Journal of the New Zealand Medical Association, 20-February-2004, Vol 117 No 1189
Emergency department overcrowding – can we fix it?
Michael Ardagh and Sandra Richardson
In the Sunday Star Times of 6 July 2003 the front-page headline read: ‘Health crisis: why our hospitals are killing us’. Three pages of the newspaper and the editorial were devoted to describing and discussing the consequences of our overwhelmed emergency departments (EDs). In the winters of 2002 and 2003 the TV1 Network News ran stories describing the management of patients in corridors of Auckland hospitals and the dangers and inconveniences associated with this. An opinion of the Health and Disability Commissioner in March 2003, reporting the death of a patient in a New Zealand Emergency Department, stated that ED overcrowding contributed to the death and was a common problem in New Zealand. The problem is not only New Zealand’s and it is not new. A report into the death of a UK pensioner while waiting for care in a London emergency department in 2001 noted that the patient had waited nine hours for treatment, despite being allocated a triage code indicating a need to be seen within one hour. The external inquiry team found that ‘A&E staff were so demoralised that they accepted grossly inadequate outcomes as normal’, and that the situation of ‘system failure’ within emergency departments was likely to be repeated.1
Issues of ED overcrowding, and the associated phenomena of ambulance diversion and hospital bypass, have been recognised in the literature since the late 1980s.2,3 Andrulis and colleagues described ED overcrowding in American teaching hospitals in 1991.4 Derlet and Richards in 2000 described ED overcrowding as an international problem, which was getting worse.5 Two years later, Derlet stated that ‘unlike ten years ago overcrowding is no longer unique to teaching hospitals but is now spread to many communities, suburban and rural hospitals’.6 Recent publications from the United Kingdom have described the overcrowding they are experiencing and the ‘Emergency Care Reform’ initiatives intended to fix it.7,8 In Canada, the situation has been recognised as a national problem, and in response to this a joint position statement on ED overcrowding was released in 2001 by the Canadian Association of Emergency Physicians and the National Emergency Nurses Affiliation.9 Included in the position statement was the following definition of overcrowding: a ‘situation in which demand for services exceeds the ability to provide care within a reasonable time, causing physicians and nurses to be unable to provide quality care’. Daniel Fatovich, a West Australian Emergency Medicine Specialist, recently stated in the British Medical Journal that ‘overcrowding is the most serious issue confronting Emergency Departments in the developed world with quality and timeliness of emergency care being compromised’.10
Emergency department overcrowding is widespread and worsening. It has a number of potential consequences that compromise patient access to care and the quality of care provided. When departments are crowded, patients wait longer for triage, medical assessment and treatment. The nursing resource is spread more thinly and nursing observations and interventions occur less frequently and less promptly than desired. Medical staff are rushed, and decisions, assessments and medical interventions may be rushed or truncated as a result. Of equal concern, and in addition to these contributors to potential adverse outcomes, are the prolonged suffering of patients and the indignity of being managed in a public corridor.
Causes of emergency department overcrowding
Patients who present to EDs can be categorised into three general types. Ambulant patients are those who present with a variety of problems that tend to be dealt with in the ED, after which the patient goes home. These include minor musculoskeletal problems, wounds, eye and ENT problems. The second category of patients consists of those with undifferentiated presentations. This is an important group and includes a variety of patients with conditions such as collapse, chest pain, abdominal pain, and headache, among others. The workloads of many EDs are made up mostly of this patient category. These patients present the greatest risk to EDs as they may harbour significant life-threatening conditions and they have the propensity to deteriorate. The third group of patients are those who are demonstrably unwell and these are the ones who require active and urgent intervention in the form of resuscitation.
The activities of an ED may be divided into three simple categories – patients come in, patients are managed, and patients go out – providing a template for the definition of causes of overcrowding, and the derivation of potential solutions. First, patients come in, and this activity is a product of the burden of ill health and injury and the availability of alternative care in the community. Second, patients are managed, and this includes reception, instigation of the clerical record, prioritisation of patients by a process of triage performed by experienced nursing staff with formal post-registration education, nursing and medical diagnostic assessment, and subsequent treatment. Third, patients go out, and this may mean the patient is discharged for ongoing care in the community or referred to a hospital-based, inpatient specialist service.
