Effects of ED Crowding

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• Effects of ED Crowding
• on Patient-Oriented Outcomes
• SAEM Annual Meeting
• May 30, 2008
• Brent Asplin, MD, MPH
• Steven L. Bernstein, MD
• Jesse Pines, MD, MBA

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Goals

• Provide update on crowding, Institute of Medicine
  report, SAEM response
• Describe evidence linking crowding with adverse
  patient outcomes
• Outline research agenda

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Conceptual model of ED crowding
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Institute of Medicine reports June 2006

• US emergency medical care is overburdened,
  underfunded, and highly fragmented
• www.iom.edu

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Fewer EDs, more patients
Sources NHAMCS, AHA
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IOM findings

• EDs and trauma centers are overcrowded
• EM care is fragmented
• Specialists often unavailable
• System unprepared for major disaster
• EMS and EDs ill-prepared to treat children

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Key Recommendation

• Hospitals should END the practice of boarding
  inpatients in the ED.

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SAEM Response

• ED Crowding Task Force
• Task Review crowdings impact on ED quality of
  care, education
• Report to Board

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Crowding and Quality

• How to get policymakers attention?
• Does ED crowding affect
• Quality of care?
• Patient safety?
• Medical error?
• Magid DJ et al., Ann Emerg Med 200444586

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IOM Definition of quality

• Quality care is
• Safe
• Patient-centered
• Timely
• Efficient
• Equitable
• Effective

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ED Crowding So What?

• What outcomes do people care about?
• The three Ms
• Mortality
• Morbidity
• Money

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Mortality
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Safety

• Mortality
• Spain ED mortality, 72 hour returns more
  frequent when crowded
• Miro O et al., European J Emerg Med 19996105
• Lancet 20003561356

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Crowding Mortality

• Sprivulis et al. MJA 2006 184 208212
• The association between hospital overcrowding and
  mortality among patients admitted via Western
  Australian emergency departments
• Overcrowding associated with day 2, day 7, and
  day 30 mortality

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Crowding and 7-day survival
ED Boarder occupancy
Both hospital occupancy and ED boarder occupancy
are associated with increased 7-day
mortality Sprivulis P, 2006, MJA 184208
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Crowding Mortality

• Richardson DB. MJA 2006 184 213216
• Increase in patient mortality at 10 days
  associated with ED crowding
• Crowding defined by quartiles of ED occupancy
• 10 day mortality higher in patients presenting
  during crowded periods
• RR 1.34 (95 CI, 1.041.72)

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Crowding Mortality

• Chalfin et al. Crit Care Med 2007 3514771483
• Impact of delayed transfer of critically ill
  patients from the emergency department to the
  intensive care unit
• ICU patients with gt6 hour delay in admission had
  higher ICU and hospital mortality, as well as
  longer length of stay

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ICU survival

• Project IMPACT database
• 90 US hospitals, 120 ICUs, 200,000 patients
• 2000-2003
• Endpoints ICU mortality, in-hospital mortality
• Independent variable ED LOS gt 6 hours after
  admit
• 50,322 pts., 1036 w/delayed transfer
• Similar age, gender, DNR status, APACHE
• Chalfin et al., Crit Care Med 2007351477

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Results, logistic model
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Crowding VAP

• Carr et al. J Trauma. 2007639 12.
• Emergency Department Length of Stay a Major Risk
  Factor for Pneumonia in Intubated Blunt Trauma
  Patients
• For every hour increase in ED length of stay, the
  risk of pneumonia increased 20

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Mortality negative studies

• Pines et al.
• Bernstein et al.
• Publication bias?

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Morbidity
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Crowding Treatment Delays

• Schull et al.
• Ambulance diversion is associated with delays in
  reperfusion therapy
• Fishman et al.
• Patients with potential ACS who presented during
  trauma team activations have higher 30-day CV
  complications

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Timeliness door to needle

• Time to lytic in acute MI
• Ontario, Canada, 1998-2000
• 25 EDs, 3452 pts.
• Network crowding none, moderate (lt60 EDs), high
  (gt60)
• Door-needle times 40, 45, 47 minutes (Plt0.001)
• Schull et al., Ann Emerg Med 200444577

