1. Dr Evil's guide to crowding part 1 What we know
Dr Ian Higginson MSc FACEM FCEM Emergency Physician

3. Crowding is EVIL!

4. It’s important
The most important problem facing EDs worldwide

5. Cunning plan
What we know about crowding

6. State of the art
crowding n : a situation in which people or things are crowded together

7. Internationally agreed definition
There is no internationally agreed definition

8. Chicken and the egg Define Measure
Lack of definition makes it hard to define the problem

9. Chicken and the egg Define Measure Causes Effects
… which makes it hard to look at causes and effects …
Causes
Effects

10. Other (not CEM) professional societies

11. We know it when we see it

12. Measures of crowding
Multidimensional
Simple

13. Multidimensional measures
EDWIN
NEDOCS
PEDOCS
ICMED

14. Multidimensional measures
ICMED candidate measures of crowding (Boyle et al)
Ability of ambulances to offload
LWBS rate
Time to triage
ED occupancy rate
Length of stay in the ED
Time to see a physician
ED boarding time
Number of patients boarding in the ED

15. Simple measures Occupancy rate Percentage of ED occupied by inpatients
Physician perception
The gold standard in many studies measuring crowding was: whether ED staff said the ED was crowded
In the UK: 4 hour standard?

16. Occupancy and 4 hour performance
The 4 hour standard actually correlates well with crowding as measured by occupancy (Higginson et al)

18. Pause for thought …… Should we measure bad things like crowding OR
Should we measure good things like flow?

19. Causes Access block (inability to access hospital beds) ED capacity
Occupancy > 90% bad
Occupancy < 85% good?
Inflection point not known
Influence of Trust size, specialised beds, single sex wards, assessment units: not known
ED capacity
Physical space + throughput
Entry overload (high acuity patients)
The old adage that overall hospital occupancy should be less that 85% can be challenged since it is based on a simple system.

20. Not causes
Low acuity patients
ED overcrowding, Higgi, Jan 2011

21. Effects  Morbidity  Mortality  LOS in the ED  LOS once admitted
 Cost
 Patient satisfaction
 Staff satisfaction

22. Effects

23. Effects

24. Effects

25. Solutions Multipronged Using operations research System wide reforms
Strategic planning
Occupancy rates
Improving ED processing capacity
Process redesign
Improved access to diagnostics
Reducing process delays (eg consults, direct admissions)
Getting staffing and skillmix right
Observation / assessment units

26. Not solutions What doesn’t work Ambulance diversion
Demand management (except ? chronic disease)
GPs in the ED
Although colocation may be useful
Building bigger EDs ….. ?

27. Effects

28. Summary of what we know Summary
The most important problem facing EDs in the developed world
Definition and measurement not agreed
Makes it hard to nail down causes, effects … and solutions
UK-specific research is thin on the ground