It is useful to perceive the factors contributing to ED overcrowding in relation to these three activities by using the analogy of the failing heart. We know that heart failure is contributed to by excessive preload, deficiencies of the heart to eject a sufficient fraction of its ventricular blood, or an excessive afterload against which it is trying to pump. An ED may be overcrowded because there is an excessive preload, meaning large numbers of patients are received beyond the ability of the ED to record, triage and manage. Generally speaking, EDs in New Zealand do not have any capacity to respond to inordinate fluctuations in preload. There is no option to ‘close the doors’ once capacity is reached, or to refuse service once the allocated resource has been utilised. In many major international cities, the overloaded ED can request a state of ‘bypass’ when the specified hospital service is overwhelmed. This state allows for the diversion of ambulance arrivals for the duration of the time of overload, and the disposition of patients to alternative EDs. The low density of emergency healthcare facilities in New Zealand means that this is seldom an option for overloaded EDs in this country. A common and unfortunate response to a perceived excess of preload has been to deny or obstruct care to those considered inappropriate for presentation at the ED. The assessment of ‘appropriateness’ at triage has consistently been shown to be inaccurate and, in addition to potentially contravening rights of access to care, ‘triaging’ patients out of the ED is dangerous and does not reduce costs.3 Lowering barriers to more appropriate care is a better solution than raising barriers to perceived inappropriate care.
Related to the second activity and analogous to the ejection fraction of the heart, is the internal capacity of the ED to cope with fluctuating demands. A large number of factors make contributions in this category, and include the physical space in the department, the human resource, and the systems employed to allow prompt and efficient decision making in patient management. Medical staff may be too few in number or insufficiently skilled to promptly manage patients. In particular, the undifferentiated patient group requires interpretation and decision-making skills borne of practise and training. Issues of shortages of specialist physicians and nurses are reported on an international level, and within New Zealand a number of factors are recognised as impacting on recruitment and retention of staff including work environment, student debt and professional satisfaction. Nursing numbers may be too few or available staff too inexperienced to undertake the task adequately. Whereas medical staff may be considered to make a time-limited contribution to the patient’s care (the medical work up and initiation of treatment) the nursing contribution is a continuous one and essential for ongoing monitoring of the patient’s condition and the delivery of the treatments required. The more unwell the patients who present to the ED, the greater the demands on the nursing resource. Furthermore, the larger the number of patients in the department at any one time, the more thinly spread is the nursing resource on duty. Many EDs in this country are noting a greater complexity of patient presentations and a longer duration of stay. The consequences of these factors for the nursing resource are perhaps greater than for any other.
The physical resource in the ED includes the space, the way that space is configured, the equipment available to monitor and manage patients, and the ability to access advanced diagnostic tests in a timely manner. A number of our larger EDs have been rebuilt (and purpose built) for the task of modern emergency medicine. However, many others in this country evolved from a simple reception area, and as a result they attempt to perform the function of a modern ED in a limited and inappropriate space. There are a variety of resources available for those who might design an ED but perhaps the most relevant and authoritative locally is the Emergency Department Design Guidelines of the Australasian College for Emergency Medicine.11 These designs include the suggestion that a modern ED should have one bed space for each 1100 patient presentations per annum. Many New Zealand EDs would fall below this standard.
The evolution of EDs in an ad hoc and somewhat uncoordinated way in New Zealand has resulted in a variety of processes for the management of patients. Some of these processes are internally derived and some are externally applied and many do not take account of the need for efficient patient flow. The unnecessary use of investigations, and the consequent wait for the results before a decision is made, prolong the length of stay in the department. Similarly, the unnecessary duplication of assessment of patients, first by ED staff and then by the receiving team, introduces significant increments to the length of stay.
