ED Overcrowding

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ED Overcrowding Throughput

• By Deb Delaney
• Massachusetts Emergency Nurses Association
• June 21,2006

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Objectives

• Acknowledge current situation of overcrowding
• Identify factors causing overcrowding

• Learn strategies to improve ED throughput time
• Understand common terminology
• Utilize consistent data for comparison
  benchmarking

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Ultimate Objective

• Realize ED overcrowding is a symptom of a greater
  problem
• and the ED is NOT the problem

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Its so simple!!
Dave Eitel MD MBA ( ESI 5 Level triage)
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Factors affecting ED Length of Stay (ED LOS)

• Input
• Throughput
• Output

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Input Arrivals

• Whos coming ?
• Emergencies other
• Why do people present to ED
• Insurance Status
• Sicker people discharged from hospital
• Unavailable Primary Care
• Perception of quality of care

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Input (cont)

• Growing number of uninsured
• 44 million and growing
• Have no alternative
• Under insured
• Cost of insurance premiums increasing
• Wait longer due to
• Saturated primary care offices
• Only game in town for nights weekends

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Throughput

• Actual ED operations
• Design of ED processes
• Registration, triage, treatment areas
• Staffing (type, skill, and number)
• Availability
• Specialists
• Diagnostic information
• Increased use of images
• Access to critical info (ie. med records, old
  EKGs,etc.)

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Throughput ED start to finish
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Output

• Hospital Admission
• Available beds?Staff?
• Transport/housekeeping
• Community Discharge
• Detox? Mental health beds?
• Rehab? SNF
• Morgue
• ME case? Prisoner? Religious issues? Etc.
• Back to OTHER
• Nursing home transfer
• Prison

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Urgent Matters Input / Throughput / Output Model
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ED overcrowding

• 91 of EDs in USA report at or over capacity
• American College of Emergency Physicians Study
• Contributing to this were the following
• High volume/acuity
• Radiology delays
• Laboratory delays
• Consultant delays
• Insufficient space
• Delays threaten patient safety
• Delays in diagnosis treatment
• decreased quality of care poorer pt outcomes
  r/t delays

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Factors Contributing to Waiting/Overcrowding
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Over capacity by region
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Where we are.

• BUT
• The good news is..
• its on everyones radar

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ED uniqueities

• Open 24 / 7 / 365
• Highly trained Physicians and Nurses
• Open to all-no referrals needed
• EMTALA-COBRA
• Americas Healthcare Safety Net
• Medicaid / uninsured / vulnerable populations
• Mix of care provided
• Major and minor treatment welcome here

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GAO Report (General Accounting Office) March 2003

• commissioned by the US Senate to evaluate extent
  of overcrowding
• Data collected from July /01 thru Feb /03
• Survey 2000 hospitals (74 response rate!)
• Indicators for comparison
• Diversion
• Boarding
• Left before medical evaluation (LWBS)

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Findings

• Diversions
• 2/3 of the nations hospitals were forced to
  divert ambulances to other facilities
• Boarding
• Major cause of ED overcrowding r/t holding of
  admitted patients
• LWBS
• Average between 3-5
• Worse in teaching hospital
• Increased risk and decreased satisfaction

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ED volume (2000)
NHAMCS 2000-National Center for Health Statistics
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CDC NHAMCS (2003)(National Hospital Ambulatory
Medical Care Survey)

• Updated totals
• 113.9 million ED visits
• (another 6 increase since 2000 report)
• of Emergency Departments 4079
• Another 98 EDs have closed

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2003 NHAMCS stats (cont)

• 15.8 million patients were admitted to the
  hospital via the ED (14)
• 2 million transfers (1.9)
• 16 million arrived by ambulance (14.2)
• Majority ambulance over 65 years old
• Only 9 of visits nationwide were clinic level
  (or triage level 5)

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Massachusetts
of Hospital Beds per 1000 residents
of admissions per hospital bed
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Wait time to MD eval

