Emergency Department Crowding Problem - Research Paper Example

EMERGENCY DEPARTMENT CROWDING: A REVIEW OF THE LITERATURE Abstract Nationwide emergency departments are dangerously overcrowded and backlogged resulting in patients being kept, or boarded, in the ED. (Walsh, Cortez, Himanshu, &Bhaktu, 2007) Studies have shown that ED boarding proves detrimental to patients; decreasing their quality of care, putting them at risk for adverse events, and compromising their safety and overall satisfaction during length of stay. (Kellerman, 2009) ED boarding has also been linked to increased mortality within a thirty day window from discharge. (Plunkett, Byrne, Breslin, Bennett, and Silke, 2011) Physician shortages, low nurse-to-patient ratios, and ambulance diversion caused by a decreased number of beds play key roles in this critical issue. (Crain, 2010) Hospital administration efforts at reducing the incidence of boarding have shown improvement in overall patient outcomes. (Dylan, 2010) Various approaches have been evaluated to find a way to reduce ED time, such as having policies in place limiting the length of stay in the ED, creating more physical space, and providing an innovative approach to telemetry options for each bed. (Green, 2007) LITERATURE REVIEW Conceptual Framework Introduction Overcrowding persists in most emergency departments across the country despite several attempts to rectify the situation. Numerous studies have been conducted to identify and evaluate issues of overcrowding, yet the problem continues. It is a systemic failure. (Dylan, 2010) There have been several causative factors impacting ED overcrowding. One significant factor is that of indigent people incorrectly using the ED with non-urgent care issues. People who have lost health insurance benefits due to the recession have also led to increased ED volume. Increased patient loads tie up available services for those requiring valid urgent care. (Carlson, 2010) Though it is certainly not the only factor in ED overcrowding, the roles the community and government play in providing primary care and prevention focused programs for the uninsured must also be taken into account. (Dylan, 2010) JCAHO and the General Accounting Office have determined that this is a financial cycle issue, which would not benefit from altering administrative hospital policies. (Olshaker, Rathlev, 2006) The recession and high unemployment rates accompanied by the loss of health insurance based reimbursement impact the revenue cycle thereby contributing to downsizing of staff and ED closures. (Olshaker, Rathlev, 2006) As hospital emergency departments continue to close, access is reduced. (Carlson, 2010) An increasing number of patients along with a decreasing number of EDs equal a crisis regarding access of care. In taking a closer look administratively, the ED overcrowding issue is really a transdepartmental issue. ED flow is directly impacted by all other departments, therefore through their support and collaboration, wait times can be drastically reduced. (Brandon, Stephen, & Deepak, (2010) Studies have shown that the average wait time to be seen is approximately one hour. (Dylan, 2010) It requires a concerted effort to apply performance improvement initiatives at every level to become patient focused as well as process oriented in order to innovatively restructure the flow of patients with regards to maximizing quality of care and minimizing wait times. (Brandon, et al, 2010) By applying LEAN principles and changing staff attitudes, the situation can be greatly improved. (Brandon, et al, 2010) The purpose of this paper is to discuss the concept of boarding with particular attention to some of the ways it can be effectively managed. Literature Review The practice of holding admitted patients in the emergency department(ED) until an inpatient bed becomes available is known as boarding. This practice is widespread and highly disruptive to ED functions. (Walsh, Cortez, Himanshu, & Bhakta, 2007) It has been implicated in medical errors, delayed care, and even in the hospital-to-community spread of severe acute respiratory syndrome. (Schull & Slaughter 2006) According to Press Gainey Associates, in 2009, over 400,000 patients waited more than 24 hours in the ED before being admitted or referred to a drug and alcohol treatment facility. (Dylan, 2010) Even though emergency departments work diligently to reduce congestion, many patients become frustrated and abandon the ED without being seen; putting themselves at rick for further harm, and possibly death. (Carlson, 2010) The triage system helps to prevent this by evaluating each patient for acuity and urgency, then treating the most critical patients first. One alternative is to board these admitted patients in the hallways of inpatient wards thereby unblocking the flow of the ED. A study was done using a cross-sectional survey to determine patient satisfaction with this practice. (Walsh, et al, 2007) A survey tool was designed asking patients what their preference would be; to be boarded in a hallway in the ED or a hallway on the inpatient ward. They were given options to choose the rationale for their answers as well as a choice of what they felt reasonable wait times would be for physician evaluation. The survey was comprised of 1,222 participants; 532 ED patients, 477 visitors, and 213 admitted patients who were being boarded. (Walsh, et al, 2007) Survey results supported that 804 preferred being boarded on inpatient units, 406 ED preferred ED boarding, and 15 had no preference. Common factors influencing