Finally, the analogy to afterload refers to the ability of the ED to transfer their patients from the department to their definitive destination. The inability to get ED patients into inpatient beds in a timely manner has been termed ‘access block’ and attempts have been made to apply a standard, defining the maximum time a patient should spend in the ED as an indicator of quality of care.7,8,12 In New Zealand access to inpatient beds is a variable contributor to ED overcrowding but one, it appears, of increasing significance.
The analogy presented above suggests that the contributors to ED overcrowding are many and various. The contributors in each individual ED will have a different composition to others. For example, a significant contributor in some hospitals may be the ability to access an inpatient bed, whereas in other hospitals it may be the size of the department, or the number of staff. Invariably, however, the contributors to ED overcrowding in any one department are multifactorial, with each contributing a small and different-sized increment to the overall problem. A consequence of this is that attending to any one contributor will not necessarily result in any measurable difference to the overcrowding problem. Personal observation suggests that many EDs in this country have become frustrated by their attempts to deal with the overcrowding problem bearing no demonstrable fruit. The first premise to fixing the problem, therefore, must be that the solutions, like the contributors, will be multidimensional.
The additional observation borne from the analogy of cardiac failure is that two of the three general areas of contribution to ED overcrowding primarily arise outside it. The preload problem relates to the amount of illness and injury in the community, and the ability and willingness of those who are ill and injured to access alternative appropriate means of healthcare. The afterload problem relates primarily to the ability of patients to access inpatient beds in a timely manner. This is related to the ability of the hospital, or service, to discharge patients in a timely manner, which, in turn, is dependent on the availability of sufficient community services and ‘step-down’ facilities.
EDs have been frustrated further by their inability to influence preload and afterload to any significant degree. The second premise to fixing the problem, therefore, is that many of the solutions lie outside the jurisdiction of the ED.
If we accept that the solutions to ED overcrowding are multidimensional and that each of these dimensions must be addressed in concert to achieve the sum of incremental benefit and, second, that many of the solutions to the problem are outside the jurisdiction of the ED, then we see that a concerted response at the level of the district health board (DHB) is the minimum requirement to attempt to fix this problem.
If a DHB were, for example, to consider the contributors to ED overcrowding at their hospital they may, with appropriate consultation, measurement, expert analysis and interpretation, decide that the following is a list of interventions that, in summation, will significantly reduce the overcrowding problem:
Regarding intrinsic capacity:
This is only an illustrative list. A different one may be compiled for a different hospital depending on the perceived needs, and the perceived benefits of each of the possible solutions. However, the key principles in this process remain the same. First, that solutions will be found in each of the areas of preload, intrinsic capacity and afterload; second, that the solutions will be multidimensional and will need to be instigated in concert to see any demonstrable benefit; and third, that many of these solutions are outside the jurisdiction of the ED and so a higher level approach is required.
Apart from the scrutiny provided by investigations such as that published in the Sunday Star Times the problem of ED overcrowding is given little emphasis. Consequently, DHBs are given little incentive to fix it. Although the solutions require a concerted effort at the DHB level it is unlikely that DHBs will consider this of highest priority unless instructed to do so and assisted in the process by the Ministry of Health.
In summary, ED overcrowding is a major problem in New Zealand, as it is internationally. The causes of and solutions to ED overcrowding can be considered under the three general headings of preload, intrinsic capacity and afterload. When considering the causes and the potential solutions we appreciate that the contributors and the solutions are multidimensional, they must be addressed in concert, and they need to be addressed at the level of the DHB. For a DHB to have the inclination and the ability to address these problems there needs to be clear direction and assistance from the Ministry of Health.
Author information: Michael Ardagh, Professor of Emergency Medicine, Christchurch School of Medicine and Health Sciences, and Emergency Department, Christchurch Hospital; Sandra Richardson, Emergency Nurse Researcher, Emergency Department, Christchurch Hospital, Christchurch
Correspondence: Professor Michael Ardagh, Emergency Department, Christchurch Hospital, Private Bag 4710, Christchurch. Fax: (03) 364 0286; email: firstname.lastname@example.org
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