Emergency department overcrowding in the United States: an emerging threat to patient safety and public health
TL;DR: The purpose of this review is to describe how ED overcrowding threatens patient safety and public health, and to explore the complex causes and potential solutions for the overcrowding crisis.
Abstract: Numerous reports have questioned the ability of United States emergency departments to handle the increasing demand for emergency services. Emergency department (ED) overcrowding is widespread in US cities and has reportedly reached crisis proportions. The purpose of this review is to describe how ED overcrowding threatens patient safety and public health, and to explore the complex causes and potential solutions for the overcrowding crisis. A review of the literature from 1990 to 2002 identified by a search of the Medline database was performed. Additional sources were selected from the references of the articles identified. There were four key findings. (1) The ED is a vital component of America's health care "safety net". (2) Overcrowding in ED treatment areas threatens public health by compromising patient safety and jeopardising the reliability of the entire US emergency care system. (3) Although the causes of ED overcrowding are complex, the main cause is inadequate inpatient capacity for a patient population with an increasing severity of illness. (4) Potential solutions for ED overcrowding will require multidisciplinary system-wide support.
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TL;DR: A growing body of data suggests that ED crowding is associated both with objective clinical endpoints, such as mortality, as well as clinically important processes of care,such as time to treatment for patients with time-sensitive conditions such as pneumonia.
Abstract: Background: An Institute of Medicine (IOM) report defines six domains of quality of care: safety, patient-centeredness, timeliness, efficiency, effectiveness, and equity. The effect of emergency department (ED) crowding on these domains of quality has not been comprehensively evaluated.
Objectives: The objective was to review the medical literature addressing the effects of ED crowding on clinically oriented outcomes (COOs).
Methods: We reviewed the English-language literature for the years 1989–2007 for case series, cohort studies, and clinical trials addressing crowding’s effects on COOs. Keywords searched included “ED crowding,”“ED overcrowding,”“mortality,”“time to treatment,”“patient satisfaction,”“quality of care,” and others.
Results: A total of 369 articles were identified, of which 41 were kept for inclusion. Study quality was modest; most articles reflected observational work performed at a single institution. There were no randomized controlled trials. ED crowding is associated with an increased risk of in-hospital mortality, longer times to treatment for patients with pneumonia or acute pain, and a higher probability of leaving the ED against medical advice or without being seen. Crowding is not associated with delays in reperfusion for patients with ST-elevation myocardial infarction. Insufficient data were available to draw conclusions on crowding’s effects on patient satisfaction and other quality endpoints.
Conclusions: A growing body of data suggests that ED crowding is associated both with objective clinical endpoints, such as mortality, as well as clinically important processes of care, such as time to treatment for patients with time-sensitive conditions such as pneumonia. At least two domains of quality of care, safety and timeliness, are compromised by ED crowding.
1,009 citations
TL;DR: Critically ill emergency department patients with a ≥6-hr delay inintensive care unit transfer had increased hospital length of stay and higher intensive care unit and hospital mortality, suggesting the need to identify factors associated with delayed transfer as well as specific determinants of adverse outcomes.
Abstract: Objective:Numerous factors can cause delays in transfer to an intensive care unit for critically ill emergency department patients. The impact of delays is unknown. We aimed to determine the association between emergency department “boarding” (holding admitted patients in the emergency department pe
874 citations
Cites background from "Emergency department overcrowding i..."
...outcome, and the link between these contributing factors and ED boarding has been well-established (11–16), the specific impact on patient outcome remains unclear (16, 17)....
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TL;DR: To quantify any relationship between emergency department overcrowding and 10‐day patient mortality, a large-scale study of accident and emergency departments in the Netherlands found no relationship.
Abstract: Objective: To quantify any relationship between emergency department (ED) overcrowding and 10-day patient mortality. Design and setting: Retrospective stratified cohort analysis of three 48-week periods in a tertiary mixed ED in 2002–2004. Mean “occupancy” (a measure of overcrowding based on number of patients receiving treatment) was calculated for 8-hour shifts and for 12week periods. The shifts of each type in the highest quartile of occupancy were classified as overcrowded. Participants: All presentations of patients (except those arriving by interstate ambulance) during “overcrowded” (OC) shifts and during an equivalent number of “not overcrowded” (NOC) shifts (same shift, weekday and period). Main outcome measure: In-hospital death of a patient recorded within 10 days of the most recent ED presentation. Results: There were 34 377 OC and 32 231 NOC presentations (736 shifts each); the presenting patients were well matched for age and sex. Mean occupancy was 21.6 on OC shifts and 16.4 on NOC shifts. There were 144 deaths in the OC cohort and 101 in the NOC cohort (0.42% and 0.31%, respectively; P = 0.025). The relative risk of death at 10 days was 1.34 (95% CI, 1.04–1.72). Subgroup analysis showed that, in the OC cohort, there were more presentations in more urgent triage categories, decreased treatment performance by standard measures, and a higher mortality rate by triage category. Conclusions: In this hospital, presentation during high ED occupancy was associated with increased in-hospital mortality at 10 days, after controlling for seasonal, shift, and day of the week effects. The magnitude of the effect is about 13 deaths per year. Further
761 citations
TL;DR: In this paper, an ethical and policy analysis of ED crowding is presented, where the authors identify and describe a variety of adverse moral consequences, including increased risks of harm to patients, delays in providing needed care, compromised privacy and confidentiality, impaired communication, and diminished access to care.