• 46.5 min ave.
• wait to see a physician
• 3.2 hours
• average
• length of stay

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Utilization

• 38.9 visits per 100 persons
• Medicaid enrollees 64.2 visits per 100
• Private insurance 21.5 visits per 100
• Uninsured 34.2 per 100

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of ED visits per hospital beds
Massachusetts
USA
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ED - Current flow

• ED Treatment Rooms24 available
• Flow One patient out another one in
• National Benchmark 1 treatment bed per 2,000
  annual visits

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ED Overcrowding

• As the available ED beds fill up, the waiting
  room begins to back up

Increased wait time decreased satisfaction
increased LWBS decreased revenue
Hall 1 2 3
Managers office
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JCAHO report

• over ½ of all reported sentinel events
• in the
• delays in treatment category
• occur in hospital EDs

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JCAHO LD 3.15 (Leadership Standard)effective
Jan 2, 2005

• JCAHO recognizes its not an ED problem!!!
• Even changed the name
• From ED Overcrowding to HOSPITAL Overcrowding
• Hospital leadership MUST develop and implement
  plans to identify and mitigate impediments to
  efficient patient flow throughout the hospital

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More leadership standards

• LD.3.20 Patients with comparable needs receive
  the same standard of care, treatment and service
  despite their physical location
• LD.3.30 Commitment to community by providing
  essential services in a timely manner

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So? What can we DO ??

• To Decompress the ED you must either
• close the front door
• Ambulance diversion
• Wait till they give up (LWBS)
• or
• Open the back door
• Allow the crowd thats present to leave

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Left Without Being Seen (LWBS)

• Patients registered triaged
• but leave before being seen by a physician
• Majority (60 ) went back to (or another) ED
• 46 of LWBS needed medical attention
• 11 were admitted to hospital within a week
• Major source of patient dissatisfaction
• Nobody cared about me
• I had an emergency but they made me wait
• Overall a Negative Experience

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Cost of LWBS ?

• Ave 225 per ED patient
• LWBS average 3-5
• LWBS loss? At least 250,000/year
• Plus cost of follow up
• Research Complaints
• Return later / need more care
• Dont return is worse!!

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US Health Care Expenditures 2004
Total 1.8 Trillion
Physician Services 23
Other 19
Nursing home 7
Prescription drugs 10
Hospital care 33
Other professional 8
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Cot of keeping up!
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CT Utilization
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Space in the hospital
Emergency department
The rest of the hospital
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• In spite of a gazillion square feet
• in the rest of the hospital
• and a zillion more staff
• who incidentally
• are actually TRAINED
• in inpatient care
• lets stuff all the overflow
• into the tiniest
• Busiest
• most critical
• and chaotic space
• in the hospital.

This is Health Care Planning as a Fraternity
Stunt.
--Peter Viccellio MD
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Areas of Variability (Competing for resources)

• Emergency Department demand
• Elective procedures (seeking same resources)
• Discharges (opening up beds)

Which factors are more easily controlled?
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SUNY -Stonybrook
Old model
New model
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Share the burden
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What can we do now?

• Plan ahead
• Data collection is mandatory
• Feds and others need to keep hearing from us
• JCAHO requires full administrative support

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What we should NOT do!

• More Ambulance Diversion
• Transfer elsewhere
• Triage out
• Ignore the safety net
• Minimize unnecessary visits
• Stop trying new ideas
• Give up!

STOP
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BUTThey dont belong here!!!

• Anti- Dumping Laws- COBRA/EMTALA
• Patients arriving to EDs are sicker and in need
  of more services
• Only 9.1 of visits nationwide were clinic
  level (or triage level 5)
• (Over 90 needed legitimate ED care)

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Societal safety net

• It IS what we do!! SHOUT IT OUT!!
• 24/7 services to all despite ability to pay
• Who else can say that!!!
• patient mix includes substantial share of
• Uninsured gt42 million uninsured US residents
  (Asplin AEM 11/01 vol 8 No 11)
• Medicaid (36 million) other vulnerable
  population
• Affirmed and mandated by federal legislation
• Increased ED burden as other social programs have
  eroded

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Why not Just build more!!!

