Emergency Department Workload and Crowding During a Major Electronic Health Record Breakdown

"I feel like I'm walking on eggshells": a qualitative study of moral distress among Chinese emergency doctors

BACKGROUND

While the number of emergency patients worldwide continues to increase, emergency doctors often face moral distress. It hampers the overall efficiency of the emergency department, even leading to a reduction in human resources.

AIM

This study explored the experience of moral distress among emergency department doctors and analyzed the causes of its occurrence and the strategies for addressing it.

METHOD

Purposive and snowball sampling strategies were used in this study. Data were collected through in-depth, semi-structured interviews with 10 doctors working in the emergency department of a tertiary general hospital in southwest China. The interview data underwent processing using the Nvivo 14 software. The data analysis was guided by Colaizzi's phenomenological analysis method.

STUDY FINDINGS

This study yielded five themes: (1) imbalance between Limited Medical Resources and High-Quality Treatment Needs; (2) Ineffective Communication with Patients; (3) Rescuing Patients With no prospect of treatment; (4) Challenges in Sustaining Optimal Treatment Measures; and (5) Strategies for Addressing Moral Distress.

CONCLUSION

The moral distress faced by emergency doctors stems from various aspects. Clinical management and policymakers can alleviate this distress by enhancing the dissemination of emergency medical knowledge to the general public, improving the social and economic support systems, and strengthening multidisciplinary collaboration and doctors' communication skills.

Emergency department crowding and mortality: an observational multicenter study in Sweden

Background

Emergency department (ED) crowding is a serious problem worldwide causing decreased quality of care. It is reasonable to assume that the negative effects of crowding are at least partially due to high staff workload, but previous crowding metrics based on high workload have not been generalisable to Swedish EDs and have not been associated with increased mortality, in contrast to, e.g., occupancy rate. We recently derived and validated the modified Skåne Emergency Department Assessment of Patient Load model (mSEAL) that measures crowding based on staff workload in Swedish EDs, but its ability to identify situations with increased mortality is unclear. In this study, we aimed to investigate the association between ED crowding measured by mSEAL model, or occupancy rate, and mortality.

Methods

All ED patients from 2017-01-01 to 2017-06-30 from two regional healthcare systems (Skåne and Östergötland Counties with a combined population of approximately 1.8 million) in Sweden were included. Exposure was ED- and hour-adjusted mSEAL or occupancy rate. Primary outcome was mortality within 7 days of ED arrival, with one-day and 30-day mortality as secondary outcomes. We used Cox regression hazard ratio (HR) adjusted for age, sex, arrival by ambulance, hospital admission and chief complaint.

Results

We included a total of 122,893 patients with 168,900 visits to the six participating EDs. Arriving at an hour with a mSEAL score above the 95th percentile for that ED and hour of day was associated with an non-significant HR for death at 7 days of 1.04 (95% CI 0.96-1.13). For one- and 30-day mortality the HR was non-significant at 1.03 (95% CI 0.9-1.18) and 1.03 (95% CI 0.97-1.09). Similarly, occupancy rate above the 95th percentile with a HR of 1.04 (95% CI 0.9-1.19), 1.03 (95%CI 0.95-1.13) and 1.04 (95% CI 0.98-1.11) for one-, 7- and 30-day mortality, respectively.

Conclusion

In this multicenter study in Sweden, ED crowding measured by mSEAL or occupancy rate was not associated with a significant increase in short-term mortality.

What Goes Up, Must Come Down: A State-of-the-Art Electronic Health Record Downtime and Uptime Procedure in a Metropolitan Health Setting

BACKGROUND

Electronic health records (EHRs) are used at most hospitals around the world, and downtime events are inevitable and common. Downtime represents a risky time for patients because patient information and critical EHR functionality are unavailable. Many institutions have used EHRs for years, with health professionals less likely to be familiar or comfortable with paper-based processes, resulting in an increased risk of errors during downtimes. There is currently limited guidance available on how to develop and operationalize downtime procedure at a local level. In this paper, we fill this gap by describing our state-of-the-art downtime and uptime procedure and its evaluation.

METHOD

A district-wide downtime and uptime procedure was revised and standardized based on lessons learned from other health care organizations. The procedure outlines downtime and uptime preparations including downtime drills, downtime viewer auditing, and downtime education; downtime response including activating downtime and tracking patient changes; and uptime recovery including medication reconciliation and uptime documentation.

IMPLEMENTATION

We implemented our new procedure across the district during an 8-hour planned downtime. A district downtime planning committee was formed, and a virtual command center was established to coordinate the downtime and uptime events. During downtime and uptime, onsite support was provided by the district's health informatics teams and clinicians. Data recovery was completed safely and efficiently with the revised uptime process. Following the event, we gathered staff feedback and reflections on implementing the procedure which highlighted its success but also revealed some areas for further improvement.

