Total access block time: a comprehensive and intuitive way to measure the total effect of access block on the emergency department

How the coronavirus disease 2019 pandemic changed the patterns of healthcare utilization by geriatric patients and the crowding: a call to action for effective solutions to the access block

The geriatric population constitutes a large slice of the population of Western countries and a class of fragile patients, with greater deaths due to COVID-19. The patterns of healthcare utilization change during pandemic disease outbreaks. Identifying the patterns of changes of this particular fragile subpopulation is important for future preparedness and response. Overcrowding in the emergency department (ED) can occur because of the volume of patients waiting to be seen, delays in patient assessment or treatment in the ED, or impediments to leaving the ED once the treatment has been completed. Overcrowding has become a serious and growing issue globally, which represents a serious impediment to healthcare utilization. To estimate the rate of ED visits attributable to the outbreak and guide the planning of strategies for managing ED access or after the outbreak of transmittable respiratory diseases. This observational study was based on a retrospective review of the epidemiological and clinical records of patients aged > 75 years who visited the Foundation IRCCS Policlinic San Matteo during the first wave of COVID-19 outbreak (February 21 to May 1, 2020; pandemic group). The analysis methods included estimation of the changes in the epidemiological and clinical data from the annual baseline data after the start of the COVID-19 pandemic. Outcome measures and analysis: Primary objective is the evaluation of ED admission rate change and ED overcrowding. Secondary objectives are the evaluation of modes of ED access by reason and triage code, access types, clinical outcomes (such as admission and mortality rates). During the pandemic, ED crowding increased dramatically, although the overall number of patients decreased, in the face of a percentage increase in those with high-acuity conditions, because of changes in patient management that have prolonged length of stay (LOS) and increased rates of access block. Overcrowding during the COVID-19 pandemic can be attributed to the Access Block. Access Block solutions are hence required to prevent a recurrence of crowding to any new viral wave or new epidemic in the future.

Impact of Coronavirus Disease 2019 Pandemic on Crowding: A Call to Action for Effective Solutions to “Access Block”

Introduction

Healthcare patterns change during disease outbreaks and pandemics. Identification of modified patterns is important for future preparedness and response. Emergency department (ED) crowding can occur because of the volume of patients waiting to be seen, which results in delays in patient assessment or treatment and impediments to leaving the ED once treatment is complete. Therefore, ED crowding has become a growing problem worldwide and represents a serious barrier to healthcare operations.

Methods

This observational study was based on a retrospective review of the epidemiologic and clinical records of patients who presented to the Foundation IRCCS Policlinic San Matteo in Pavia, Italy, during the coronavirus disease 2019 (COVID-19) outbreak (February 21–May 1, 2020, pandemic group). The methods involved an estimation of the changes in epidemiologic and clinical data from the annual baseline data after the start of the COVID-19 pandemic.

Results

We identified reduced ED visits (180 per day in the control period vs 96 per day in the pandemic period; P < 0.001) during the COVID-19 pandemic, irrespective of age and gender, especially for low-acuity conditions. However, patients who did present to the ED were more likely to be hemodynamically unstable, exhibit abnormal vital signs, and more frequently required high-intensity care and hospitalization. During the pandemic, ED crowding dramatically increased primarily because of an increased number of visits by patients with high-acuity conditions, changes in patient management that prolonged length of stay, and increased rates of boarding, which led to the inability of patients to gain access to appropriate hospital beds within a reasonable amount of time. During the pandemic, all crowding output indices increased, especially the rates of boarding (36% vs 57%; P < 0.001), “access block” (24% vs 47%; P < 0.001), mean boarding time (640 vs 1,150 minutes [min]; P 0.001), mean “access block” time (718 vs 1,223 min; P < 0.001), and “access block” total time (650,379 vs 1,359,172 min; P < 0.001).

Conclusion

Crowding in the ED during the COVID-19 pandemic was due to the inability to access hospital beds. Therefore, solutions to this lack of access are required to prevent a recurrence of crowding due to a new viral wave or epidemic.

Development of performance indicators for systems of urgent and emergency care in the Republic of Ireland: Systematic review and consensus development exercise

Objectives: To develop a set of performance indicators to monitor the performance of emergency and urgent care systems in the Republic of Ireland. Design: This study comprised of an update of a previously performed systematic review and a formal consensus development exercise. Results: Initial literature searches yielded 2339 article titles.  After further searches, sixty items were identified for full-text review. Following this review, fifty-seven were excluded. Three articles were identified for inclusion in the systematic review. These papers produced 42 unique indicators for consideration during the consensus development exercise. In total, 17 indicators had a median of greater than 7 following the meeting and met our pre-specified criterion for acceptable consensus. Discussion: Using this systematic review and nominal group consensus development exercise, we have identified a set of 17 indicators, which a consensus of different experts regard as potentially good measures of the performance of urgent and emergency care systems in Ireland.

