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| Journal of the New Zealand Medical Association,
20-February-2004, Vol 117 No 1189
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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 overcrowdingPatients 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.
SolutionsThe 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
preload:
Regarding
intrinsic capacity:
Regarding
afterload:
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: michael.ardagh@cdhb.govt.nz
References:
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