CONCLUSION

In this paper, we describe a state-of-the-art EHR downtime and uptime procedure and lessons learned from its implementation. The implementation was successful with staff well prepared and information reconciled efficiently ensuring safe continuity of care. It was only through extensive planning, significant commitment, and engagement of all stakeholders that this outcome was possible.

Understanding the perceived role of electronic health records and workflow fragmentation on clinician documentation burden in emergency departments

OBJECTIVE

Understand the perceived role of electronic health records (EHR) and workflow fragmentation on clinician documentation burden in the emergency department (ED).

METHODS

From February to June 2022, we conducted semistructured interviews among a national sample of US prescribing providers and registered nurses who actively practice in the adult ED setting and use Epic Systems' EHR. We recruited participants through professional listservs, social media, and email invitations sent to healthcare professionals. We analyzed interview transcripts using inductive thematic analysis and interviewed participants until we achieved thematic saturation. We finalized themes through a consensus-building process.

RESULTS

We conducted interviews with 12 prescribing providers and 12 registered nurses. Six themes were identified related to EHR factors perceived to contribute to documentation burden including lack of advanced EHR capabilities, absence of EHR optimization for clinicians, poor user interface design, hindered communication, increased manual work, and added workflow blockages, and five themes associated with cognitive load. Two themes emerged in the relationship between workflow fragmentation and EHR documentation burden: underlying sources and adverse consequences.

DISCUSSION

Obtaining further stakeholder input and consensus is essential to determine whether these perceived burdensome EHR factors could be extended to broader contexts and addressed through optimizing existing EHR systems alone or through a broad overhaul of the EHR's architecture and primary purpose.

CONCLUSION

While most clinicians perceived that the EHR added value to patient care and care quality, our findings underscore the importance of designing EHRs that are in harmony with ED clinical workflows to alleviate the clinician documentation burden.

Wilhelms D. Differentiating properties of occupancy rate and workload to estimate crowding: A Swedish national cross-sectional study

BACKGROUND

Emergency department (ED) crowding causes increased patient morbidity and mortality. ED occupancy rate (OR; patients by treatment beds) is a common measure of crowding, but the comparability of ORs between EDs is unknown. The objective of this investigation was to investigate differences in ORs between EDs using staff-perceived workload as reference.

METHODS

This was a national cross-sectional study in Sweden. EDs provided data on census, treatment beds, staffing, and workload (1-6) at 5 time points. A baseline patient turnover was calculated as the average daily census by treatment beds, denoted turnover per treatment bed (TTB), for each ED. A census ratio (CR), current by daily census, was calculated to adjust for differences in the number of treatment beds.

RESULTS

Data were returned from 37 (51%) EDs. TTB varied considerably (mean = 4, standard deviation = 1.6; range, 2.1-9.2), and the OR was higher in EDs with TTB >4 compared with ≤4, 0.86 versus 0.43 (0.43; 95% confidence interval [CI], 0.27-0.59), but not workload, 2.75 versus 2.52 (0.23; 95% CI, -0.19 to 0.64). After adjusting for confounders, both TTB (k = -0.3; 95% CI, -0.49 to -0.14) and OR (k = 3.4; 95% CI, 1.76-5.03) affected workload. Correlation with workload was better for CR than for OR (r = 0.75 vs 0.60, respectively).

CONCLUSION

OR is affected by patient-to-treatment bed ratios that differ significantly between EDs and should be accounted for when measuring crowding. CR is not affected by baseline treatment beds and is a better comparable measure of crowding compared with OR in this national comparator study.

Prevalence of crowding, boarding and staffing levels in Swedish emergency departments - a National Cross Sectional Study

Background

Emergency Department (ED) crowding occurs when demand for care exceeds the available resources. Crowding has been associated with decreased quality of care and increased mortality, but the prevalence on a national level is unknown in most countries.

Method

We performed a national, cross-sectional study on staffing levels, staff workload, occupancy rate and patients waiting for an in-hospital bed (boarding) at five time points during 24 h in Swedish EDs.

Results

Complete data were collected from 37 (51% of all) EDs in Sweden. High occupancy rate indicated crowding at 12 hospitals (37.5%) at 31 out of 170 (18.2%) time points. Mean workload (measured on a scale from 1, no workload to 6, very high workload) was moderate at 2.65 (±1.25). Boarding was more prevalent in academic EDs than rural EDs (median 3 vs 0). There were an average of 2.6, 4.6 and 3.2 patients per registered nurse, enrolled nurse and physician, respectively.

Conclusion

ED crowding based on occupancy rate was prevalent on a national level in Sweden and comparable with international data. Staff workload, boarding and patient to staff ratios were generally lower than previously described.