Systematic Review of Emergency Department Crowding: Causes, Effects, and Solutions

https://www.annemergmed.com/article/S0196-0644(05)01989-X/pdf

Analysis of ambulance transports and diversions among US emergency departments.

Emergency departments (EDs) are a vital component in our health care safety net, available 24 hours a day, 7 days a week, for all who require care. There has been a steady increase in the volume and acuity of patient visits to EDs, now with well over 100 million Americans (30 million children) receiving emer- gency care annually. This rise in ED utilization has ef- fectively saturated the capacity of EDs and emergency medical services in many communities. The resulting phenomenon, commonly referred to as ED overcrowding, now threatens access to emergency services for those who need them the most. As managers of the pediatric med- ical home and advocates for children and optimal pedi- atric health care, there is a very important role for pedi- atricians and the American Academy of Pediatrics in guiding health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care. Pediatrics 2004;114:878-888; ac- cess to emergency care, ambulance diversion, emergency medical services for children, EMTALA, emergency depart- ment overcrowding.

Overcrowding Crisis in Our Nation's Emergency Departments: Is Our Safety Net Unraveling?

Objectives: To examine the effects of emergency department (ED) expansion on ambulance diversion at an urban, academic Level 1 trauma center.

Methods: This was a pre-post study performed using administrative data from the ED and hospital electronic information systems. On April 19, 2005, the adult ED expanded from 28 to 53 licensed beds. Data from a five-month pre-expansion period (November 1, 2004, to March 1, 2005) and a five-month postexpansion period (June 1, 2005, to October 31, 2005) were included for this analysis. ED and waiting room statistics as well as diversion status were obtained. Total ED length of stay (LOS) was defined as the time from patient registration to the time leaving the ED. Admission hold LOS was defined as the time from the inpatient bed request to the time leaving the ED for admitted patients. Mean differences (95% confidence interval [CI]) in total time spent on ambulance diversion per month, diversion episodes per month, and duration per diversion episode were calculated. An accelerated failure time model was performed to test if ED expansion was associated with a reduction in ambulance diversion while adjusting for potential confounders.

Results: From pre-expansion to postexpansion, daily patient volume increased but ED occupancy decreased. There was no significant change in the time spent on ambulance diversion per month (mean difference, 10.9 hours; 95% CI =−74.0 to 95.8), ambulance diversion episodes per month (two episodes per month; 95% CI =−4.2 to 8.2), and duration of ambulance diversion per episode (0.3 hours; 95% CI =−4.0 to 3.5). Mean (±SD) total LOS increased from 4.6 (±1.9) to 5.6 (±2.3) hours, and mean (±SD) admission hold LOS also increased from 3.0 (±0.2) to 4.1 (±0.2) hours. The proportion of patients who left without being seen was 3.5% and 2.7% (p = 0.06) in the pre-expansion and postexpansion periods, respectively. In the accelerated failure time model, ED expansion did not affect the time to the next ambulance diversion episode.

Conclusions: An increase in ED bed capacity did not affect ambulance diversion. Instead, total and admission hold LOS increased. As a result, ED expansion appears to be an insufficient solution to improve diversion without addressing other bottlenecks in the hospital.

https://onlinelibrary.wiley.com/doi/pdf/10.1197/j.aem.2006.12.005

The Effect of Emergency Department Expansion on Emergency Department Overcrowding

Objectives: To review the current literature on the effects of ambulance diversion (AD). Methods: The authors performed a systematic review of AD and its effects. PubMed, EMBASE, the Cochrane database, societal meeting abstracts, and references from relevant articles were searched. All articles were screened for relevance to AD. Results: The authors examined 600 citations and reviewed the 107 articles relevant to AD. AD is a common occurrence that is increasing in frequency. AD is associated with periods of emergency department (ED) crowding (Mondays, mid-afternoon to early evening, influenza season, and when hospitals are at capacity). Interventions that redesign the AD process or that provide additional hospital or ED resources reduce diversion frequency. AD is associated with increased patient transport times and time to thrombolytics but not with mortality. AD is associated with loss of estimated hospital revenues. Short of anecdotal or case reports, no studies measured the effect of AD on ED crowding, morbidity, patient and provider satisfaction, or EMS resource utilization. Conclusions: Despite its common use, there is a relative paucity of studies on the effects of AD. Further research into these effects should be performed so that we may understand the role of AD in the health system. ACADEMIC EMERGENCY MEDICINE 2006; 13:1220‐1227 a 2006 by the Society for Academic Emergency

https://onlinelibrary.wiley.com/doi/pdf/10.1197/j.aem.2006.05.024

Patricia A. Nadle

Papers

Utilization and impact of ambulance diversion at the community level.

Reducing ambulance diversion: a multihospital approach.