1. Emergency Department Overcrowding Why Is It Getting Worse? James Quinn MD MS Director of Research, Division of Emergency Medicine

2. We Know There is a Problem ER Conditions Critical. USA Today. February 2001. Code Blue: Crisis in the ER. US News and World Report. September 2001. Overcrowding Spreads into Crisis Territory. Los Angeles Times. October 2000.

3. The problem has been there for a while! The etiology of medical gridlock: causes of emergency department overcrowding in New York City EJ Gallagher J Emerg Med 1990 The witching hour: overcrowded emergency departments. Emerg Med News 1992; 21:40-41 American College of Emergency Physicians, Task Force on Overcrowding: Measures to deal with emergency department overcrowding. Ann Emerg Med 1990; 19:944-945

4. Its Only Getting Worse Visits Increasing Capacity decreasing Hospitals on ambulance diversion 20% of the time 1992 – 2001 Comparison of National Ambulatory Survey - CDC

5. How Many ED Visits? 1992-2000 Source: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 1992-2000 20% increase Number of visits (in thousands)

6. How Many Hospital Beds? 1992-2000 Source: American Hospital Association, Hospital Statistics 16% decrease 4,547EDs 4,177EDs 8% decrease

7. Why is it Getting Worse? A symptom of a larger problem of the healthcare system? - can we afford any system that has excess capacity? Some (policy and decision makers) do not see it as a problem - Overcrowding is poorly defined - We don’t define or measure bad outcomes very well -Is overcrowding an inconvenience or are people having bad outcomes and dying?

8. What Is ED Overcrowding? AHRQ Definition Need for emergency services outstrips available resources More patients than staffed ED beds, long wait times Patients typically treated and monitored in hallways Constrains ability to triage patients

9. Measuring Overcrowding - AHRQ No established way to measure –AHRQ is developing a set of measures Time from arrival to physician contact Number of patients being boarded Boarding time Time on ambulance diversion

10. Defining Overcrowding Survey of 575 ED Directors in the US patients in hallways all ED beds occupied full waiting rooms >6 hours/day acutely ill patients who wait >60 minutes to see a physician. 33% reported that a few patients had actual poor outcomes as a result of overcrowding Derlet, Acad Emerg Med, 2001

11. Poor Outcomes Will Change Policy! How do we define them How do we measure them

12. How Do We Count The Bodies? Measures of Quality Need Better Definitions/ Less Noise -LWBS -Return Visits -Morbidity and Mortality -Errors

13. How Do We Study That Outcome? RCT – Impractical Case Crossover Design – Likely the most useful design for this problem -Useful for studying the transient effects in the environment on outcomes. Maclure, Am J Epidemiol 1991

14. Case-Crossover Design Match on time intervals Case interval is a time interval where the outcome of interest occurs. Matched on the time of day and day of the week when the outcome did not occur. Allows one to look what was occurring in the environment that was associated with the outcome.

15. Examples of Case- Crossover Cell – Phone Car Crash Redelmeier, NEJM 1997 Exercise and Cardiac Arrest Overcrowding and LWBS Quinn and Polevoi, Acad Emerg Med 2003

16. Summary Change will only occur if… 1)We define “Bad Outcomes” 2)We measure them better Need to show that overcrowding is not just an inconvenience. Single cases and opinion are not going to change policy We need an accurate “body count” to change policy