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Crowding Treatment for Pain

• Hwang et al.
• Higher ED census is associated with lack of
  analgesia and delays to analgesia administration
  in pts. w/ hip fx (JAGS 2006)
• Pines et al.
• Waiting room number and ED occupancy rate were
  associated with delays in analgesia (Annals of EM)

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Timeliness analgesia

• Penn, adult ED, 4/05-9/06
• 13,758 pts. w/severe pain
• 49 received analgesia
• Endpoint no analgesia OR delay in analgesia
• Pines et al., Ann Emerg Med Jan. 2008

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Results
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Crowding Pneumonia

• Two articles in Annals of EM Nov. 2007
• Pines et al. waiting room number and recent LOS
  associated with delays and lack of antibiotic
  administration
• Fee et al. antibiotic treatment delays more
  likely with higher ED volume and complexity of
  patients

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Timeliness antibiotics

• Time to antibiotic for pneumonia
• U. Penn, 2003-2005
• Outcome Abx gt 4 hours (or no Abx)
• Crowding measures no. patients in waiting room,
  LOS for admitted pts.
• 694 adults, 44 treated lt 4 hours
• P (delayed Abx) 0.31 at 2 lowest quartiles,
  0.72 at highest
• Pines et al., Ann Emerg Med 2007

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Crowding and ACS Treatment

• Prolonged ED length of stay associated with less
  adherence to the ACC guidelines for ACS/NSTEMI
  care
• Diercks et al., Annals of EM 200750489
• The Emergency Department Crowding Paradox The
  Longer You Stay, the Less Care You Get
• Hollander, Pines, Annals of EM 200750499

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Effectiveness

• Adherence to AHA/ACC guidelines for NSTEMI
• CRUSADE registry 500 US hospitals
• 2003-2005
• 42,780 eligible pts.
• Median ED LOS 4.3 hours (IQR 2.9, 6.3)
• 15 gt8 hrs.
• Diercks et al., Ann Emerg Med 2007 50489

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Results medication
All P lt 0.05
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Results procedures in-hospital
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Money
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Financial implications

• 1994 admitted patients who stay in the ED gt 1
  day have an increased hospital length of stay of
  1.2 days
• May result in decreased reimbursement
• Krochmal P, Am J Emerg Med 199412265

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Pines et al 2008 (SAEM)

• ED LOS was not associated with hospital LOS (log
  transformed)
• Longer ED LOS was associated with a higher
  hospital contribution margin (600/patient)

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Crowding Money

• McConnell et al., Ann Emerg Med 200648702
• Diversion associated with lost hospital revenue
• Falvo et al., Acad Emerg Med 200714332-337
• Opportunity costs associated with boarding
  patients in the ED

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Whats Next?

• Consensus around measurement
• Current trends
• ED census
• ED length of stay
• The number of waiting room patients/time
• Total ED treatment hours
• Crowding scales

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A research agenda

• Refine measures of crowding
• Development of crowding research databases
• Study impact on quality
• Design, implement, evaluate solutions
• International comparisons

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National Quality Forum (NQF) Process

• Proposed measures of ED quality/efficiency
• Total ED LOS (median time in minutes)
• Admitted vs discharged
• ED Boarding Time
• Time to see physician/mid-level provider
• Patients who leave without being seen

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21st century developments

• 2003 GAO report
• Hallway transfers
• Joint Commission standards
• Robert Wood Johnson Foundation Urgent Matters
• September 11, 2001

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Crowding scores

• ED Work Index (EDWIN)
• Bernstein SL et al., Acad Emerg Med 200310938
• National Emergency Department Overcrowding Score
  (NEDOCS)
• Weiss SJ, Acad Emerg Med 20041138
• ED Work Score
• Epstein SK, Acad Emerg Med 200613421
• Real-time Analysis of Emergency Demand Indicators
  (READI)
• Reeder TJ, Acad Emerg Med 2004101084
• Boarding burden, occupancy rate
• McCarthy ML et al., Ann Emerg Med 2007, in press

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Potential uses of crowding indices

• Real-time dashboard
• Early-warning system
• Surge capacity/MCI preparedness
• Quality indicators MI, pneumonia, etc.

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Conclusions

• Crowding affects all domains of quality of care
  in ED
• Greater recognition needed by policymakers,
  administrators, clinicians
• Three parallel tracks moving forward
• Crowding research agenda
• Public policy/regulatory agenda (e.g. NQF)
• Internal hospital operations

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Questions?