to a disc$arge area so t$at
,eds can ,e made a'aila,le for #atients ($o
need admission+
M Relocate admitted patients (oarding in the
emergency department ,ecause of lack of
a'aila,le ,eds on t$e in#atient units to $all(ays
conference rooms or solaria ;e+g+ full ca#acity
#rotocol (( ( + $ o s # i t a l o ' e r c r o (d ing + c o m<
(it$in t$ose in#atient units+ Ait$ eac$ unit
taking a small num,er of #atients t$e emergency
de#artment can continue to function to care
for emergencies (it$out unduly stressing t$e
in#atient units+
M Hire a 7(ed c@ar08 T$is #erson s$ould command
all $os#ital ,ed use and ,e res#onsi,le for
t$e a##ro#riate and timely matc$ing of ,ed
resources to #atient needs+ /deally t$e ,ed cGar is
inde#endent of $os#ital de#artments and re#orts
to senior administration+
M Consider an express admission unit0 For
emergency #atients admitted to t$e $os#ital
consider $a'ing a #lace a(ay from #atient care
areas in t$e emergency de#artment to do t$e
#a#er(ork for #rocessing admissions ($ic$ can
take time+ T$is can ,e cou#led (it$ an e6#ress
admit team from t$e emergency de#artment
dedicated to getting #atients u#stairs+
M Consider the use of a generic admission order
set initiated (y the emergency physician0 T$is
order set (ould ,e limited to ,asic orders
suc$ as acti'ity diet allergies 2:> Pdo not
resuscitateQ status and #er$a#s a single order
for #ain medication+ /t is not effecti'e for t$e
emergency #$ysician to ,e res#onsi,le for
(riting com#re$ensi'e treatment orders for
admitted #atients+
M Esta(lish hospital-wide protocols for addressing
capacity issues in the emergency department
and implement an alert system when the
hospital is o*er capacity0 /dentify circumstances
for alerts and actions to ,e taken+ Measure t$e
success and use t$e measurements to modify
and im#ro'e t$e alert system+
M Cancel electi*e admissions when hospital
capacity is at maximum0
R E E R E N C ES
"+ FranasGek JB+ Moonlig$ting+ ' Emerg Med(
"H89?";2<3"I")"I9+
2+ Duick&tats3 Percentage of emergency de#artment 'isits
(it$ (aiting time for a #$ysician of R " $our ,y raceE
et$nicity and triage le'el S %nited &tates 2009)200!+
MM)R( 200I?55;"I<?!I9+
9+ Pines JM 4ollander JE Bocalio A> et al+ T$e association
,et(een emergency de#artment cro(ding and $os#ital
#erformance on anti,iotic timing for #neumonia and
#ercutaneous inter'ention for myocardial infarction+
A"ad Emerg Med( 200I?"9;8<3809)808+
!+ 2unn >+ >educed access ,lock causes s$orter emergency
de#artment (aiting times3 An $istorical control
o,ser'ational study+ Emerg Med (*remant+e)+
2009?"5;9<292S298+
5+ Pines JM 4ollander JE+ Association ,et(een
cardio'ascular com#lications and E2 cro(ding+ American
College of Emergency P$ysicians 2000 &cientific
Assem,ly? 7cto,er 8)"" 2000? &eattle AA+
I+ Jroc$mal P >iley TA+ /ncreased $ealt$ care costs
associated (it$ E2 o'ercro(ding+ Am ' Emerg
Med(
"HH!?"2;9<32I5)2II+
0+ >ic$ardson 2B+ T$e access),lock effect3 relations$i#
,et(een delay to reac$ing an in#atient ,ed and in#atient
lengt$ of stay+ Med ' A#st( 2002?"00;H<3!H2)!H5+
8+ Bie( 2 Bie( 2 Jennedy MP+ Emergency de#artment
