Overcrowding in the emergency department (ED) has become an increasingly significant worldwide public health problem in the last decade. It is a consequence of simultaneous increasing demand for health care and a deficit in available hospital beds and ED beds, as for example it occurs in mass casualty incidents, but also in other conditions causing a shortage of hospital beds. In Italy in the last 12-15 years, there has been a huge increase in the activity of the ED, and several possible interventions, with specific organizational procedures, have been proposed. In 2004 in the United Kingdom, the rule that 98 % of ED patients should be seen and then admitted or discharged within 4ho f presentation to the ED ('4 hr ule') was intro- duced, and it has been shown to be very effective in decreasing ED crowding, and has led to the development of further acute care clinical indicators. This manuscript represents a synopsis of the lectures on overcrowding problems in the ED of the Third Italian GREAT Network Congress, held in Rome, 15-19 October 2012, and hope- fully, they may provide valuable contributions in the understanding of ED crowding solutions.

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Overcrowding in emergency department: an international issue

Hospitals are complex systems with essential societal benefits and huge mounting costs. These costs are exacerbated by inefficiencies in hospital processes, which are often manifested by congestion and long delays in patient care. Thus, a queueing-network view of patient flow in hospitals is natural for studying and improving its performance. The goal of our research is to explore patient flow data through the lens of a queueing scientist. The means is exploratory data analysis (EDA) in a large Israeli hospital, which reveals important features that are not readily explainable by existing models. Questions raised by our EDA include: Can a simple (parsimonious) queueing model usefully capture the complex operational reality of the Emergency Department (ED)? What time scales and operational regimes are relevant for modeling patient length of stay in the Internal Wards (IWs)? How do protocols of patient transfer between the ED and the IWs influence patient delay, workload division and fairness? EDA also unde...

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On patient flow in hospitals: a data-based queueing-science perspective

Objective: We explored the relationship between the National Emergency Access Target (NEAT) compliance rate, defined as the proportion of patients admitted or discharged from emergency departments (EDs) within 4 hours of presentation, and the risk-adjusted in-hospital mortality of patients admitted to hospital acutely from EDs Design, setting and participants: Retrospective observational study of all de-identified episodes of care involving patients who presented acutely to the EDs of 59 Australian hospitals between 1 July 2010 and 30 June 2014 Main outcome measure: The relationship between the risk-adjusted mortality of inpatients admitted acutely from EDs (the emergency hospital standardised mortality ratio [eHSMR]: the ratio of the numbers of observed to expected deaths) and NEAT compliance rates for all presenting patients (total NEAT) and admitted patients (admitted NEAT) Results: ED and inpatient data were aggregated for 125 million ED episodes of care and 116 million inpatient episodes of care A highly significant (P<0001) linear, inverse relationship between eHSMR and each of total and admitted NEAT compliance rates was found; eHSMR declined to a nadir of 73 as total and admitted NEAT compliance rates rose to about 83% and 65% respectively Sensitivity analyses found no confounding by the inclusion of palliative care and/or short-stay patients Conclusion: As NEAT compliance rates increased, in-hospital mortality of emergency admissions declined, although this direct inverse relationship is lost once total and admitted NEAT compliance rates exceed certain levels This inverse association between NEAT compliance rates and in-hospital mortality should be considered when formulating targets for access to emergency care

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The National Emergency Access Target (NEAT) and the 4-hour rule: time to review the target