their decisions for inpatient ward boarding were privacy and noise levels. Those factors which attracted ED boarding were easy access to a physician and the excitement of seeing other patients receive care. (Walsh, et al, 2007) The boarding of ED admissions on inpatient wards has been used effectively by hospital management nationwide to increase the flow of patients through the ED and reduce wait times. (Dylan, 2010) Factors influencing the flow. In 2008 a survey of 250 EDs found that 11% used regular diversion to other hospitals, while 73% were boarding two or more patients; 59% of those hospitals used hallways for patient boarding, and 47% used non-clinical areas for patient coverage. (Briggs, Patel, Birkhahn, & Datillio, 2010) A common response to the problem involved creating more physical space to accommodate the influx of patients. (Briggs, et al, 2010) This study used a cross-sectional cohort study of patients visiting the ED from 8p.m. on Monday through Friday over a six week period. (Briggs, et al, 2010) The variables of door to doctor and boarding times across three triage levels, A, B, C, were compared for 1,543 participants over a 42 day period. Triage level A, the patients with the highest acuity requiring the most emergent care, and level C, the patients with the least acuity requiring the least emergent care. The survey supported evidence that those patients with level A received inpatient beds before the other two levels of patients. This data supported that it was not the critical level A patients contributing to the backflow of ED patients and increased wait times; they received inpatient beds before the other two levels. However, it was noticed that level C patients also received inpatient beds before level B patients due to the fact that telemetry beds were in much shorter supply than regular non-monitored beds. (Briggs, et al, 2010) One strategy used in other studies to address the issue of lack of telemetry beds was to make all beds capable of telemetry with an on/off option; thereby reducing wait times for a telemetry bed. (Green, 2007) Three other factors impacting boarding and wait times were staffing shortages, lack of materials to measure and monitor patient flow, and an overall decreased availability of beds resulting from hospital closures. (Briggs, et al, 2010) One factor greatly affecting the flow through the triage system is the increased influx of indigent patients who use the ED for non-urgent care. Many of these patients have no health care benefits to see primary care providers so they present at the ED instead. (Olshaker, Rathlev, 2006) This practice of incorrectly using the ED is responsible for increased workloads on ED staff, as well as decreased bed availability during the evaluative phase. (Olshaker, Rathlev, 2006) Patients leaving without being seen. ED boarding of patients is also seen as a factor in patient abandonment of the ED. (Crain, 2010) Research supports that boarding ED patients increases potential risks to the patient and can prove harmful. (Crain, 2010) Emergency departments use a triage system whereby patients are initially evaluated as to their level of illness and symptoms. This ensures that the most critically ill patients are seen first; however, not all ill patients present with critical symptoms initially. (Dylan, 2010) The potential for a real crisis may occur if a patient abandons the ED without being seen. Strategies aimed at increasing patient flow would help prevent this potential crisis. (Crain, 2010) Additional research indicated that hospital policy could significantly impact ED wait times. (Kellerman, 2009) A policy one hospital enforced was that of making inpatient beds available within 30 minutes for ED admissions; this effort showed a dramatic increase in quality for overall length of stay. (Kellerman, 2009) A separate study indicated that when ED waiting times and boarding of patients was a quality indicator monitored by the hospital administration, the effort at improving flow through the ED was significantly higher. (Crain, 2010) It was concluded that greater transparency concerning ED boarding and wait times along with interdepartmental collaboration to increase efforts at reducing the backlog in the ED would result in higher patient satisfaction, less patient risk, and improved outcomes for patients. (Crain, 2010) Nurse to patient ratios during wait time. A research study to evaluate the impact of nurse-to-patient ratios (NPRs) on the flow of EDs was done at two urban academic teaching level one trauma hospital emergency departments in two different states; state mandated nurse per patient ratios were different. The premise was that State mandated NPRs impacted the wait times and flow through the ED, as well as the length of boarding. (Chan, Killeen, Vilke, Marshall, & Castillo, 2010) Nurses play an integral role in patient care, therefore increased workloads compromise patient safety along with quality of care, which in turn compromises the necessary flow through the ED. (Kellerman, 2009) The method of tracking patients through the ER was through an electronic tracking device embedded in the electronic medical record (EMR). This device linked nurse-patient assignments, clinical documentation, and patient acuity levels. Due to the fact that both patient acuity and numbers could change frequently over time in the ED, the data was collected in consecutive ten minute intervals over the space of one year. The purpose of this study was to show the correlation between NPRs as impacting patient safety and decreased waiting