Emergency department crowding and mortality for patients presenting to emergency departments in New Zealand

OBJECTIVE

The association between ED crowding and mortality has been established internationally, but not in New Zealand. The aim was to determine which measures of crowding were associated with mortality for new patients presenting to New Zealand EDs. The primary outcome was mortality for patients within 7 days of arrival in the ED.

METHODS

This was a retrospective cohort study, using administrative data from 2006 to 2012. The crowding conditions at the time of presentation of each patient were recreated. Multivariable Cox proportional hazard modelling was used to determine the probability of death within 7 days of the presentation to ED. Each crowding measure was added independently to the optimum mortality model to determine how each crowding metric influenced the model.

RESULTS

Twenty-five of 28 (89%) eligible acute hospitals in New Zealand were included, with 5 793 767 ED visits by 2 214 865 individuals. Seven-day mortality was higher for patients arriving at times when there was more than 10% hospital access block (hazard ratio [HR] 1.10, 95% confidence interval [CI] 1.05, 1.17) or non-compliance with the 4-h emergency access target (HR 1.07, 95% CI 1.01, 1.12). ED occupancy did not influence the model importantly, while the number of arrivals in the previous 6 h was associated with lower mortality (HR 0.90, 95% CI 0.84, 0.97).

CONCLUSION

Access block had the strongest association with 7-day mortality. That ED occupancy and the number of arrivals were not associated with increased mortality suggests that system issues related to long ED stays may be most important in the link between ED crowding and mortality.

Two Hour Evaluation and Referral Model for Shorter Turnaround Times in the emergency department

OBJECTIVE

The objective of this study was to assess the implementation of a novel ED model of care, which combines clinical streaming, team-based assessment and early senior consultation to reduce length of stay.

METHODS

A pre-post-intervention study was used to compare ED performance following an extensive clinical redesign programme. Clinical teams and work sequences were reconfigured to promote the role of the staff specialist, with a focus on earlier decisions regarding disposition. Primary outcome measures were ED length of stay and National Emergency Access Target (NEAT) compliance. Secondary outcomes included referral and workup times, wait times by triage category, ambulance offload times, ward discharges and unit transfers within 24 h of admission, representation within 48 h, and Medical Emergency Response Team (MERT) calls within 24 h of admission.

RESULTS

Two seasonally matched 26 week intervals were compared with adjustment for demographics, triage category and arrival by ambulance. Overall, there was an 18.4% rise in NEAT performance (95% confidence interval (CI): 17.7-19.1) while ED length of stay decreased by a total of 86.8 min (95% CI: 83.6-90.1). Time series analysis did not suggest any preexisting trends to explain these results. The average time to referral decreased by 74.7 min (95% CI: 69.8-79.6) and waiting times decreased across all triage categories. Rates of MERT activation and unplanned representation were unchanged.

CONCLUSION

A facilitated team leader role for senior doctors can help to reduce length of stay by via early disposition, without significant risks to the patient.

Early lessons from COVID-19 that may reduce future emergency department crowding

The COVID‐19 pandemic has produced significant changes in emergency medicine patient volumes, clinical practice, and has accelerated a number of systems‐level developments. Many of these changes produced efficiencies in emergency care systems and contributed to a reduction in crowding and access block. In this paper, we explore these changes, analyse their risks and benefits and examine their sustainability for the future to the extent that they may combat crowding. We also examine the necessity of a system‐wide approach in addressing ED crowding and access block.

Mental health patients in emergency departments are suffering: the national failure and shame of the current system. A report on the Australasian College for Emergency Medicine's Mental Health in the Emergency Department Summit

OBJECTIVES

Inadequate capacity in Australia's mental health system means that many people turn to emergency departments (ED) in crisis for care and support, often because it is the only service available. Australian Governments have set a 4-h target for all ED care, but the data shows that people presenting to an ED in a mental health crisis are the group most likely to wait more than 24 h for care. These long waits, seemingly with no end in sight, are harmful for patients and deeply frustrating for clinicians.

