Despite the fact that ED crowding is associated with a range of concerning outcomes, including higher mortality rates, higher rates of complications, and increased errors, there is new evidence many EDs are leaving proven strategies for improvement in this area on the table. In a study looking at crowding at U.S. hospitals from 2007-2010, researchers found that while the adoption of interventions to reduce crowding has increased, some of the most crowded EDs have failed to take advantage of approaches that have been shown to work.1
Leah Honigman Warner, MD, MPH, an attending physician in the Department of Emergency Medicine at Long Island Jewish Medical Center in New Hyde Park, NY, and the lead author of the study, notes that the data suggest ED crowding is still not a priority at many hospitals.
“ED crowding has become increasingly commonplace and I worry that a crowded ED is now the new status quo, which reduces the incentive to change,” she explains. “Additionally, since the influx of patients to the ED cannot be easily controlled, on first glance ED crowding might seem difficult to change. However, many [interventions] actually affect the efficiency by which patients are cared for in the ED or reduce the amount of time admitted patients are kept in the ED.”
Researchers evaluated the adoption of both ED-based and hospital-level interventions. The ED-level tactics reviewed included:
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bedside registration;
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use of an electronic tracking system or dashboard;
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computer-assisted triage, which involves using algorithms to improve the reliability of triage decisions;
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zone nursing, which ensures that all of a nurse’s patients are in one area;
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establishment of a fast-track area for patients with minor illnesses or injuries;
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increasing the number of ED beds;
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physically expanding ED space;
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establishment of an ED-based observation unit;
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radio frequency identification (RFID) tracking, in which patients receive tags so that their physical location can be tracked and monitored throughout their ED stay.
The hospital-level tactics reviewed included:
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bed census availability or a system that lets staff know the number and type of beds that are available;
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avoiding elective admissions during ambulance diversion;
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pooled nursing or maintaining supplemental staff who work on a flexible schedule based on patient volume;
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use of a bed czar whose job is to manage beds hospital-wide and to ensure the efficient transfer of ED patients to inpatient beds;
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full-capacity protocol, in which admitted ED patients are moved to inpatient areas so that the burden of patient boarding is not borne entirely by ED staff;
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transfer of boarded patients to inpatient hallways, similar to full-capacity protocol;
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establishment of a separate operating room for ED patients;
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surgical schedule smoothing, which involves planning surgical procedures over six or seven days to match the availability of inpatient beds.
Take a multidisciplinary approach
Investigators found that the average number of interventions adopted increased during the four-year study period from 5.2% to 6.6%. However, while the most crowded EDs increased their implementation of crowding interventions, their adoption of interventions that have been shown to work was still lacking. For instance, researchers found that 19% of the most crowded EDs did not use bedside registration and that 94% did not adopt surgical schedule smoothing. (See below: “Focused effort boosts throughput, efficiency.")
Why wouldn’t hospitals take advantage of proven strategies? The reasons most likely vary, but investigators acknowledge that addressing a problem like crowding is not an easy process for a hospital.
“It involves putting together a multidisciplinary team that needs longitudinally to conduct quality improvement interventions. Sometimes it involves buying technology to try to facilitate some of the interventions, which can involve costs. It is not something that has an easy fix,” explains Jesse Pines, MD, MBA, director of the Office of Clinical Practice Innovation and a professor of emergency medicine and health policy at the George Washington University School of Medicine and Health Sciences and a co-author of the study. “It requires both considerable staff time and often trying to change the culture of how people operate within the hospital. The reason a lot of hospitals haven’t done it is because although there are evidence-based fixes out there, they are hard to achieve and they involve a lot of time and energy.”
However, Pines adds that it is clear some hospitals have prioritized crowding while others have not.
“What we found in the study is that many of the hospitals that were most crowded really had not implemented a lot of these interventions that are easier to do,” he says.
For example, Pines notes that bedside registration, in which registrars enter the ED so that they can register patients right from their beds, thereby eliminating a step from the process, is not particularly difficult to implement, but he notes that many hospitals have not moved to implement this intervention.
Embrace systemic solutions
Investigators note that some hospitals have failed to implement two proven interventions that can be implemented at little or no cost: surgical schedule smoothing and full capacity protocol. But Pines acknowledges that while these interventions require little in the way of resources, they are not necessarily easy fixes.
“With the full capacity protocol, [for example], you’ve got to work with both the ED and other departments at the hospital and come to an agreement of what the hospital is going to do when the ED is overrun with patients, and that is even harder than getting stakeholders in the ED to agree on making a change,” he explains. “There is still in many hospitals a silo mentality where everyone is trying to protect their own units — the ORs, the ED, the ICU, and the hospital floors — and there is not a great priority to improve flow throughout the hospital.”
However, while many of these units or floors have a fixed capacity, the ED has no top-off valve, Pines observes.
“People will continue to come to the ED regardless of whether there is space, so that tends to really disadvantage EDs because there is no right of refusal in the ED,” he says.
Another issue that can come into play is economics, according to Pines. That may, for example, be why hospitals may continue to perform elective procedures even while their ED is on diversion.
“Elective procedures tend to have higher margins than patients who are admitted through the ED, so despite losing the influx of low-margin patients, hospitals make the economic decision to maintain the inflow of high-margin patients because they are more profitable,” he explains.