times. Results indicated that when NPRs were lower, the patients had to wait approximately 42 minutes longer for room availability. This increased patient waiting time also increased risk potential as ED patients can require emergent assistance at a moment’s notice. (Carlson, 2010) This study also indicated that when nurses had more than four patients, the ED boarding time was increased; there was less time to call report and transfer the patient to their inpatient bed. (Chan, et al, 2010) Further research is indicated to effectively measure the impact of NPRs on patient outcomes. Patient safety. The impact of ED wait times on hospital patient mortality has often been the subject of debate in the medical community. (Plunckett, Byrne, Breslin, Bennett, and Silke, 2011) The American Journal of Emergency Medicine published a study that linked ED patients’ wait time with increased mortality. Over the last two years there has been increasing concern and research regarding the phenomenon of ED boarding and its effect on patient processing, ambulance diversion, patient satisfaction, and patient safety. (Plunkett, et all, 2011) While patient satisfaction has been studied widely, comprehensive in-depth studies on patient safety are few and far between. (Kellerman, 2009) In this study, given the continuous backlog of patients in the ED, hospital administration set a target goal of no more than four hours for a patient to remain in the ED; regardless if admitted or discharged. (Plunkett, et al, 2011) This target goal was randomly selected as a variable for the purpose of this study, not one supported by research. The results of this study indicated a direct relationship of increased mortality over a thirty day time frame when the patient had remained in the ED for more than four hours. (Plunkett, et al, 2011) While there may have been other factors involved, such as underlying disease conditions at various stages of progression, however, the trend continued across the population studied. Another variable in this study was acuity level; the particular tool used was for indicating urgency as opposed to illness. (Kellerman, 2009) Framework The framework for this study is based on the evidence that long wait times in EDs generally indicate customer flow or server capacity issues such as ED boarding when there are no available admission beds. (Dylan, 2010) An effective ED process flow is critical for all hospitals. Short wait times and a positive experience are important drivers of patient satisfaction; inefficient processing that cannot regulate peak demands could result in lost revenues, low community image, and compromise patient safety. (Carlson, 2010) The emergency department is an excellent place to initiate change throughout the hospital system; it has clearly defined boundaries yet collaborates interdepartmentally as the point of entry for most patients. (Carlson, 2010) Study Description The purpose of this literature review is to objectively examine current research with regard to effective ED management strategies aimed at alleviating ED congestion through decreasing ED boarding and wait times. Conceptual Framework Map Description of Conceptual Framework Map Emergency physicians and staff are committed to providing high quality emergency care in a timely manner. (Garcia, Rivera, Thomas, and Lizotte, 2008) Every minute in the United States an ambulance is diverted, delaying care for critically ill patients. (Garcia, et al, 2008) The gridlock in EDs, also known as “boarding” is caused by the patients being admitted for more than minor illnesses. (Dylan, 2010) Three factors which can result in boarding are: on-call physician shortages, local disasters, and the Triage process. When ambulances are being diverted, frustrated patients are abandoning the ED without being seen, and, timely emergent care to critically ill patients is delayed, then liability for patient safety is increased and frustrations rise, impacting patient satisfaction. (Kellerman, 2009) In 2008, 200 emergency physicians were surveyed; each one of them recalling personal situations where a patient had abandoned the ED in frustration and died as a result of not receiving care. (Kellerman, 2009) The problems have been identified, yet ED congestion continues to have a significant impact on health care today. Proposition Statements Proposition 1: By imposing timeframes for discharge by a physician from the ED, the gridlock will be alleviated allowing for increased flow. Proposition 2: By increasing flow through the ED, patients will receive timely evaluation, thereby reducing the need for ambulance diversion, patient frustration, and patient liabilities for safety; increasing overall satisfaction and potential for a positive outcome. Variable Table Concept Construct Variable Responsibility for Problem resolution Hospital Facility Patient length of stay in ED Identification of problem, risks, resources and strategies for resolution Interdepartmental Collaboration Interdepartmental goals for achievement of targeted indicators Application of strategies for improvement Hospital Facility Patient Outcomes, Safety, Satisfaction Conceptual and Operational Definitions Length of Stay: Operationally for the purpose of this study, arrival time will be defined as the time when the patient is entered into the financial database of the ED. Discharge time will be the time when the patient is discharged by physician order to home or to the inpatient unit. Patient Satisfaction: Patient satisfaction as measured by a nationally recognized survey tool such as