Emergency Department Overcrowding: A Manageable Crisis
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April 27, 2023
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Emergency Departments (“ED”s) serve as the conduit for 65 percent of hospital admissions.1 EDs serve also as temporary boarding sites for patients traversing the hospital system. Boarding is a function of overcrowding as defined by the American College of Emergency Physicians: “A situation that occurs when the identified need for emergency services exceeds available resources for patient care in ED, hospital, or both.”2 ED boarding is defined as “the patients stay in the ED after the admission was accepted in the hospital, because of absence of inpatient beds.”3
Managing an ED is complex, with variable inputs, throughput and outputs.4 Given the interdependency of hospital bed availability, ED management cannot remain limited to the confines of the ED itself. An integrated vision with relevant metrics is required. Increased ED wait times are associated with several negative events.5,6,7,8,9,10
An Effective/Efficient ED Requires An Interdepartmental Shared Vision
FTI Consulting analysis. Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions
Journal of Personalized Medicine. February 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8877301/
EDs with longer boarding times “have a disproportionate number of patient visits, higher proportions of urgent visits, longer wait times to be seen, higher average hospital occupancies, greater hospital admission rates and longer lengths of stays in the hospital.”11 Academic medical centers meet many, if not all, of these criteria.12 According to The Joint Commission, boarding should not exceed four hours.13
In this article, the authors discuss operational challenges and generate recommendations for implementation.
Operational challenges
Overcrowded EDs face operational challenges when managing boarded patients. These patients are in the ED for extended periods, leading to three primary issues: space/flow, staffing and (lost) revenues.
Space/flow problems occur when boarded patients take up valuable space in the ED, impacting patient flow and increasing wait times. This can create a domino effect, causing patients to back up in the waiting area and thereby increase frustration for patients and staff. Often the ED must create nontraditional treatment spaces, such as hallway beds, to accommodate the boarded and newly arriving patients. Such improvised changes negatively affect the patient experience (satisfaction) scores and make the ED appear cluttered to visitors.14
Creating new treatment areas leads to communication problems:
- How do you get patient-location messages to radiology, clinical laboratory, specialists and the admitting team?
- Does the pharmacy have the space to manage inpatient and ED medications? Is there a location for the routine timed medications that are now part of the inpatient medication regimen?
- Are there queues that could be added to the tracking board regarding the whereabouts of patients in new surge locations?
- How do nurses communicate to the interdisciplinary team when you encounter status changes (hospital admission, specialist consultation)?
- Are the new orders still considered stat, or have they been changed to a routine order after the patient has been admitted?
Poor communication can lead to delays in diagnosis and treatment and increased length of stay.15 These delays are magnified once nontraditional treatment areas are created for the support-service departments and the increased volume of patients added to the queue. These obstacles need to be considered and communicated with the team to maintain flow and decrease delays in patient care.
It also affects patient satisfaction. Dissatisfaction is correlated with several process of care measures: (a) untimely receipt of care, (b) a poor explanation of problem causes and test results, and (c) not being told about potential wait time, the resumption of normal activities and timing of return to the ED (or clinic).16 In summary, “interpersonal skills/staff attitudes; provision of information/explanation; [and] perceived waiting times.”17 Experience also dictates the importance of contact frequency.
Staffing represents another obstacle to overcrowding and the boarding of admitted patients. Staffing challenges become a problem when the waiting areas are at full capacity while the ED team has yet to see all the patients. Depending on the size of the waiting area, rounding could require up to three staff members for reassessment. This has been a focus area for the Joint Commission and the Centers for Medicare & Medicaid Services (“CMS”).18,19
- Where does this staff come from — per diem, float pool, inpatient nurses, on call nurses, etc.? And what type of staff needs to be added?
- Do you have a blended model of nurses, paramedics, and emergency medical technicians (“EMT”s) who could be integrated into a team-care model?
- Can inpatient nurses be utilized to manage boarders?
- Can you expand the nursing ratios from approximately 4:1 to 5:1 or higher, the better to reflect patient acuity and the composition of the interdisciplinary team?
- What are the rules for or scope of paramedics in your state?
- What are your options associated with boarding Intensive Care Unit (“ICU”) admissions? Are you required to change the nurse staffing ratio to reflect higher patient-acuity, i.e., ICU requirements?