CONCLUSIONS

In response, in 2018, the Australasian College for Emergency Medicine (ACEM) organised the national Mental Health in the Emergency Department Summit. Delegates from across clinical disciplines and user groups were unified in their deep concern at the unacceptable state of mental health support available to people seeking help through EDs. The Summit identified four priorities for urgent action and urged government to take immediate steps to improve this situation.

Emergency department enlargement in China: exciting or bothering

BACKGROUND

Emergency department (ED) enlargement became a trend with its development. However, there came some problems such as ED overcrowding and increasing medical disputes. Here we did a survey about the development tendency of EDs in 3A grade hospitals in China, analysed the problems we facing and rendered some solutions combining some special characteristics in China.

METHODS

We randomly selected 17 3A grade general hospitals from 12 provinces from the 50 members of Chinese College of Emergency Physician. A questionnaire survey was conducted. The basic information and problems of EDs were collected and analysed.

RESULTS

The gross area, the number of beds and the attention paid by the hospitals of EDs increased during the development, so did the patients admitted to EDs, also more doctors and nurses devoted into emergency medicine. But it had become more difficult for doctors to admit ED patients to inpatient wards. Besides the problem of increasing crowding degree, EDs faced more medical disputes and complains during the development.

CONCLUSIONS

ED expanding was the result of emergency medicine development, but the enlargement of ED should be more rational. We should improve our doctors' medical skills, optimize the health system, pay more attention to preventive medicine and push hard for health-care reform instead of forcing ED enlargement to satisfy the need for ED.

Identifying reasons for delays in acute hospitals using the Day-of-Care Survey method

This paper describes a new tool called 'Day-of-Care Survey', developed to assess inpatient delays in acute hospitals. Using literature review, iterative testing and feedback from professional groups, a national multidisciplinary team developed the survey criteria and methodology. Review teams working in pairs visited wards and used case records and bedside charts to assess the patient's status against severity of illness and service intensity criteria. Patients who did not meet the survey criteria for acute care were identified and delays were categorised. From March 2012 to December 2013, nine acute hospitals across Scotland, Australia and England were surveyed. A total of 3,846 adult general inpatient beds (excluding intensive care and maternity) were reviewed. There were 145 empty beds at the time of surveys across the nine sites, with 270 definite discharges planned on the day of the survey. The total number of patients not meeting criteria for acute care was 798/3,431 (23%, range 18-28%). Six factors accounted for 61% (490/798) of the reasons why patients not meeting acute care criteria remained in hospital. This survey gives important insights into the challenges of managing inpatient flow using system level information as a method to target interventions designed to address delay.

Does volume or occupancy influence emergency access block? A multivariate time series analysis from a single emergency department in Sydney, Australia during the COVID-19 pandemic

OBJECTIVE

The study aims to determine whether ED presentation volume or hospital occupancy had a greater impact on ED performance before and during the COVID-19 health response at a tertiary referral hospital in Sydney, Australia.

METHODS

Single centre time series analysis using routinely collected hospital and ED data from January 2019 to September 2020. The primary outcome was ED access block measured by emergency treatment performance (ETP; i.e. percentage of patients who were discharged or transferred to a ward from ED within 4 h of ED arrival time). Secondary outcomes were hospital occupancy, elective theatre cases and ambulance ramping. Multivariate time series analysis was performed using vector autoregression, to model effects of changes in various endogenous and correlated variables on ETP.

RESULTS

There was an increase in ETP, drop in ED presentations and decrease in hospital occupancy between April and June 2020. Elective surgery and hospital occupancy had significant effects up to 2 days prior on ETP, while there were no significant effects of either ED or ambulance presentations on ETP. Hospital occupancy itself increased with ED presentations after 2-4 days and decreased with elective surgery after 1 day. Shocks (a one standard deviation increase) in hospital occupancy had a peak impact nearly two times greater compared to ED presentations (-1.43, 95% confidence interval -1.92, -0.93 vs -0.73, 95% confidence interval -1.21, -0.25).

