Table of Contents
ED overcrowding and bed access block
see also:
summary
- ED bed access block in Australia is defined as the delay patients who need hospital admission experience in the emergency department (ED) when their inpatient bed is unavailable and occurs once that delay exceeds 4 hours
- ED access block and overcrowding is a whole of hospital issue and is NOT caused by the ED and as such NEAT targets were introduced with aims to have ED LOS reduced to less than 4hrs as a mechanism to bring about culture and process changes throughout the hospital, not just in ED.
- ED access block results in ED overcrowding which in turn reduces the number of available ED patient treatment spaces available for patients who present, which leads to prolonged waiting times, longer ED length of stay, further ED overcrowding, increased morbidity and mortality, increased inpatient length of stay and inpatient morbidity and mortality, and increased rates of failure to wait to be seen in ED and resultant unmanaged clinical risks.
- once you reach a critical level of occupancy, clinical adverse events increase dramatically
- high occupancy adds complexity to the management of patient flow and beds
- NEAT is strongly related to cases per hour ie the more cases, the more likely the breach.
- if the hospital system activity level falls below or exceeds an optimal level, NEAT breaches rise
- Access block is minimally effected by cases per hour, but more strongly effected by occupancy of the hospital 1)
quantifying ED over-crowding
US National Emergency Department Overcrowding Scale (NEDOCS)
- the proprietary NEDOCS calculator yields a score between 0 and 200 and utilizes a number of variables2), including:
- institutional constants: ED and hospital beds
- common elements: number pts in ED, number of critical care pt, longest door-admit times
- model specific: number pts in ED awaiting a bed, wait-cubicle time for last patient called in
- 0–20 (green) = Not busy
- 21–60 (yellow-green) = Busy
- 61–100 (yellow) = Extremely busy but not overcrowded
- 101–140 (orange) = Overcrowded
- 141–180 (red) = Severely overcrowded ⇒ ramp-up resources, eg. “HEWS alert” open beds, call in EP to do wait room medicine, etc
- 181–200 (black) = Dangerously overcrowded ⇒ consider ambulance bypass, open up more capacity, staff, IP staff see new pts in ED
- > 200 = Disaster
strategies to reduce ED overcrowding
reduce patient demand on ED
- improve primary prevention of illness and trauma
- improve management of chronic conditions
- reduce hospital failed discharge rates
- ensure patients discharged from hospital are able to be reviewed in a non-ED environment if complications or issues arise
- ensure discharges from hospital are optimally risk managed
- ensure ED and GP processes and patient costs do not encourage non-emergent patients to present to EDs
- ensure patients have timely and appropriate alternatives to ED such as rapid access specialty outpatient clinics
- reduce need for nursing home patients to be managed in an ED
- nursing home patients usually require an ED trolley or bed for the duration of their stay and can be a major component of ED overcrowding, particularly as they generally need to wait for ambulance transfer back to their nursing home
- the stresses and noise of ED's generally increase rates of delirium in this cohort
- aged care liaison teams and community geriatrician teams are important in optimising care without transfer to ED, and if possible they should be able to directly admit to hospital without transfer to ED
- ensure load balancing of patient load is optimised between ED's within a region
- ambulance control processes to redirect ambulances:
- hospital ambulance bypass and HEWS processes
- ED ambulance ramping as indicator of the ED being over-whelmed
- improved utilisation of ED workload data and critical care bed availability by the ambulance service
- improved liaison with LMO's:
- easier access for LMO's to discuss cases with ED doctor BEFORE sending the patient to ED allows opportunities for ED doctors to advise on alternative care options where appropriate and minimise inappropriate presentations to an ED or excessive waits for a non-emergent issue (eg. hospital does not have that speciality, ED does not have access to the desired intervention such as an ultrasound examination)
- empower patients with appropriate advice on alternative options at triage
- high clinical risk patients (triage 1-3) should be strongly encouraged to remain at that ED, other patients may choose to go to an alternative if more timely and appropriate care is likely
improve ED processes to shorten ED length of stay
- efficient IT support systems
- patient flow supports
- risk management supports and flagging at risk scenarios
- improved communication between team members
- decision support systems
- hospital systems knowledge support systems - clinical guidelines, roster systems, communication systems
- reduce duplication and waste
- early senior clinician assessment and ordering of investigations
- front of house rapid assessment teams
- early senior clinician supervision and clinical decision making support for junior medical staff
- avoids unnecessary investigations which may prolong ED length of stay
- hastens referral to investigations or to inpatient units
- reduces delayed diagnoses or misdiagnoses
- faster pathology and radiology result turn-around times
- on-site investigations
- results “pushed” to clinicians
- ensure adequate number of cubicles are kept free to continue the assessment process for those not needing a ED trolley
- “fast track” for low complexity conditions or single limb injuries
- ability to assess and continue investigation in ED observation units
- reduce ED waste by creating processes to reduce inpatient unit referral refusals
- rapid access to inpatient units to assess in ED:
- aims:
- expedite admission processes
- expedite decision making and planning alternatives to admission
- requires dedicated medical and surgical teams who preferably do not have roles external to the ED, in particular, should not be unavailable to the ED for lengthy periods due to requirement of being in theatre, etc.
