Dr Katherine Henderson MB BChir FRCP FCEM Consultant in Emergency Medicine London Registrar Royal College of Emergency Medicine UK

The NHS has enough beds to care for patients effectively and safely

 Patients in the Emergency Department (ED) requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame

 The whole patient journey can be affected by exit block ◦ Access to an ambulance ◦ Emergency Department journey ◦ Admission ◦ Delayed discharge to home or community beds  But it is in the ED that the pressure is most obvious

PeriodType 1 attendances Type 1 % <4hrs All A&Es % <4hrs W/E 28/12/ %90.50% W/E 04/01/ %86.70% W/E 11/01/ %89.80% W/E 18/01/ %92.40% W/E 25/01/ %93.00% W/E 01/02/ %92.30% W/E 08/02/ %92.90% W/E 15/02/ %91.60% W/E 22/02/ %92.0%

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

1. Increased patient 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 Over 500,000 patients a year are affected.

Crowding in the ED is associated with increased mortality for patients References in appendix

 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

 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

 AND also significantly 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< )

 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

 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  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%).

 Not well 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.

Fellows and members Toolkit -RCEM guideline:- Advocated in the Department of Health's 'Operational resilience and capacity planning for 2014/15 Guidance) Endorsed by NHS England, Monitor and the Trust Development Association. Themed issue on Emergency Medicine – British Journal of Hospital Medicine Nov 2014

 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  Hospital bed occupancy is so high that beds are not available when you need them.  Once the hospital accepts this possible to make progress  Use the RCEM resources to get the message understood

What it is and Tackling Exit Block