ED Overcrowding: Solutions that Work

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ED Overcrowding Solutions that Work

• CAEP Annual Conference
• Calgary, AB
• June 7, 2009

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Schedule

• Chair Dr. Gil Curry, Calgary, AB
• 1345-1352 Dr. Brian Rowe, Edmonton, AB
• ED Overcrowding interventions.
• 1352-1359 Dr. Michael Schull, Toronto, ON
• The Ontario integration experience.
• 1359-1406 Dr. Marco Duic, Toronto, ON
• Staffing models.
• 1406-1414 Dr. Grant Innes, Calgary, AB
• Full Capacity Protocol
• 1414-1430 Discussion

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Overcrowding model and interventions to reduce
over-crowding.

• Brian H. Rowe, MD, MSc, CCFP(EM), FCCP
• Professor and Research Director
• Canada Research Chair
• Department of Emergency Medicine
• University of Alberta
• Emergency Physician,
• Alberta Health Services

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Disclosure

• I do not have an affiliation (financial or
  otherwise) with a commercial organization that
  may have a direct or indirect connection to the
  content of this presentation.

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Outline

• ED Overcrowding background.
• The CADTH project
• Measures of ED Overcrowding
• Interventions to reduce ED overcrowding.
• Focus
• Front-end operations.
• Lessons learned and future directions.

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ED Overcrowding

• Definition a situation in which the demand for
  emergency services exceeds the ability of
  physicians and nurses to provide quality care
  within a reasonable time
• Overcrowding is a complex, system-wide issue
  caused by a combination of input, throughput and
  output factors.
• Should be considered part of the waiting times
  problem in the context of the Canadian health
  system.

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Conceptual Model
THROUGHPUT
INPUT
OUTPUT
Triage Diagnosis Treatment
LWBS/LAMA Discharge Admit
Referrals Ambulances Walk-ins
SYSTEM-WIDE INFLUENCES
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Consequences

• Patients
• Ambulance diversions
• Prolonged waits without assessment or treatment
• Delays in delivery of time-sensitive care (AMI,
  pain, CAP, etc) that influences outcomes
• Medical errors
• ? Communicable disease spread.
• Staff
• Nursing/Physician dissatisfaction and departures.
• Administrators headaches!

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Example LAMA/LWBS Rates (AB)
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Recent publicity
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Interventions to Reduce ED Overcrowding

• Summarizing the evidence

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Research Methods

• Design
• Comprehensive systematic review.
• Selection
• ED manuscripts, abstracts, reports, policies on
  interventions to improve ED overcrowding (and
  design).
• Publication bias avoidance
• MEDLINE, EMBASE, Cochrane, 13 other databases
• Selection bias avoidance
• Multiple independent reviewers.
• Quality assessment
• RCT Jadad Non-RCTs Downs and Black

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Results

• Multiple interventions identified (input,
  throughput, output and system wide).
• Most studies (n 69) provided control data
  (pre-post or time series studies).
• Traditional meta-analytic pooling was not
  possible.
• Pre-post change score was calculated and plotted
  for the variable outcomes reported.
• Warning these graphs are small..

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Limitations

• Many system wide interventions have not been
  included due to a lack of published evidence
• Examples
• Over-capacity protocol/FCP
• NHS 4-hour rule
• RAZ units.
• Administrators ? Researchers
• Grey literature
• Need better measurement of interventions
• Disconnect between program interventions and
  knowledge dissemination.

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Front-end management

• Alternatives and synergies.

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What is a TLP?

• Triage Liaison Physician (TLP)
• Experienced emergency clinician assigned to work
  in triage area with ED staff to improve flow.
• Main roles
• Expediting care (rapid x-rays)
• Answering incoming physician calls
• Assessing ambulance patients at presentation
• Assisting with triage hot-heads
• Liaising with consultants/administrators.

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Summary of Evidence

• Systematic review of all available evidence
  regarding TLP and similar interventions
  completed.
• All the evidence collected demonstrates that,
  when implemented, TLP resulted in significant
  improvement in the effectiveness of ED
  functioning and reduction in ED overcrowding.

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Other Front-end Options

• Triage process
• Almost all major Canadian EDs now do this
• Evidence suggests this does not improve flow.
• Triaging away
• Low acuity patients do not cause ED crowding
• Triaging low acuity patients to ED fast track
  areas appears effective
• Triaging low acuity patients to other locations
  seems inefficient.
• Media campaigns/phone lines ineffective.

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Patient Waiting Area

• Triage protocols
• Critically important and growing use
• Some evidence that these work.
• Navigators
• Limited evidence however, a favourite of
  administrators
• ? cost-effectiveness.
• Kiosks
• Used in preventive programs however, not much
  evidence for acute assessment.

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Summary

• ED hospital overcrowding unlikely to go away
  quickly.
• Front-end operations are important for
• Patient safety
• Quality of care
• Patient satisfaction.
• TLP and variations of this approach appear to
  improve flow and increase staff satisfaction.

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Thank you!