Development of performance indicators for systems of urgent and emergency care in the Republic of Ireland: Systematic review and consensus development exercise

Objectives: To develop a set of performance indicators to monitor the performance of emergency and urgent care systems in the Republic of Ireland.

Design: This study comprised of an update of a previously performed systematic review and a formal consensus development exercise. The literature search was conducted in PubMed and covered the period 2008 to 2014. The results of the review were used to inform a consensus group of 17 national experts on urgent and emergency care in Ireland. The consensus development exercise comprised an online survey followed by a face-to-face nominal group technique meeting. During this meeting participants had the opportunity to revise their preferences for different indicators after listening to the views of other group members. A final online survey was then used to confirm the preferences of participants.

Results: Initial literature searches yielded 2339 article titles.  After further searches, sixty items were identified for full-text review. Following this review, fifty-seven were excluded. Three articles were identified for inclusion in the systematic review. These papers produced 42 unique indicators for consideration during the consensus development exercise. In total, 17 indicators had a median of greater than 7 following the meeting and met our pre-specified criterion for acceptable consensus.

Discussion: Using this systematic review and nominal group consensus development exercise, we have identified a set of 17 indicators, which a consensus of different experts regard as potentially good measures of the performance of urgent and emergency care systems in Ireland. Pragmatic implications are discussed with reference to three subsequently performed original studies which used some of the indicators

A stream for complex, ambulant patients reduces crowding in an emergency department

OBJECTIVE

The study aims to evaluate the effect of adding a stream for complex, ambulatory patients in an ED.

METHODS

The setting was an ED in a principal referral hospital in New South Wales, Australia. In 2011, a new stream was added to the pre-existing acute care (high complexity patients) and fast track (low complexity patients) streams. Space in acute care was set aside for the purpose of assessing patients who would previously have been assigned to acute care and who were capable of sitting in a chair with limited nursing care. The stream was separately resourced with staff redeployed from acute care. Early involvement of an emergency physician was a core characteristic of the process. Two 13 week periods before and after the intervention were compared.

RESULTS

Presentations increased by 8.2%. Forty-three per cent of patients were triaged to the new stream. The median ED length of stay fell from 327 (interquartile range [IQR] 192-527) min to 267 (IQR 163-412) min (P < 0.001), the average daily occupancy of the department fell from 38.1 patients to 34.9 patients (95% confidence interval [CI] for difference 1.6-4.8, P < 0.001) and the proportion of patients who did not wait to be seen fell from 12% to 5.6% (95% CI for difference 5.8-7.1, P < 0.001).

CONCLUSION

The use of an appropriately resourced stream directed towards seeing a complex group of patients who do not require ongoing nursing care and who are capable of sitting in a chair improved departmental flow.

Prolonged length of stay in the emergency department in high-acuity patients at a Chinese tertiary hospital

OBJECTIVE

ED overcrowding is a worldwide issue, with most evidence coming from developed countries. Until now, little was known about this subject in China. The aim of this study was to investigate the situation of prolonged lengths of stay (LOS) in the ED for high-acuity patients in a Chinese tertiary hospital and to identify associated factors.

METHODS

A retrospective study was performed in a Chinese tertiary hospital from 1 January to 31 December 2010. The primary outcomes were ED LOS and associated factors in overall high-acuity patients. Multivariate Cox regression analysis was used.

RESULTS

In this consecutive study period, 7966 high-acuity patients presenting to the ED were triaged to the resuscitation room. The median LOS in the ED for these patients was 10.6 h (IQR, 3.1-23.1 h). In the multivariate analysis, the most significant factor associated with prolonged LOS was boarding for more than 2 h (OR, 4.29; 95% CI, 4.03-4.57). Patients requiring emergency operation or intensive care unit admission experienced a shorter LOS (OR, 0.56 and 0.76; 95% CI, 0.53-0.60 and 0.71-0.81, respectively). Older patients, night shift arrivals, non-spring visitors, general internal medicine patients and patients leaving without receiving advanced therapy had longer LOS.

CONCLUSIONS

We found an excessive LOS in the resuscitation room in this tertiary hospital. The most significant reason for prolonged LOS was boarding block. Shortage of inpatient beds and reluctance of the wards to admit these patients might be the primary reasons for extremely long boarding.

Statewide validation of a patient admissions prediction tool

We validate a proprietary system to predict hospital emergency department presentations. A key advantage in planning health service delivery requirements and catering for the large numbers of people presenting to hospitals is the ability to predict their numbers. Year-ahead forecasts of daily hospital presentations were generated for 27 public hospitals in Queensland, Australia from five years of historic data. Forecast accuracy was assessed by calculating the Mean Absolute Percentage Error and Root Mean Squared Error between predictions and observed admissions. Emergency Department presentations were found to be not random and can be predicted with an accuracy of around 90%. Highest accuracy was over weekends and summer months, and Public Holidays had the greatest variance in forecast accuracy. Forecasts for urban facilities were generally more accurate than regional (accuracy is related to sample size).