Economics also may have something to do with the finding that the number of ED-based observation units actually declined during the study period, although Pines acknowledges that he was surprised by this decline.
“ED observation units can be very effective, particularly at reducing admissions for patients who just need short-term hospital care,” he explains, noting that patients with such conditions as chest pain, cellulitis, or asthma are often treated in observation units. “The fact is that you can bill more for an inpatient bed than for an observation bed in the ED, so in a world where you think you can fill beds with patients who will have a full admission to the hospital, it would make sense to focus on creating more inpatient beds.”
Warner observes that the hospitals that have been successful at addressing ED crowding are those that embrace systemic solutions.
“ED leaders should collaborate with hospital leadership to develop solutions to reduce crowding. There are many evidence-based interventions, both which we evaluated as well as others, that should be considered,” she says. “Some would simply require a change in protocol [inpatient boarding through a full capacity protocol], while others would require changes in staffing [pooled nursing and surgical schedule smoothing]. Other interventions require more capital investment, such as upgraded technology or the creation of new treatment space [observation units or fast tracks].”
Warner adds that once ED crowding is recognized as an issue that affects the entire hospital, it should be easier to find successful solutions.
Hold leaders accountable
Pines is calling for a national strategy to hold hospitals accountable for flow in the ED. He notes this has already begun with new measures for patient flow, and he hopes to see the issue gain more prominence in pay-for-performance initiatives.
Pines would also like to see the United States follow the lead of other countries in adopting limits for how long a patient can remain in the ED, with hospital leaders held accountable for their performance in adhering to such limits.
“The United Kingdom, back in 2003, implemented what is called the four-hour rule where patients could only be in the ED for up to four hours. Beyond that was unacceptable, and hospital leaders would be held responsible,” he explains. “Since then, the rule has been relaxed, but there are still major priorities for ED flow in the United Kingdom.”
Similarly, Pines notes that Australia’s rule does not allow patients to spend more than eight hours in an ED.
“Personally, I think that is a more reasonable target, given the complexity of patients that are seen in the ED, and the time it actually takes to sort out whether they need to be admitted,” Pines observes.
REFERENCE
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Warner L, et al. The most crowded U.S. hospital emergency departments did not adopt effective interventions to improve flow, 2007-10. Health Aff 2015;34:2151-2159.
SOURCES
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Jesse Pines, MD, MBA, Director, Office of Clinical Practice Innovation, and Professor, Emergency Medicine and Health Policy, George Washington University School of Medicine and Health Sciences, Washington, DC. E-mail: [email protected].
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Leah Honigman Warner, MD, MPH, Attending Physician, Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, NY. E-mail: [email protected].
Focused effort boosts throughput, efficiency
During an 18-month period, 42 hospitals in 16 communities worked collaboratively to improve patient flow, and the results are encouraging. Investigators reported that two-thirds of the participating hospitals showed improvement on at least one of four measures:
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discharged length-of-stay (LOS);
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admitted LOS;
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boarding time;
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left without being seen (LWBS) rate.1
The hospitals were invited to participate through the Aligning Forces for Quality (AF4Q) program, an initiative of the Princeton, NJ-based Robert Wood Johnson Foundation. Each hospital identified one or more interventions that they intended to implement to improve patient flow, and then submitted data on the four measures. In addition, the hospitals regularly provided reports about any challenges they encountered and solutions to these challenges. Investigators reported that the 42 hospitals implemented a total of 172 interventions between October 2010 and March 2012. Among the two-thirds of participants that showed improvement, the average reduction in discharged LOS was 26 minutes, the average reduction in admitted LOS was 36.5 minutes, average reduction in boarding time was 20.9 minutes, and LWBS rates declined by 1.4 percentage points. While most participants demonstrated improvement during the collaborative, investigators reported that 14 hospitals did not make any progress on patient flow.
Jesse Pines, MD, MBA, a study co-author, observes that it is clear that to be successful in any type of quality improvement (QI), several ingredients are necessary. “You need a local leader who can be a champion. You need the support from management over time where it is really a priority and where whatever unit is trying to make a change gets the resources they need. You need the ability to look at data. You really need staying power over time so that [the QI effort] is not just a flash in the pan that is important for a couple of weeks and then goes away,” Pines says. “You really do need a sustained effort to keep things going. There is a tendency to slide back to the old way of doing things and you see this in many examples of quality improvement.”
Pines explains that, not unexpectedly, investigators traced improvement to these four key ingredients in the 42-hospital collaborative. “The hospitals that were not able to really have a champion, engaged leadership, and sustained power over time were not able to improve their ED flow in any real way and sustain it over time,” he says. However, Pines observes that collaborative efforts, through which participants regularly share solutions and ideas with each other, are very effective at keeping people engaged so that successful interventions can be sustained. “When there is peer-to-peer coaching, and you can hear the lessons from other people who are trying to do something similar … that can be very effective at [helping people] conceptualize how to do things locally,” he says.
REFERENCE
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Zocchi MS, et al. Increasing throughput: Results from a 42-hospital collaborative to improve emergency department flow. Jt Comm J Qual Patient Saf 2015;41:532-553.
