1. Emergency Department Crowding: What Is It, Is It a Problem, & How Do We Fix It? Jennifer Wiler MD, MBA

2. Q: Is Emergency Department Crowding Problem?

3. Increasing ED Patient Volumes “Hospital Ambulatory Medical Care Survey” 9/06 www.CDC.gov 1994-2004: Annual number of U.S. ED visits rose by 18% (93M to 110M)  EDs decreased 12%

4. ED Becoming Hospital's Front Door Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact- File.html; AHRQ Nationwide Inpatient Sample & Thompson Healthcare Projected Inpatient Databasehttp://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact- File.html % of Inpatient Admissions from ED Is on the Rise

5. ED Becoming Hospital's Front Door Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact- File.html; AHRQ Nationwide Inpatient Sample & Thompson Healthcare Projected Inpatient Databasehttp://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact- File.html Service Line Break Down

6. Aging Adult Population www.princetoncme.com

7. 2006 report - % of pts 65 yo or older with self-reported select chronic conditions during 2 yr period Increasing # with Chronic Conditions & Obesity Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact- File.html;http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact- File.html Kaiser Family Foundation www.statehealth.org

8. Number of Uninsured in Missouri = 14 th Highest In USA Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html; Kaiser Family Foundation www.statehealth.orghttp://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html

9. Increasing Number Of Uninsured Patients… And -- Federal Safety Net Spending Not Kept Pace Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html; Kaiser Family Foundation www.statehealth.orghttp://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html

10. Physicians NOT Accepting Medicaid Patients is On the Rise Modern Physician 11/06

11. Projected Workforce Shortage – Physicians Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact- File.html;http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact- File.html

12. Current* Workforce Shortage – Healthcare Professionals Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact- File.html;http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact- File.html * American Hospital Assoc. survey data Dec 2005

13. Shortage of On Call Specialists Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact- File.htmlhttp://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact- File.html Affecting nearly 75% of all hospitals

14. EMTALA … 1986 Consolidated Omnibus Budget Reconciliation Act (COBRA) –a.k.a. Federally Mandated Uncompensated Care

15. “Back End” Issues Increased Elective Surgery Cases ($$) Decreased Hospital Capacity –Mental Health In Pt Beds At Inpt Capacity –Dec staffing, dec specialty bed availability, inc census = Increased BOARDING (variable definitions)

16. The Result … Your ED Waiting Room Looks Like This And It is Not Just Us...

17. Missouri 13 th Most Busy ED’s in Nation* Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html; Kaiser Family Foundation www.kaiserfamily foundation.orghttp://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html * ED Visits By State: Number of ED visits/1,000 people in 2005

18. % of Hospitals with ED At or Over Capacity Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.htmlhttp://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html

20. “I mean, people have access to healthcare in America. After all, you just go to an emergency room.” President Bush Cleveland Ohio June 10, 2007

21. Many ED’s Report Being On Diversion… Source : http://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html; American Hospital Association, 2007 Survey of Hospital Leadershttp://www.healthleadersmedia.com/content/205614/topic/WS_HLM2_FFL/Fact-File.html 500,000 Ambulance Diversions Qyr  On average one every minute

22. EDs Have No Surge Capacity Hospital Emergency Surge Capacity: Not Ready For The “Predictable Surprise” –34 hospitals in New York City, Washington, Los Angeles, Chicago, Houston, Denver, and Minneapolis (March 25, 2008 at 4:30 p.) –Washington Hospital Center at 286% capacity –“Shortages of" ED "capacity and intensive care beds will grow worse if Bush administration Medicaid changes are implemented…the Department of Health and Human Services "has issued three Medicaid regulations that will reduce federal funds to public and teaching hospitals by tens of billions of dollars over the next five years," which could further exacerbate the situation. Chairman Rep. Henry A. Waxman (D-CA)

23. IOM 2006: “Hospital Based Emergency Care – At The Breaking Point” Many EDs and trauma centers are overcrowded. Emergency care is highly fragmented. The emergency care system is ill-prepared to handle a major disaster. EMS and EDs are not well equipped to handle pediatric care. www.iom.edu

24. Q: Is Emergency Department Crowding a Problem? A: YES

29. And It Is Not Just the USA Australia UK Korea Canada Greece

30. ED Crowding/Boarding Effects Prolonged Pt Wait Times Inc Pt Dissatisfaction/ Inc Pt Complaints Dec Staff Satisfaction (Inc turnover, Inc cost) Decreased Physician Productivity Increased Pt Violence Against Physicians

31. ED Crowding/Boarding: Worse Outcomes Adverse Outcomes –Significant increase in serious complications (~6 vs.3%) ACS pts during crowding 1 –Overcrowding causes deaths. 2 High occupancy est. to cause 13 pt deaths/yr –Overcrowding increases errors & complications. 50% sentinel events causing serious injury/death occur in ED ~1/3rd related to crowding 3 Reduced Quality –Inc door to needle time 4 –Worse treatment of pain 5 Impaired Access (Diversion & LWBS) Pts who LWBS 2x likely to report worsened health problems 6 1 Pines JM, Hollander JE. the emergency department to the intensive care unit. Crit Care Med. 2007; 35(6):1477-1483. 3 Joint Commission. Sentinel Event Alert, June 17, 2002; http://www.jointcommission.org/sentinelevents/ statistics. Accessed 4 June 2007.); 4 Schull 2004; 5 Hwang, 2006; 6 Bindman, 1991.http://www.jointcommission.org/sentinelevents/