- use of transit lounges for those awaiting transport from ED
- increase physical spaces for treatment and assessment
- increase ED staffing to meet patient demand levels
- reduce need for ED to act as an high acuity ward
- improve access to HDU, ICU, CCU, high acuity mental health beds
- up skill wards with ability to manage higher acuity patients
- improved ED discharge planning
- early booking of ambulances
- early decisions to discharge
- nurse-initiated discharges for certain cohorts
- ED Discharge Initiative Nurse (EDDI)
- advanced practice ED nurse
- free up time for medical staff by consulting and educating patients for discharge
- supports to assist in early ward admissions
- processes and staffing to support early transfer to ward, interim care plans and medication chart completion when inpatient units cannot complete in a timely manner
reduce ED access block
- reduce number of admissions
- role of care coordinators to assist with community supports
- role of inpatient units to create alternative options of care
- role of Hospital-in-the-Home
- role of “frequent flyer” intervention programmes
- reduce inpatient length of stay
- reduce unnecessary investigations, interventions and waste
- reduce complication rates
- reduce ED LOS
- adequate senior clinical supervision
- investigation result checking processes
- clinical decision support systems and guidelines
- reduce medication errors:
- pharmacist in ED and on wards reviewing charts and supporting clinicians
- IT support systems - electronic prescribing
- reduce time pressures on clinicians
- more frequent clinical review and earlier decision making
- expedite investigations or interventions which need to be performed prior to discharge
- role of medical assessment and planning units (MAPU):
- higher intensity multi-discipline care for 24-72hrs
- higher priority access to radiology, interventions
- can reduce mortality and morbidity, inpatient LOS and ED access block substantially
- improved liaison and integration with post-discharge care such as rehabilitation services, residential care
- improved community support systems
- early discharge planning
- use of transit lounges for those awaiting transport
- optimise bed stock
- rigorous bed management
- optimal scheduling of elective cases
- monitor aberrant cases
- flexible bed configurations
- early time of day for discharge
- the diurnal surge in patient arrivals to ED starts at 9am-11am then persists into the evening, thus beds need to be freed up by discharges from ward no later than 11am if hospital occupancy is > 90%
- hospitals have a diurnal flow of ward occupancy which generally peaks at 9am then has a nadir at 4pm
- bed demand modelling
- utilise predictive patient admission demand software
- avoid preventable bed closures - eg. gastro outbreaks
- open more beds, particularly in surge conditions such as Winter demand
- reduce time for discharged bed to be available
- efficient processes for house cleaning
- early declaration of available bed
- 23 hour surgical short stay ward
- may also take overflow from ED observation unit and MAPU
- aim to avoid overnight admissions pre-op for elective procedures
Resources and papers on the internet
- ACEM summit on bed access block, Melbourne, Sept 2008:
-
-
- from 1984-2009, acute public beds have fallen by 60% per head of population despite the population becoming older and with greater complexity of conditions
- hospital overcrowding is NOT caused by GP-style patients swamping emergency departments