1. The Safer Care Committee The College of Emergency Medicine Why is Crowding an Important Issue? Dr Susan Robinson 20 th October 2014

3. Why is Crowding an Important Issue? 85 patients in the ED 10 ambulances waiting to offload 3 patients in the ambulance for >1hr 15 on the inbound Delayed diagnosis ischaemic bowel Missed diagnosis of ACS Failed sepsis 6 in all cases

6. What is Quality? Safe – avoiding harm Effective – providing care based on evidence Patient-centred – care that is respectful and responsive Timely - reducing delays for those who receive and give care Efficient – avoiding waste Equitable – avoiding variation in quality because of personal or geographical location Crossing the Quality Chasm (Institute of Medicine 2001)

7. Safety - Mortality 43% increase in mortality 10 days post admission via a crowded ED Richardson DB et al. Med J Aust 2006;184:213-6

8. Plunkett PK et al. Eur J Emerg Med 2011;18:192-196 Safety - Mortality

9. Chalfin DB et al. Crit Care Med 2007;35:1477-83 50,322 ICU admissions Median hospital LOS 7.0 (delayed) v. 6.0 days (non-delayed) (p <.001) ICU mortality 10.7% (delayed) v. 8.4% (non-delayed) (p <.01) In-hospital mortality 17.4% (delayed) v. 12.9% (non-delayed) (p <.001) Safety - Mortality

10. Patient Outcome - Mortality 1296 patients requiring resuscitative procedures In those with a delay in resuscitation Mortality in ED higher OR, 3.39; 95% CI, 1.22-9.45 Mortality in hospital higher OR, 3.36; 95% CI, 2.28-6.88 Hong KJ et al. Am J Emerg Med 2013;31:509-15

11. Guttmann A et al. BMJ 2011;342:d2983

12. Safety – Adverse events All patients > 65 years 75% experienced prolonged ED LOS At least 1 AE in 14.3% of case notes For every 1 hr spent in the ED, the odds of experiencing an in hospital AE increased by 3% Those with AE had x2 LOS (20.2 v 9.8 days, p<0.00001) Ackroyd-Stolarz s et al. BMJ Qual Saf 2011;20:564-569

13. Efficiency Readmission rates for AMI r =0.14, P<0.001 Readmission rates for Pneumonia r = 0.17, P < 0.001 Central line infections r = 0.37, P <0.001 Mullins PM et al. Am J Emerg Med 2014; 32:634-39

14. Efficiency ED stay 4-8 hrs increases inpatient LOS by 1.3 days ED stay >12 hrs increases in patient LOS by2.35 days Liew D et al. MJA 2003; 179;524-526

15. Timeliness - CAP 28% of patients received antibiotics within 4 hrs when waiting room occupancy and ED LOS in highest quartile v 69% in lowest quartiles. Pines JM et al. Ann Emerg Med 2005;50(5):510-16

16. Time Timeliness – Time to Analgesia Sills M et al. Acad Emerg Med 2011;18(12):1330-38 decrease the likelihood of timely treatment by as much as 47% increase the likelihood of no analgesia by as much as 17%

17. Timeliness – Time to Analgesia 13,758 patient with severe pain Non administration associated with numbers in waiting room and occupancy rate OR = 1.03 for each additional waiting patient. CI 1.02 -1.03 OR = 1.01 for each 10% increase in occupancy; 95% CI = 0.99 -1.04 Pines JM et al. Ann Emerg Med 2008;51:1-5

18. Patient Centred Care Not informed about prolonged waits ass with greater dissatisfaction OR = 0.48; 95% CI = 0.39 to 0.57 Sun BC et al. Ann Emerg Med 2008;51:426-34

19. Patient Centred Care Preference for boarding in a ward corridor Garson CHJ et al. Ann Emerg Med 2008;51:9-12 Patient satisfaction increases with boarding in a ward corridor Viccellio P, Ann Emerg Med 2008;51:13-14

20. Lack of Privacy

21. Quality indicators

22. The College of Emergency Medicine

24. The standard we walk past is the standard we accept…. Lieutenant General David Morrison Chief of Army, Australian Army