- How do you monitor and transport patients safely and effectively outside the ED for imaging and other non-ED tests and procedures?
- Charting would be the next obstacle to be addressed regarding management of the boarded patient in the ED. Are inpatient and ED EMR templates interoperable? Can the EMR’s be modified to meet the requirements of inpatient documentation?
Lost revenue represents another challenge for the ED. The number of patients Left Without Being Seen (“LWBS”) or Left Without Treatment (“LWOT”) rises each time there is significant overcrowding in the ED; the net result is a substantial financial loss for the hospital.20 The ED will not be credited for initiated but incomplete visits. The national average for LWOT approximates 2 percent of ED volume but can be as high as 6–7 percent.21 For a mid-to-large hospital with 70,000 ED visits, that can be as much as 4,200–4,900 visits of lost level-charge revenues.
ED room turnover typically occurs every 3–4 hours during a 24-hour shift.22 Once an admitted patient occupies a room, that room is no longer available to other ED patients, and accommodations must be made to manage the daily ED volume. This can lead to a significant loss in level charges for the ED.
Accepting transfers from another ED when an inpatient bed is not available is problematic: billing is restricted to one ED visit per 24 hours.23
Recommendations
One of the best ways to streamline communication among departments is to initiate interdisciplinary meetings to include all parties affected by (a) adding surge areas and by b) changing the patient location. Interdisciplinary meetings should include physicians, nurses, radiology, pharmacy, IT and laboratory personnel; and such meetings bridge the communication gap by allowing staff to identify obstacles and propose changes.
An example of process improvement is the pharmacy storage of timed medications. The pharmacist adds the correct medication to well-positioned dispensing machines, allowing the nurse to dispense medications to admitted patients quickly, accurately and effectively. Most large EDs have up to six different locations for the dispensing of medications. Communication is vital in situations such as this, to maintain the department’s flow.
Another idea would be to set up staging areas for radiology, whereby the CT or X-ray tech will need only scan, and not transport, most of their time.
Also, work with the IT team to build disaster beds into the electronic medical record for the surge spaces that would be needed.
The nurse staffing shortage has been widely reported. There are several ways to mitigate this issue, think outside the box and get creative. Team nursing, combined with stretch assignments, has been effective in many inpatient departments and clearly has applications in the ED.
Paramedics represent a potential source of ED staffing, as the scope of license varies by state. Most states do not allow the paramedic to perform triage or to provide discharge instructions and patient teaching. Paramedics can administer a broad range of medications and their critical care skill set is leverageable in the ED setting. Paramedics could become a critical member of the team without taxing your nursing resources.
One way to decrease the number of LWBS or LWOT patients would be to implement an internal waiting area within the ED for lower-acuity and results-pending patients. Pathways for Level 3 patients have been successfully implemented as a method to optimize treatment and decompress the waiting area.
A key to ED reimbursement is adequate documentation of the critically ill and discharged patient.
Bottom line:
Increased ED wait time for medical care results in increased morbidity and a prolonged length of stay.24 Opportunities exist to enhance process efficiencies while improving outcomes in over-crowded EDs. A focus on space/flow, staffing and revenues is required. Among the recommendations are the proactive identification of surge and internal waiting areas, interdisciplinary communications, medication management, the creation of imaging staging areas and use of paramedics.
Footnotes:
1: Julian Richardson, Luke Neill, and Tim Loftus. “Emergency Department Boarding.” Emergency Medicine Resident Education: NUEM Blog (March 30, 2020). https://www.nuemblog.com/blog/ed-boarding.
2: Gabriele Savioli, et al. “Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions.” Journal of Personalized Medicine (February 14, 2022). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8877301/.
3: Zoubir Boudi, et al. “Association between boarding in the emergency department and in-hospital mortality: A systematic review.” PLoS One (April 15, 2020). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7159217/.
4: Gabriele Savioli, et al. “Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions.” Journal of Personalized Medicine (February 14, 2022). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8877301/.
5: Hertaline Menezes do Nascimento Rocha, et al. “Adverse Events in Emergency Department Boarding: A Systematic Review.” Journal of Nursing Scholarship (March 31, 2021). https://sigmapubs.onlinelibrary.wiley.com/doi/10.1111/jnu.12653.