32. ED Crowding/Boarding: More Costly Boarding Increases the Total Hospital LOS 1 –Est inc cost $6.8M over 3 yrs –Worsening access Boarding Increases Walkouts 2 –Lost hospital revenue $204/pt Increased Ambulance Diversion 3 Increases Medical Negligence Claims 4 1 Krochmal P, Riley TA. Increased health care costs associated with ED overcrowding. Am J Emerg Med 1994; 12(3):265-266.; Richardson B. The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay. Med J Aust. 2002; 177(9):492-495.; Liew D, Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust. 2003; 179(10):524-526. 2 Richardson DB, Bryant M. Confirmation of Association between overcrowding and adverse events in patients who do not wait to be seen. Acad Emerg Med. 2004; 11(5):462.3. 3 Burt CW, McCaig LF. Staffing, Capacity, and Ambulance Diversion in Emergency Departments: United States, 2003–04. Advance data from vital and health statistics; no. 376. Hyattsville, MD: National Center for Health Statistics. 2006. 4 ED Crowding: High Impact Solutions www.acep.com

33. Q: What Is Crowding?

34. Crowding – What Is It? You just know…

37. Crowding – What Is It? No Consensus on Definition –Staff do not agree (Reeder, 2003) –Ambulance Diversion –LWTC (LWBS) –Boarding ACEP “Crowding occurs when the identified need for emergency services exceeds available resources for patient care in the ED, hospital, or both.” “…measure flow - not crowding” (Asplin, 2006) Surrogate Markers of Crowding

38. Crowding Models NEDOCS (National ED Overcrowding Scale) EDWIN (ED Work Index) READI (Real-time Emergency Analysis of Demand Indicators) Work Score ED Occupancy Rate EDCS (ED Crowding Scale) Discrete Event Simulation Queuing Theory = ∑ n i t i /N a (B T -B A ) = sum of ESI (t i ) of all active patients (n i ) in ED / number of attending physicians each hr (N a ) x # currently available tx bays (B T ) – (B A ) = (Total # pts in ED)/ Total #ED treatment bays/hr = a(pts in waiting rm/#ED tx ∑ nt areas) + b(∑ reverse ESI/#nurses) + c(boarders/#ED tx areas) Using: Total #pts in ED, #tx spaces, patient arrivals, pt acuity, #staff Calculate: bed ratio, acuity ratio, provider ratio, demand value Uses: # attendings, # staffed beds, # critical care pts, #total staffed hospital beds, hospital occupancy Uses: total #ED beds, #inpt beds, total #ED pts in ED, total # pts on ventilator, longest current pt stay (hrs), total # pts in ED boarding, (hrs) last pt placed in ED tx rm

39. Q: How Do We Fix ED Crowding?

40. TJC Implemented a new leadership standard “Managing Patient Flow”, which mandates that hospitals, “… develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital”. TJC January 2005

41. How Do We Fix It? Myths: –It Is an ED Problem –Uninsured Are the Problem –Non-Urgent & “Frequent Flier” Pts are Problem –Build More Beds –Pts Who LWBS Are Not Sick –Arrival Pattern of Patients is Unpredictable Medicaid and SCHIP pts use ED 2x more often than uninsured and 4x more than insured* Hospital “Back End” Problem * www.heritage.org 12/8/07; ** EDBA 2008 Data;  CDC/NCHS, *** Baker, 1991www.heritage.org Does not fix boarding problem Highest ED utilization is by NH pts (2 nd by infant <1 year old) ** 46% pts who LWBS needed immediate medical attention, 11% hospitalized in next wk. “Too sick to wait ” *** Arrival rate is very predictable by hr per day 

44. ED Crowding Solutions ED Operational Improvements Regionalized IT healthcare networks (RHIO) Increase State Subsidies for Uncompensated care Access to Emergency Medical Service Act (HR 882; S 1003) Liability Protection for EMTALA Providers Deferral of Care –“You don’t have emergency today…copay please” –Houston, Denver, Others –http://abcnews.go.com/Video/playerIndex?id=2561039&affil=kdnlhttp://abcnews.go.com/Video/playerIndex?id=2561039&affil=kdnl UK Model (98% Disposed within 4 hrs)

45. How Do We Fix ED Crowding?

46. High Impact, Low Cost Solutions Move Admitted Pts Out of ED to Inpatient Areas –i.e. Hallways, Conference Rms, etc. DC of Inpts before Noon Coordinate Scheduling of Elective & Surgical Pts

47. Others Solutions – ED Based Bedside Registration Limit triage to what is crucial & bypass triage altogether when beds are available Close the waiting room Physician Triage Use protocols and order sets Observation Units Fast Track Units Minimize silos within the ED Use scribes for documentation Electronic medical record (EMR)

48. Others Solutions – ED Based Establish clearly defined turn-around-time (TAT) goals Decrease turnaround times associated with ancillary services Define response times for both initiation & completion of consultations Monitor individual practitioners in the ED Deferred care of nonurgent patients Expand the size of the ED Staff to Match Volume (Inc staffing during times of increased volume/demand)

49. Hospital Wide Actions Cancelling elective surgeries Creation of an institutional awareness of the dangers associated with ED crowding due to boarding of emergency patients. Match resources to needs. Move toward a 24/7 operational culture. Coordinate the scheduling of elective patients and surgical cases. Address delays in moving emergency patients admitted to the hospital caused by nursing reports. Have all inpatient services managed by hospitalists, and have all ICUs managed by intensivists.

50. Use discharge lounges for patients awaiting discharge. Hire a “bed czar” unit. Consider the use of a generic admission order set initiated by the ED. Establish hospital-wide protocols for addressing capacity issues in the emergency department & implement an alert system when the hospital is over capacity. Cancel elective admissions when hospital capacity is at maximum. Hospital Wide Actions

52. Thank You