CONCLUSION

The main determinants of the reduction of ED overcrowding and access block during the pandemic were associated with reductions in hospital occupancy and elective surgery levels, and more research is required to assess more complex associations beyond the scope of this manuscript.

Improvement in emergency department length of stay using an early senior medical assessment and streaming model of care: A cohort study

OBJECTIVE

Australian EDs are required to conform to the National Emergency Access Target (NEAT): patients must be discharged within 4 h of arrival. The aim of the present study was to determine if a model of care called Senior Assessment and Streaming (SAS) would increase the proportion of patients achieving NEAT.

METHODS

Stable, ambulant patients considered to have problems that early consultant-level assessment was likely to improve processing efficiency were streamed through a dedicated clinical area staffed by an ED physician, intern and nurse. The proportion of patients achieving NEAT were compared between days with or without SAS, adjusted for confounding variables.

RESULTS

The 18 962 patients presented during the study, 6828 on days with SAS, 12 134 on days without. On days with SAS, there were more presentations, more admissions, lower access to ward beds and fewer staff working hours. After controlling for confounding, the odds of meeting NEAT on days with SAS was 15% higher compared with days without (odds ratio, 1.15; 95% confidence interval [CI], 1.07-1.24; P < 0.001). For the subgroups of patients admitted, discharged, triage category 3, 4, 5, or presentation 12.00-18.00 the odds of meeting NEAT on days with SAS was, respectively, 1.10 (95% CI, 0.98-1.23; P = 0.10), 1.17 (95% CI, 1.07-1.28; P < 0.001), 1.17 (95% CI, 1.08-1.27; P < 0.001) and 1.19 (95% CI, 1.06-1.35; P = 0.003). The odds of a patient not waiting to be seen on days with SAS was 28% lower compared with days without (odds ratio, 0.72; 95% CI, 0.58-0.90; P = 0.003).

CONCLUSION

Through the introduction of SAS, the present study has demonstrated that providing early senior medical assessment can improve an ED's ability to meet NEAT.

Age and admission times as predictive factors for failure of admissions to discharge-stream short-stay units

OBJECTIVE

Discharge-stream emergency short-stay units (ESSU) improve ED and hospital efficiency. Age of patients and time of hospital presentations have been shown to correlate with increasing complexity of care. We aim to determine whether an age and time cut-off could be derived to subsequently improve short-stay unit success rates.

METHODS

We conducted a retrospective audit on 6703 (5522 inclusions) patients admitted to our discharge-stream short-stay unit. Patients were classified as appropriate or inappropriate admissions, and deemed successful if discharged out of the unit within 24 h; and failures if they needed inpatient admission into the hospital. We calculated short-stay unit length of stay for patients in each of these groups. A 15% failure rate was deemed as acceptable key performance indicator (KPI) for our unit.

RESULTS

There were 197 out of 4621 (4.3%, 95% CI 3.7-4.9%) patients up to the age of 70 who failed admission to ESSU compared with 67 out of 901 (7.4%, 95% CI 5.9-9.3%, P < 0.01) of patients over the age of 70, reflecting an increased failure rate in geriatric population. When grouped according to times of admission to the ESSU (in-office 06.00-22.00 hours vs out-of-office 22.00-06.00 hours) no significant difference rates in discharge failure (4.7% vs 5.2%, P = 0.46) were noted.

CONCLUSION

Patients >70 years of age have higher rates of failure after admission to discharge-stream ESSU. Although in appropriately selected discharge-stream patients, no age group or time-band of presentation was associated with increased failure rate beyond the stipulated KPI.

