1. Dr Katherine Henderson MA FRCP FCEM Consultant in Emergency Medicine St Thomas’ Hospital London Registrar College of Emergency Medicine UK

2. COI Disclosure I have no relevant relationship or financial/ material support to disclose. Presenter: Dr. Henderson

3.  Crowded- Recognition ◦ Ambulances cannot offload, ◦ There are long delays for high acuity patients to see a doctor, ◦ There are high rates of patients with a ‘Left before being seen’ code, ◦ There are more trolley patients in the ED than there are cubicle spaces, ◦ Patients are waiting more than two hours for an in- patient bed after a decision to admit has been made. ■  ‘Access block’ or ‘exit block’ ◦ Patients in the ED requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame.  Beniuk 2011, Moskop 2009, Hoot 2008, Weiss 2008

4. 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

5.  Crowding is important because it reduces the quality of care that patients receive.  It is also a poor working environment for staff and a difficult environment for learning  A crowded ED represents a crowded Emergency Care system- pre-hospital through to in-hospital

6.  Crowding in the ED is associated with increased mortality for patients

7.  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, 1.1-1.6), 1.3 (95% CI, 1.2-1.5) and 1.2 (95% CI, 1.1-1.3), 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 1998-2008  20–30% increased mortality rate due to access block and ED overcrowding

8.  Design and setting: ◦ Single hospital, Retrospective stratified cohort analysis of three 48-week periods 2002–2004. Mean “occupancy” calculated for 8-hour shifts and for 12-week periods. The shifts of each type in the highest quartile of occupancy were classified as overcrowded (OC v NOC).  Main outcome measure: ◦ In-hospital death of a patient recorded within 10 days of the most recent ED presentation  Results: ◦ There were 34 377 OC and 32 231 NOC presentations (736 shifts each); the presenting patients were well matched for age and sex. Mean occupancy was 21.6 on OC shifts and 16.4 on NOC shifts. There were 144 deaths in the OC cohort and 101 in the NOC cohort (0.42% and 0.31%, respectively; P = 0.025).

9.  The relative risk of death at 10 days was 1.34 (95% CI, 1.04–1.72) ◦ Subgroup analysis showed that, in the OC cohort, there were more presentations in more urgent triage categories, decreased treatment performance by standard measures, and a higher mortality rate by triage category ◦ The magnitude of the effect is about 13 deaths per year. (Department seeing 50,000 pts per year)

10.  Crowding is associated with an increased mortality rate amongst patients considered well enough to be discharged after attending the ED. ◦ Guttman 2011.  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

11.  Objectives. Overcrowding known to affect the care of high acuity patients but most EM patients actually go home and the effect on them unknown, Long waits also associated with increased ‘left without of treatment’ (LWOT) rates. This rate is often quoted as being a patient safety concern.  Design and setting, participants – Ontario large Emergency departments 2003-2007 ◦ The study compared patients with similar levels of illness (based on Canadian Triage Acuity Scale- CTAS) and identified the mean length of stay of the shift they were seen in.  Main outcome measures ◦ The short term outcomes of 13934542 non admitted patients were reviewed. ◦ LOS in the department used as a proxy for overcrowding. ◦ Adverse event defined in this study as death or admission to hospital within 7 days of the index ED visit.

12.  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. ◦ For mean length of stay ≥6 v <1 hour the adjusted odds ratio (95% confidence interval) was 1.79 (1.24 to 2.59) for death and 1.95 (1.79 to 2.13) for admission in high acuity (Triage 1-3) patients and 1.71 (1.25 to 2.35) for death and 1.66 (1.56 to 1.76) for admission in low acuity patients (Triage 4&5).  Contrary to general belief LWOT patients do not show an increase in short term adverse events.

14.  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- 20.2 v 9.8 days (p< 0.00001)

15.  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

16.  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 0.004 to 0.55, P = 0.015  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%).

17.  Crowding is nearly always 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  Once the hospital accepts this it is possible to make progress

18. St Thomas Full to capacity plan 1 of 2 Leicester risk Register Thanks to F. Davies

19. Emergency Care Pathway Escalation Protocol Dr Simon Eccles Consultant in Emergency Medicine Clinical Lead for Transformation

20. Emergency Care Pathway – Escalation Protocol The metrics and triggers:- St Thomas’ Occupancy project Occupancy and waiting times 4pm

21. Emergency Care Pathway – Escalation Protocol 8am Midnight

22. Whole system problem Hallways are not wards

23.  And the community...........  Healthcare system with strong community healthcare 24/7 do not report significant crowding issues (yet?)  Have escalation/ when the hospital full policies agreed in advance  Demonstrate that this is a significant patient safety issue and it cannot be ignored.

24. Dr Katherine Henderson katherine.henderson@gstt.nhs.uk