Evaluation of emergency department (ED) performance remains a difficult task due to the lack of consensus on performance measures that reflects high quality, efficiency, and sustainability. To describe, map, and critically evaluate which performance measures that the published literature regard as being most relevant in assessing overall ED performance. Following the PRISMA guidelines, a systematic literature review of review articles reporting accentuated ED performance measures was conducted in the databases of PubMed, Cochrane Library, and Web of Science. Study eligibility criteria includes: 1) the main purpose was to discuss, analyse, or promote performance measures best reflecting ED performance, 2) the article was a review article, and 3) the article reported macro-level performance measures, thus reflecting an overall departmental performance level. A number of articles addresses this study’s objective (n = 14 of 46 unique hits). Time intervals and patient-related measures were dominant in the identified performance measures in review articles from US, UK, Sweden and Canada. Length of stay (LOS), time between patient arrival to initial clinical assessment, and time between patient arrivals to admission were highlighted by the majority of articles. Concurrently, “patients left without being seen” (LWBS), unplanned re-attendance within a maximum of 72 hours, mortality/morbidity, and number of unintended incidents were the most highlighted performance measures that related directly to the patient. Performance measures related to employees were only stated in two of the 14 included articles. A total of 55 ED performance measures were identified. ED time intervals were the most recommended performance measures followed by patient centeredness and safety performance measures. ED employee related performance measures were rarely mentioned in the investigated literature. The study’s results allow for advancement towards improved performance measurement and standardised assessment across EDs.

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Evaluation of emergency department performance – a systematic review on recommended performance and quality-in-care measures

Objective To estimate prevalence and explore potential causes and consequences of compassion satisfaction and compassion fatigue in UK emergency medicine consultants. Methods A sequential mixed-methods design. Cross-sectional e-survey to all UK NHS emergency medicine consultants (n=1317) including Professional Quality of Life (ProQOL) (compassion satisfaction/fatigue), followed by interviews with consultants scoring above (n=6) and below (n=6) predefined ProQOL thresholds. Results 681 (52%) consultants responded. Most (98%) reported at least ‘average’ compassion satisfaction. Higher scores were associated with type of workplace (designated trauma centres faring better) and number of years worked as a consultant (gradually worsen over time, except 20 years onwards when it improves). Consultants with lower (worse) compassion satisfaction scores were more likely to report being irritable with patients or colleagues and reducing their standards of care (a third reported these behaviours at least monthly) and were more likely to intend to retire early (59% had such plans). Key features distinguishing ‘satisfied’ from ‘fatigued’ interviewed consultants included having strategies to deal with the high work intensities associated with their role and having positive views of the team within which they worked. The degree of variety in their roles and the ability to maintain empathy for their patients were also distinguishing features between these groups. Conclusions Findings support an urgent review of workforce and resources in emergency medicine and suggest that a multifactorial approach to identification, prevention and treatment of occupational stress in the workforce is required that considers individual, job and organisational factors, particularly those that impact on perceived control and support at work.

https://emj.bmj.com/content/emermed/32/8/588.full.pdf

Prevalence, causes and consequences of compassion satisfaction and compassion fatigue in emergency care: a mixed-methods study of UK NHS Consultants

Governments in Australasia are introducing emergency department length of stay (EDLOS) time targets similar to the UK 'four hour rule'. There is debate about whether this rule had beneficial effects on health-care outcomes. We sought to determine what effects the four hour time target for EDLOS had on clinically relevant outcomes in the UK by conducting a systematic search for evidence. Articles were screened by both authors independently and assessed for quality using standard tools. Differences in outcomes measured and how they were measured precluded meta-analysis. There were inconsistencies between target achievement reported by Trusts and that reported in the studies, and empirical evidence that the target might be unattainable. National Health Service spending on ED increased £820,000,000.00 (1998-2007) and emergency admissions rose overall by 35% (2002-2006), but not in all hospitals. Time to see a treating clinician and hospital mortality was unchanged. One hospital demonstrated a small reduction in return rate. The impact of the introduction of an ED time target and the associated massive financial investment has not resulted in a consistent improvement in care with markedly varying effects being reported between hospitals. Countries seeking to emulate the UK experience should proceed with caution.

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Karen Schimanski

Papers

The four hour target to reduce emergency department ‘waiting time’: A systematic review of clinical outcomes

Comparison study of upper arm and forearm non-invasive blood pressures in adult Emergency Department patients.

Factors to consider for family violence screening implementation in New Zealand emergency departments