The International Federation for Emergency Medicine report on emergency department crowding and access block: A brief summary

OBJECTIVE

To develop comprehensive guidance that captures international impacts, causes, and solutions related to ED crowding and access block.

METHODS

Emergency physicians representing 15 countries from all the International Federation for Emergency Medicine (IFEM) regions composed the task force. Monthly meetings were held via video-conferencing software to achieve consensus for report content. The report was submitted and approved by the IFEM Board on June 1, 2020.

RESULTS

A total of 14 topic dossiers, each relating to an aspect of ED crowding, were researched and completed collaboratively by members of the task force.

CONCLUSIONS

The IFEM report is a comprehensive document intended to be used in whole or by section to inform and address aspects of ED crowding and access block. Overall, ED crowding is a multifactorial issue requiring systems-wide solutions applied at local, regional, and national levels. Access block is the predominant contributor of ED crowding in most parts of the world.

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.

Prolonged length of stay is associated with reduced hand hygiene compliance in the emergency department: A single centre retrospective study

OBJECTIVE

To examine whether patient flow factors in the ED such as prolonged length of stay are associated with hand hygiene (HH) compliance.

METHODS

We conducted a retrospective study at an urban district hospital utilising available data from January 2018 to December 2021. Compliance to the World Health Organization five moments of HH expressed as percentage of total moments observed were collated every 2 months. Patient flow measures including proportion of patients referred or discharged within 4 h (LOS4), proportion of patients with ED length of stay >24 h (LOS24) and total number of patient presentations, were obtained for each 2-month periods. The association between these patient flow measures and HH compliance was examined using Pearson's correlation (P < 0.05).

RESULTS

The results showed a moderate and significant association between rates of HH compliance and LOS24 (r = -0.48, P = 0.025). That is, lower proportion of patients with ED length of stay >24 h was associated with improved HH compliance. There was no significant correlation between HH compliance and LOS4 (r = 0.38, P = 0.085) or total number of ED presentations (r = -0.30, P = 0.17).

CONCLUSIONS

The findings show that prolonged ED length of stay may explain, at least partly, lower rates of HH compliance. Improvements in ED HH compliance should also include strategies that enhance patient flow.

Ambulance offload performance, patient characteristics and disposition for patients offloaded to different areas of the emergency department

OBJECTIVE

Ambulance transfer of care (TOC) is a key performance indicator for New South Wales EDs, with 90% of ambulances to be offloaded within 30 min of arrival. Nepean Hospital ED has a number of strategies to improve TOC, including ambulatory areas where patients can be offloaded immediately. Offload data are supplied by ambulance and there is no study into its accuracy. The aim is to audit the accuracy of ambulance data of TOC compared to times recorded in the Nepean ED information system, and to examine TOC and patient demographics for different offload destinations.

METHODS

A retrospective observational study was performed for patients presenting by ambulance between 1 July and 31 December 2022. TOC was calculated from FirstNet and compared to ambulance data using a paired-sample t test. Patients were categorised by offload destination within the ED and examined for age, TOC, disposition and specialty team if admitted.

RESULTS

TOC for ambulance and ED data was 60.8% versus 64.1%, respectively (difference 3.33%, P < 0.001). Patients offloaded to acute care were older, with 61.9% being >65 years; had a TOC of 37.3% compared to the resuscitation and ambulatory areas with TOC close to 90%; and were likely to be admitted with a 63.8% admission rate and 24.1% of admissions being under the geriatric service.

CONCLUSION

Patients arriving by ambulance requiring an acute care bed were likely to be elderly and frail, and suffered substantial ambulance offload delays. Delays to ambulance offload for these patients is likely driven by acute care bed availability and access block.

An initiative to reduce psychiatric boarding in a Cape Town emergency department

Background

Psychiatric boarding in Emergency Departments (ED) is a global challenge which results in long ED length of stays (LOS) with significant consequences on patient care and staff safety.

Aim

This study investigated the impact of an initiative to reduce psychiatric boarding on LOS and readmission rate, as well as explored the relationship between boarding times and LOS.