• Mass Laws-Department of Public Health 105 CMR
  130.834 regarding ED requirements
• Hospital staffing based on of staffed beds
• Decreased utilization and lower reimbursements
  reduce inpatient beds
• More beds for specialties () reduce flexibility

• Reduced SNF and home health care for hospital
  discharges
• Insurance reviewers scrutiny
• Balanced Budget act (BBA) reimbursement changes
  to Medicare

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Region 3
Region 2
Region 1
Region 4
Region 5
Massachusetts Census 2000 Population
6,349,097 State Acreage Total 5,176,255.6
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The Commonwealth of MassachusettsExecutive
Office of Health and Human ServicesDepartment of
Public Health250 Washington Street, Boston, MA
02108-4619

• Over the past five years The Department of Public
  Health (Department) has been working
  collaboratively with the Massachusetts Hospital
  Association and other stakeholders on initiatives
  to address problems associated with Emergency
  Department (ED) overcrowding, patient boarding,
  and ambulance diversion. This letter is one of an
  ongoing series that communicates to hospitals the
  Departments expectations regarding policies that
  address these ED issues.

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• The goal of all of these efforts is maintain the
  hospitals capacity to accept and manage new
  patients presenting for emergency care, which
  requires that hospitals move admitted patients
  out of the ED as quickly and safely as possible.
  This year, to facilitate the expeditious movement
  of patients out of the ED, the Department has
  reviewed the widely discussed approach of
  temporarily
• placing stabilized patients admitted through
  the ED, onto inpatient floors, where they can be
  monitored by nursing staff while waiting for a
  bed to become available.
• Recognizing that receiving care on an inpatient
  unit is usually preferable to receiving care
  while boarding in the ED, the Department will
  endorse this practice, and expects that hospitals
  will implement this option as appropriate, as one
  of many strategies to prevent boarding in the ED.
  In order to assure the safety of patients,
  hospitals that adopt this practice must have
  developed protocols approved by their governing
  bodies that address issues identified in Addendum
  A (see attached).

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So how do we fix it?

• Understand the problem
• Need clinical quality measures
• PI / CQI / QA / TQM etc.
• AND also ED Benchmark data
• Dashboard monitors
• Data for comparison (vs. ourselves others)
• Uniform definitions r/t ED operations

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State the problem clearly
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ED Dashboard Monitors
Volume/Age/Payer mix Patient satisfaction of
Inpatient admissions originating from ED of ED
admissions Acuity LWBS Diversion hours Boarder
hours Times from disposition to admit by unit
Time from arrival to triage Triage time Triage to
bed Bed to provider Consultant response
time Overall ED length of stay Discharged ED
LOS Admit LOS Staff turnover/vacancy
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Collect and measure

• Choose your dashboard criteria
• Pick a few that are easily collectable
• Tracking boards?
• Timestamps?
• Daily logs?
• Establish GOALS
• Benchmarks available

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Diversion logsample
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Urgent Matters research

• 10 safety net hospitals received grant
• ED bed assigned to ED doc
• Total throughput time
• Inpatient bed assignment till pt leaves ED
• Hours on diversion
• Disposition by MD to decision made

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Sample Performance Indicators report
form Urgent Matters
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Benchmarking goals
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Parallel Processing
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Proven Methods That have worked for others
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Moving admission upstairs
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Easy Cruisin ahead ?
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Baby boomer effect???

• Baby boomer generation80 million strong
• Born 1946-1964 the first turned 60 this year!
• majority of ambulance arrivals are over 65 years
  of age (approx 40 are gt 65)
• increase in visits by elderly patients past three
  years (59)
• fastest growing segment of society now reaching
  retirement age
• Increased emphasis on cardiac care/home
  care/innovative treatment modalities/long term
  care/etc

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Dont add roadblocks..
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But when this happens..
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Have a plan
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Final thought

• Our greatest glory
• is not in never failing
• but in rising up every time we fail
• -Ralph Waldo Emerson
• If we wanted easywe wouldnt be in the ED.

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If a tree falls in the forestand nobody hears
it.

• Is it still the ERs fault?