Press Ganey or NRC Picker. Patient satisfaction evaluator will be a survey related to wait time. Left Without Being Seen(LWBS): Defined as the percentage of all patients that abandon the ED without seeing a physician, nurse practitioner, or physician’s assistant. It includes triaged and non-traiged patients. Upfront Process Involvements: Those changes to the process of ED flow that affect patient arrival to the physician examination. Back End Process Improvements: Those changes to the process of ED flow that affect time lapse between physician evaluation and discharge from ED to home or inpatient unit. Boarding: The practice of holding patients in the ED as a result of unavailability of inpatient beds. Patient Safety: The discipline of health care professionals whereby safety science methods are applied towards the goal of achieving a trustworthy system of health care delivery. Patient safety is also defined as an attribute of health care systems that minimizes the incidence and impact of adverse events and maximizes recovery from such events. Conclusion Emergency department crowding is a national problem which has become chronic in many hospitals. Overcrowding is defined as a situation in which demand for services exceeds the ability for a facility to provide quality care within a reasonable time frame. (Trzciak, 2007) As physicians and nurses feel rushed and overextended, the rick of errors which could lead to adverse patient outcomes is increased. (Trzciak, 2007) With increased wait times, patients are boarded in hallways in the ED exposing them to greater risks, frustrated patients abandon the ED without being seen, which could prove fatal, and overworked, understaffed ED personnel become increasing liable for the unavoidable effects of lack of access to the emergency departments. The first critical step in alleviating the problem is acknowledging that patients requiring hospital admission do not receive adequate and effective care on stretchers in the ED. All patients deserve access to high quality ED care. This requires a comprehensive approach at all levels from the government to the local hospital administrations to acknowledge there is a problem with overcrowding and access to ED services. The second step is to recognize that the cause of ED overcrowding generally lies outside the ED. (Trzciak, 2007) ED overcrowding is a systemic failure, however despite efforts to alleviate it at the facility level, more innovations at the community and federal level for primary and preventative health care are required to minimize the need for emergent care, thereby improving ED access and flow efficiency. (Dylan, 2010) References Brandon, C., Stephen, C., Deepak, K. (2010). A hospital-wide strategy for fixing emergency- department overcrowding. Healthcare Payor and Provider Practice. January 2010. Web. 4 April, 2011. http://www.mckinseyquarterly.com/Health_Care/A_hospital-wide_strategy_for_fixing_ED_overcrowding_2505 Briggs, A.A., Patel, S., Datillo, P.A., Birkhahn, B.A. (2010). Factors influencing flow: emergency department crowding. Journal of Emergency Medicine.11(1), 10-15. Brooklyn, N.Y Carlson, J. (2010) Losing some wait. Retrieved from http://www.modernhealthcare.com/article/20101101/magazine/101029947 Chan, T. C., Killeen, J.P., Vilke, G.M., Marshall, J.B., & Castillo, E.M. (2010). Effect of mandated nurse-patient ratios on patient wait time and care time in the emergency department. Society for Academic Emergency Medicine 110(6,) 545-552 doi:10.111/j. 1553-2712.2010.00727.x. Crain, M.E. (2010). “Boarding” of patients in the ER associated with higher rates of patients leaving without treatment. The Maryland Nurse News Journal 77(19), 46-51 Dylan, L. (2010). Health Plan: Taking steps to decrease emergency room wait time. American College of Emergency Physicians 118(11), 43-61 doi:10.1016/j. acep. 2010.16.8908 Emergency Department Waiting Times (2010). Why do patients wait in emergency departments. Retrieved from http://www.acep.org/content.aspxid.25908 Garcia, M.L., Rivera, N.D., Thomas,W. A., Lizotte, J.I.(2008). Reducing time in ER via a fast exit. doi:10.1109/jemermed.wsc.2008.478898 Green, J. (2007). Emergency department flow and the boarded patient: how to get admitted patient upstairs. Journal of Emergency Medicine 49(1), 68-70 Kellerman, A.D. (2009). Emergency department overcrowding patient preference for hallway location. Academy of Emergency Medicine 35(5), 83-85 Olshaker, JS, Rathlev, NK, (2006). Emergency Department overcrowding and ambulance diversion: the impact and potential solutions of extended boarding of admitted patients in the Emergency Department. Journal of Emergency Medicine 30(3),351-6 Web. 4April 2011, http://www.ncbi.nlm.nih.gov/pubmed/16677993 Plunkett, P.K., Byrne, D.G., Breslin,T., Bennett, K. & Silke, B. (2011). Increasing wait times predict increasing mortality for emergency medical admissions. European Journal of Emergency Medicine 112(14), 2-5. doi: 10.1097/MEJ.0b013e328344917e Schull, M.J., Slaughter, V.M. (2006). Emergency department crowding and delays in patients with acute myocardial infarctions. Journal of Emergency Medicine 104(85), 577-585 Trzciak, S.R., (2007). Emergency department overcrowding in the United States: an emergency threat to patient safety and public health. Journal of Emergency Medicine 5(20), 402-405 Walsh, M. B., Cortez, V., Himanshu, J.E. & Bhakta, S.Y. (2008). Patients prefer ward to emergency department boarding while awaiting inpatient beds. Journal of Emergency Medicine 34(2), 221-226 doi: 10.1016/j.jemermed. 2008.05.012 Read More