Why Crowding matters Dr Katherine Henderson FRCP FCEM Registrar Royal College of Emergency Medicine UK Consultant in Emergency Medicine St Thomas’ Hospital London

Crowding is important because it reduces the quality of care that patients receive Crowding is most frequently caused by exit block – Exit block can compromises the care of an individual patient requiring admission and affect the care of everyone else by causing crowding. Crowding also creates a poor working environment for staff and a difficult environment for learning Why Exit block and crowding matters

Exit block definition Patients in the Emergency Department (ED) requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame. This means Exit block is directly related to hospital indicators other than just ED attendance and admission rate Bed availability- total number of beds Bed occupancy rate including delayed transfer of care patients Elective workload ‘Exit block is the single most serious ‘pathology’ in the Emergency Care Pathway’

Exit block across the Emergency Pathway The whole patient journey can be affected by exit block Access to an ambulance Emergency Department journey Admission PROCESS- timeliness and ‘right ward’ Delayed discharge to home or community beds and provision of appropriate social care But it is in the ED that the pressure is most obvious

We know it when we see it

The 4 hour target national performance – what does it tell us

4 hr target breaches Wales

8 hours in the ED Wales

The worry – 12 hours in ED

Size of the problem Between and the number of admissions for patients aged between 60 and 74 increased by 10,913. This equates to an increase of 9.22%. For patients aged 75 and over this number increased by 12,693. This equates to an increase of 13.01%.

When crowded?- Simple measures Physician perception The gold standard in many studies measuring crowding was: whether ED staff said the ED was crowded Occupancy rate Percentage of ED occupied by inpatients In the UK: 4 hour standard, >6 hrs, >8 hrs >12 hrs in the dept. International Crowding Measure in Emergency Departments (ICMED)

Exit block and crowding is a patient safety issue Crowding in the ED is associated with increased mortality for patients

The evidence 1.Increased mortality 2.Increased Length of stay (LOS) of admitted patients. 3.Delayed time critical intervention a)Less frequent and less adequate pain relief b)Delayed antibiotic administration 4.Associated with increased risk of adverse events 5.Decreased departmental function – ‘under triage’, inferior care in terms of standard performance measures, increased Left without Treatment (LWOT) rates, blockage to ambulance off load.. 6.Decreased patient satisfaction 7.Staff stress and burnout

Mortality  Multiple papers show the patient safety problem ◦ Richardson 2006  The relative risk of death at 10 days was 1.34 (95% CI, 1.04–1.72) ◦ Sprivutis 2006  Overcrowding was associated with an increased Day 2, Day 7 and Day 30 hazard ratio for death of 1.3 (95% CI, ), 1.3 (95% CI, ) and 1.2 (95% CI, ), respectively. ◦ Singer 2011  Hospital mortality and hospital LOS are associated with length of ED boarding ◦ Richardson 2009  High hospital occupancy is associated with ED exit (access) block and overcrowding which is associated with an increased mortality rate. ◦ Forero 2010  Literature review  20–30% increased mortality rate due to access block and ED overcrowding

Mortality in discharged patients Crowding is associated with an increased mortality rate amongst patients considered well enough to be discharged after attending the ED. Guttman Presenting during shifts with longer waiting times is associated with a greater risk in short term death and admission to hospital for non admitted patients. LWOT patients do not show an increase in short term adverse events

Guttmann A et al. BMJ 2011;342:d2983

Crowding-Length of stay and adverse events  Significant increased risk of an adverse event as an inpatient. ◦ The association between a prolonged stay in the Emergency Department and adverse events in older patients admitted to hospital: a retrospective cohort study ◦ Ackroyd-Stolarz 2011  Every hour spent in the ED the odds of experiencing an AE in hospital increases by 3%  Experiencing an AE doubles LOS in hospital v 9.8 days (p< )

Lack of Privacy

Quality of Care Critical interventions Documented lower quality of care Pneumonia Jo 2012 Emergency department crowding is associated with 28-day mortality in community-acquired pneumonia patients Pain relief in hip fracture Hwang 2006 Less frequent and less adequate pain relief ED crowding associated with deceased documentation of and increased time to pain assessment

Departmental function Decreased departmental function Richardson 2009 ‘under triage’, inferior care in terms of standard performance measures, increased Left without Treatment (LWOT) rates, mortality still increased even accounting for triage differences- suggesting an element of under triage during overcrowded shifts. Patients time to assessment not meeting Australasian College of Emergency medicine standards. Fatovich 2005 blockage to ambulance off load. Increased crowding led to ambulance diverts and decreased ambulance performance

Patient and Staff views Decreased patient satisfaction Tekwani 2013 The likelihood of failure to meet patient satisfaction goals was associated with an increase in average ED occupancy rate (odds ratio [OR] 0.32, 95% confidence interval [CI] 0.17 to 0.59, P < 0.001) and an increase in EDWIN score (OR 0.05, 95% CI to 0.55, P = Staff stress and burnout Bond 2007 A survey of ED directors, 62% of whom reported overcrowding as a major or severe problem during the past year. They perceived ED overcrowding to have a major impact on increasing stress among nurses (82%).

Why the need to raise awareness Not always recognised outside the ED. No awareness of the patient safety implications. No awareness of the effect on staff. If you work in the ED you know exactly what it feels like working in a gridlocked department. If you work on an admission ward you know what it is like to see the same patient ward round after ward round waiting for community placement

Recent RCEM publication

What are our key recommendations ? Trust Boards need to recognise the patient and staff issues of exit block and crowding It should be considered unacceptable to allow patients and staff to manage under these conditions Full capacity plans in place Delayed transfers of care must be addressed by health and social care. Plus- Ambulatory models maximised and supported.

What to do about it – get it understood- it matters Crowding is because of exit block Exit block is not a problem that can be owned by the ED in isolation from the rest of the hospital There is a clear link between the front door and the back door – DTOC patients matter very much to everyone in the pathway Once the hospital accepts this possible to make progress

Eliminating Exit block Whole system focus on ‘right patient, right place’ ‘Improving “patient flow” throughout the hospital is vital’ Collaborative working between hospital teams Whole system focus on reducing delayed transfers of care so that patients who no longer benefit from acute hospital care get what they need, where they need it. Collaboration between health and social care. Support service availability 7/7 especially late into the evening

Questions?