lengt$ of stay inde#endently #redicts e6cess in#atient
lengt$ of stay+ Med ' A#st( 2009?"0H;"0<352!)52I+
H+ Aeiss &J Ernst A A :ick TC+ >elations$i# ,et(een
t$e :ational E2 o'ercro(ding scale and t$e num,er of
#atients ($o lea'e (it$out ,eing seen in an academic
E2+ Am ' Emerg Med( 2005?293288)2H!+
"0+ >ic$ardson 2B Bryant M+ Confirmation of Association
,et(een o'ercro(ding and ad'erse e'ents in #atients
($o do not (ait to ,e seen+ A"ad Emerg Med(
200!?"";5<3!I2+
""+ Aeissman J& >ot$sc$ild JM Benda'id E et al+
4os#ital (orkload and ad'erse e'ents+ Med Care(
2000?!5;5<3!!8)!55+
"2+ Co(an >M TrGeciak &+ Clinical re'ie(3 emergency
de#artment o'ercro(ding and t$e #otential im#act on t$e
critically ill+ Crit Care( 2005?H;9<32H")2H5+
"9+ Joint Commission+ &entinel E'ent Alert June "0
2002? $ t t # 3 EE (( ( + 8 o i n t c o mm i s s i o n + o r g E s e n t i n e l e ' e n t s E
statistics+ Accessed ! June 2000+
"!+ Bie &A et al+ Fre*uency of ad'erse e'ents and errors
among #atients ,oarding in t$e emergency de#artment+
A"ad Emerg Med( 2005?"2;5<Tsu##lT"3!H)50+
"5+ &#ri'ulis PC 2a &il'a JA Jaco,s /C et al+ T$e association
,et(een $os#ital o'ercro(ding and mortality among
#atients admitted 'ia Aestern Australian emergency
de#artments+ Med ' A#st( 200I?"8!;5<3208)2"2+
"I+ >ic$ardson 2B+ /ncrease in #atient mortality at "0 days
associated (it$ emergency de#artment o'ercro(ding+
Med ' A#st( 200I?"8!;5<32"9)2"I+
"0+ C$alfin 2B TrGeciak & BikoureGos A et al+ /m#act of
delayed transfer of critically ill #atients from t$e
emergency de#artment to t$e intensi'e care unit+
Crit Care Med( 2000?95;I<3"!00)"!89+
"8+ Burt CA McCaig BF+ &taffing Ca#acity and Am,ulance
2i'ersion in Emergency 2e#artments3 %nited &tates
2009 S 0!+ Ad'ance data from 'ital and $ealt$
statistics? no+ 90I+ 4yatts'ille M23 :ational Center for
4ealt$ &tatistics+ 200I+
"H+ 7ls$aker J& >at$le' :J+ Emergency de#artment
o'ercro(ding and am,ulance di'ersion3 t$e im#act and
#otential solutions of e6tended ,oarding of admitted
#atients in t$e emergency de#artment+ ' Emerg Med+
200I?90;9<395")95I+
20+ Burt CA McCaig BF @al'erde >4+ Analysis of am,ulance
trans#orts and di'ersions among %& emergency
de#artments+ Ann Emerg Med( 200I?!0;!<39"0)92I+
2"+ Minority staff s#ecial in'estigations di'ision committee
on go'ernment reform+ %& 4ouse of >e#resentati'es+
:ational #re#aredness3 am,ulance di'ersions im#ede
access to emergency rooms+ (( ( + $o u s e + g o ' E r e f o r m E
min 7ct "I 200"+
22+ P$am JC Patel > Millin MC et al+ T$e effects of
am,ulance di'ersion3 a com#re$ensi'e re'ie(+ A"ad
Emerg Med( 200I?"9;""<3"220)"220+
29+ &c$ull MJ Morrison BJ @ermeulen M et al+ Emergency
de#artment o'ercro(ding and am,ulance trans#ort
delays for #atients (it$ c$est #ain+ CMA'(
2009?"I8;9<3200)89+
2!+ :ic$oll J Aest J Coodacre & et al+ T$e relations$i#
,et(een distance to $os#ital and #atient mortality in
emergencies3 an o,ser'ational study+ Emerg Med '(
2000?2!;H<3II5)II8+
25+ &c$ull MJ BaGier J @ermeulen M et al+ Emergency
de#artment contri,utors to am,ulance di'ersion3 a
*uantitati'e analysis+ Ann Emerg Med( 2009?!";!<3!I0)!0I+