Setting

This study was conducted at Mitchells Plain Hospital, a large district-level hospital in Cape Town.

Methods

This cross-sectional study collected data for 24 months, which included a 9-month period prior to the initiative and 16 months thereafter. Data were collected retrospectively from official electronic patient registries. The initiative comprised of inpatient hallway boarding as a full-capacity protocol with the accompanying capacitation of psychiatric wards to accommodate the additional burden.

Results

The initiative was associated with a decrease of 95% (p < 0.001) in boarding time, 13% (p < 0.001) in ward LOS and 25% (p < 0.001) in hospital LOS. Ward LOS were found to be independent of ED boarding times. The readmission rate increased from 12% to 18% post intervention.

Conclusion

The initiative resulted in a sustainable improvement in boarding times and LOSs. The observational nature of this study precludes concrete conclusions and further investigations into psychiatric inpatient hallway boarding are recommended.

Contribution

Inpatient hallway boarding could be a feasible option to reduce the risk. Psychiatric boarding times in the ED are independent of ward LOS, rendering it devoid from any value from a lean and economic perspective.

A brief history of ramping

'Ramping' is a commonly used term in contemporary Australian healthcare. It is also a part of the public and political zeitgeist. However, its precise definition varies among sources. In the published literature, there are distinctions between related terms, such as 'entry overload' and 'Patient Off Stretcher Time Delay'. How ramping is defined and how it came to be defined have significance for policies and procedures relating to the described phenomenon. Through examination of the history of the term, insights are obtained into the underlying issues contributing to ramping and, accordingly, associated possible solutions.

Building a public-private partnership to confront the emergency department boarding crisis

The nation's critically crowded emergency departments have aptly been called "the sentinel canaries in the health care system," given their nexus point between inpatient, ambulatory, perioperative, and long-term care systems. Emergency department boarding-holding or physically keeping a patient in an emergency department after the clinical decision to admit the individual to the hospital-is a critical symptom of overload and breakdown of the more extensive health care delivery system. Despite more than 25 years of incontrovertible scientific evidence that the practice is associated with significant harm, little progress has been made in confronting its structural and economic drivers at a national scale. This article, authored by federal health care leaders, opens the Health Affairs Scholar Featured Series by highlighting the importance of a public-private partnership approach and lays the foundation for a series that will further present a holistic evaluation of the topic, encouraging a multi-faceted approach toward resolving this critical health system issue.

24 hours - Life in the E.R.: A state-wide data linkage analysis of in-patients with prolonged emergency department length of stay in New South Wales, Australia

OBJECTIVE

Describe the characteristics and predictors of mortality for patients who spend more than 24 h in the ED waiting for an in-patient bed and compare baseline clinical and demographic characteristics between tertiary and non-tertiary hospitals.

METHODS

This was a state-wide analysis data linkage analysis of adult (age >16 years) ED presentations across New South Wales from 2019 to 2020. Cases were included if their mode of separation from ED indicated admission to an in-patient unit including critical care ward and their ED length of stay was greater than or equal to 24 h. Cases were categorised by service-related groups based on principle diagnosis.

RESULTS

A total of 26 854 eligible cases were identified. The most common diagnosis groups were psychiatry, cardiology and respiratory. The odds ratio (OR) for 30-day all-cause mortality in admitted patients with an ED length of stay greater than 24 h were highest in those aged >75 years (OR 15.18, 95% confidence interval [CI] 9.99-23.07, P < 0.001), oncology (OR 10.45, 95% CI 7.93-13.77, P < 0.001) and haematology patients (OR 2.95, 95% CI 2.01-4.33, P < 0.001).

CONCLUSION

Interventions and models of care to address ED access block need to focus on mental health patients, older patients particularly those with cardiorespiratory illness and oncology and haematology patients for whom risk of mortality is disproportionately higher.