454 citations
TL;DR: The results show that the nature of the communication process in the ED is complex and cognitively taxing for the clinicians, which can compromise patient safety and the need to tailor existing generic electronic tools to support adaptive processes like multitasking and handoffs in a time-constrained environment is discussed.
427 citations
Cites background or result from "Emergency department overcrowding i..."
...ED overcrowding has been recognized as an emerging threat to patient safety and has been described by Trzeiack and Rivers as a prime example of a system problem that contributes to a high risk environment for medical errors [24]....
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...No patient is turned away from the door, similar to the process reported elsewhere [24]....
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References
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TL;DR: This study randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit.
Abstract: Background Goal-directed therapy has been used for severe sepsis and septic shock in the intensive care unit. This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand. The purpose of this study was to evaluate the efficacy of early goal-directed therapy before admission to the intensive care unit. Methods We randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit. Clinicians who subsequently assumed the care of the patients were blinded to the treatment assignment. In-hospital mortality (the primary efficacy outcome), end points with respect to resuscitation, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were obtained serially for 72 hours and compared between the study groups. Results Of the 263 enrolled patients, 130 were ...
8,811 citations
TL;DR: The JCAHO launched its Agenda for Change to create a more modern and sophisticated accreditation process to place primary emphasis on actual performance in 1987, including two for infection control standards.
Abstract: The Joint Commission on Accreditation of Healthcare Organizations was founded in 1951 as a private, not-for-profit organization that evaluates and accredits hospitals and other healthcare organizations. In 1987, the JCAHO launched its Agenda for Change to create a more modern and sophisticated accreditation process to place primary emphasis on actual performance. Coincident with this new emphasis, a number of task forces were established, including two for infection control standards.
1,461 citations
TL;DR: In this article, a complex web of interrelated issues described in this article is used to show that ED overcrowding has multiple effects, including placing the patient at risk for poor outcome, prolonged pain and suffering of some patients, long patient waits, patient dissatisfaction, ambulance diversions in some cities, decreased physician productivity, increased frustration among medical staff, and violence.
914 citations
TL;DR: Episodic, but frequent, overcrowding is a significant problem in academic, county, and private hospital EDs in urban and rural settings and its causes are complex and multifactorial.
Abstract: . Objective: To describe the definition, extent, and factors associated with overcrowding in emergency departments (EDs) in the United States as perceived by ED directors. Methods: Surveys were mailed to a random sample of EDs in all 50 states. Questions included ED census, frequency, impact, and determination of overcrowding. Respondents were asked to rank perceived causes using a five-point Likert scale. Results: Of 836 directors surveyed, 575 (69%) responded, and 525 (91%) reported overcrowding as a problem. Common definitions of overcrowding (>70%) included: patients in hallways, all ED beds occupied, full waiting rooms >6 hours/day, and acutely ill patients who wait >60 minutes to see a physician. Overcrowding situations were similar in academic EDs (94%) and private hospital EDs (91%). Emergency departments serving populations ≤250,000 had less severe overcrowding (87%) than EDs serving larger areas (96%). Overcrowding occurred most often several times per week (53%), but 39% of EDs reported daily overcrowding. On a 1-5 scale (±SD), causes of overcrowding included high patient acuity (4.3 ± 0.9), hospital bed shortage (4.2 ± 1.1), high ED patient volume (3.8 ± 1.2), radiology and lab delays (3.3 ± 1.2), and insufficient ED space (3.3 ± 1.3). Thirty-three percent reported that a few patients had actual poor outcomes as a result of overcrowding. Conclusions: Episodic, but frequent, overcrowding is a significant problem in academic, county, and private hospital EDs in urban and rural settings. Its causes are complex and multifactorial.
547 citations
TL;DR: There are limits to the occupancy rates that can be achieved safely without considerable risk to patients and to the efficient delivery of emergency care, and spare bed capacity is therefore essential for the effective management of emergency admissions.
Abstract: Objective: To examine the daily bed requirements arising from the flow of emergency admissions to an acute hospital, to identify the implications of fluctuating and unpredictable demands for emergency admission for the management of hospital bed capacity, and to quantify the daily risk of insufficient capacity for patients requiring immediate admission. Design: Modelling of the dynamics of the hospital system, using a discrete-event stochastic simulation model, which reflects the relation between demand and available bed capacity. Setting: Hypothetical acute hospital in England. Subjects: Simulated emergency admissions of all types except mental disorder. Main outcome measures: The risk of having no bed available for any patient requiring immediate admission; the daily risk that there is no bed available for at least one patient requiring immediate admission; the mean bed occupancy rate. Results: Risks are discernible when average bed occupancy rates exceed about 85%, and an acute hospital can expect regular bed shortages and periodic bed crises if average bed occupancy rises to 90% or more. Conclusions: There are limits to the occupancy rates that can be achieved safely without considerable risk to patients and to the efficient delivery of emergency care. Spare bed capacity is therefore essential for the effective management of emergency admissions, and its cost should be borne by purchasers as an essential element of an acute hospital service. Key messages Acute hospitals which operate at bed occupancy levels of 90% or more face regular bed crises, with the associated risks to patients Management interventions should focus on measures with long term benefits to counteract the growth trend in demand for admission Many initiatives have only a short term effect; they briefly delay the worst effects but do not address the growing mismatch between supply and demand Evaluating management interventions year on year at a single hospital is futile—any effects are swamped by random variations
472 citations