6: Stephen L. Bernstein, et al. “The Effect of Emergency Department Crowding on Clinically Oriented Outcomes.” Academic Emergency Medicine (December 29, 2008). https://onlinelibrary.wiley.com/doi/full/10.1111/j.1553-2712.2008.00295.x.
7: Zoubir Boudi, et al. “Association between boarding in the emergency department and in-hospital mortality: A systematic review.” PLoS One (April 15, 2020). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7159217/.
8: Leila Salehi, et al. “Emergency department boarding: a descriptive analysis and measurement of impact on outcomes.” Canadian Journal of Emergency Medicine (April 5, 2018). https://pubmed.ncbi.nlm.nih.gov/29619913/.
9: Julian Richardson, Luke Neill, and Tim Loftus. “Emergency Department Boarding.” Emergency Medicine Resident Education: NUEM Blog (March 30, 2020). https://www.nuemblog.com/blog/ed-boarding.
10: Jesse M. Pines, et al. “The effect of emergency department crowding on patient satisfaction for admitted patients.” Academy Emergency Medicine (September 2008). https://pubmed.ncbi.nlm.nih.gov/19244633/.
11: Julian Richardson, Luke M. Neill and Tim Loftus. “Emergency Department Boarding.” Emergency Medicine Resident Education Blog. (last visited April 19, 2023). https://www.nuemblog.com/blog/ed-boarding.
12: Gabor D. Kelin, et al. “Emergency Department Crowding: The Canary in the Health Care System.” NEJM Catalyst (September 28, 2021). https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0217.
13: Alexander T. Janke, Edward R. Melnick, and Arjun K. Venkatesh. “Hospital Occupancy and Emergency Department Boarding During the COVID-19 Pandemic.” JAMA Network (September 2022). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9526134.
14: Dana M. King, et al. “Emergency Department Overcrowding Lowers Patient Satisfaction Scores.” Presented at the Society of Academic Emergency Medicine Annual Meeting. (May 2019). https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14046
15: Young Eun Kim and Hyang Yuol Lee. “The effects of an emergency department length-of-stay management system on severely ill patients’ treatment outcomes.” BMC Emergency Medicine (December 13, 2022). https://bmcemergmed.biomedcentral.com/articles/10.1186/s12873-022-00760-z.
16: BC Sun, et al. “Determinants of patient satisfaction and willingness to return with emergency care.” Annals of Emergency Medicine (May 2000). https://pubmed.ncbi.nlm.nih.gov/10783404/.
17: C Taylor and JR Benger. “Patient satisfaction in emergency medicine.” Emergency Medicine Journal. Volume 21 (5) (2004). https://emj.bmj.com/content/21/5/528.
18: Part 482- Conditions of Participation for Hospitals. Section 455 – Condition of Participation: Emergency Services. Center for Medicare & Medicaid Services. (last visited April 19, 2023). https://www.govinfo.gov/content/pkg/CFR-2017-title42-vol5/xml/CFR-2017-title42-vol5-part482.xml#seqnum482.55
19: Emergency Department. Measure Specific Resources. ED Measures Resource Links (Revised May 2022). The Joint Commission. (last visited April 19, 2023). https://www.jointcommission.org/measurement/measures/emergency-department/
20: Courtney M. Smalley. Emergency Department Patients Who Leave Before Treatment Is Complete. Western Journal of Emergency Medicine. (March 2021). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972384/
21: Courtney M. Smalley, et al. “Emergency Department Patients Who Leave Before Treatment Is Complete.” Western Journal of Emergency Medicine (March 2021). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972384.
22: Ronny Otto, et al. “Length of stay as quality indicator in emergency departments: analysis of determinants in the German Emergency Department Data Registry (AKTIN registry)”; Volume 17(4). International Emergency Medicine. (January 6, 2022). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9135863/
23: “Medicare Claims Processing Manual.” Chapter 12 Section 30.6.9.1E. Centers for Medicare & Medicaid Services. (last visited April 20, 2023). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS018912
24: Stephen L. Bernstein, et al. “The Effect of Emergency Department Crowding on Clinically Oriented Outcomes.” Academic Emergency Medicine (December 29, 2008). https://onlinelibrary.wiley.com/doi/full/10.1111/j.1553-2712.2008.00295.x.
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April 27, 2023
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