Emergency Department Overcrowding and Inpatient Boarding: A Statewide Glimpse in Time

Felton, B.; Reisdorff, Earl J.; Krone, Christopher N.; Laskaris, Gus A.

doi:10.1111/j.1553-2712.2011.01209.x

Cited by 17 publications

(12 citation statements)

References 25 publications

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“…Some North American studies have evaluated crowding measures against the need for ambulance diversion; this response to ED crowding is rarely used in the UK. There is also US evidence that many EDs are very crowded, but do not use ambulance diversion 29. The physicians were not blinded to the variables that we were collecting, as this information is used to run an ED.…”

Section: Limitationsmentioning

confidence: 99%

Initial validation of the International Crowding Measure in Emergency Departments (ICMED) to measure emergency department crowding

et al. 2013

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Introduction Emergency department (ED) crowding is recognised as a major public health problem. While there is agreement that ED crowding harms patients, there is less agreement about the best way to measure ED crowding. We have previously derived an eight-point measure of ED crowding by a formal consensus process, the International Crowding Measure in Emergency Departments (ICMED). We aimed to test the feasibility of collecting this measure in real time and to partially validate this measure. Methods We conducted a cross-sectional study in four EDs in England. We conducted independent observations of the measure and compared these with senior clinician's perceptions of crowding and safety. Results We obtained 84 measurements spread evenly across the four EDs. The measure was feasible to collect in real time except for the 'Left Before Being Seen' variable. Increasing numbers of violations of the measure were associated with increasing clinician concerns. The area under the receiver operating characteristic curve was 0.80 (95% CI 0.72 to 0.90) for predicting crowding and 0.74 (95% CI 0.60 to 0.89) for predicting danger. The optimal number of violations for predicting crowding was three, with a sensitivity of 91.2 (95% CI 85.1 to 97.2) and a specificity of 100.0 (92.9-100). The measure predicted clinician concerns better than individual variables such as occupancy. Discussion The ICMED can easily be collected in multiple EDs with different information technology systems. The ICMED seems to predict clinician's concerns about crowding and safety well, but future work is required to validate this before it can be advocated for widespread use.

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Section: Limitationsmentioning

confidence: 99%

Initial validation of the International Crowding Measure in Emergency Departments (ICMED) to measure emergency department crowding

et al. 2013

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“…5 Increasingly, these skills will be practised in an overcrowded, high-pressure environment with limited resources. [6][7][8][9][10] Emergency physicians supervise doctors of varying skill and experience: emergency medicine registrars, career medical officers and prevocational junior doctors. The most senior doctor in the department varies, although in most metropolitan hospitals a FACEM oversees patient care and provides supervision and advice to junior doctors during day and evening shifts.…”

Section: Introductionmentioning

confidence: 99%

‘Registrar in charge shifts’: Learning how to run a busy emergency department

Craig

Dowling

2013

Emerg Medicine Australasia

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Objectives:In Australasia, emergency registrars usually gain experience 'running' an ED overnightwithout supervision. This paper describes the introduction of FACEM-supervised daytime 'registrar in charge' (RIC) shifts into a tertiary adult ED over a 6 month period. Methods:Each registrar was allocated at least one RIC shift during their 13 week ED term. Structured questionnaires gathered data regarding the educational impact of the shifts, any adverse effects on departmental function, changes to work practices, and perceptions of teaching and learning. Data were analysed using thematic analysis. Results:During the study period, 16 senior ED registrars were rostered for 26 RIC shifts. Questionnaires were completed by 16/16 registrars and 13/16 emergency physicians. The RIC shifts were viewed positively by the emergency registrars -93% reported useful feedback, felt that the shifts provided a good insight into their workplace behaviour, and that they should be rolled out across other departments. FACEMs were also positive in their evaluation, and reported little negative impact on departmental function. Major themes identified by both registrars and emergency physicians included communication skills, knowledge and experience, delegation, professionalism and organisational skills. Additional themes that were more prominent in FACEM responses included multitasking, dealing with interruptions, managing patient flow and being aware of the whole department. Conclusions:RIC shifts are a feasible and acceptable method to teach running the floor in the ED. Further study should assess impact on patient outcomes.

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“…Since the GAO report, there have been several empirical, geographically limited studies of ED boarding. [4][5][6][7] One 2008 study inferred boarding times indirectly from data on overall visit length in the 2003 through 2005 national ED surveys. 8 The GAO report noted that while representative visit-level measures of boarding were being collected by the National Center for Health Statistics (NCHS), a branch of the Centers for Disease Control and Prevention, they were not yet available at that time.…”

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confidence: 99%

A Cross-sectional Study of Emergency Department Boarding Practices in the United States

et al. 2014

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Objectives: The median emergency department (ED) boarding time for admitted patients has been a nationally reportable core measure that now also affects ED accreditation and reimbursement. However, no direct national probability samples of ED boarding data have been available to guide this policy until now. The authors studied new National Hospital Ambulatory Medical Care Survey (NHAMCS) survey items to establish baseline values, to generate hypotheses for future research, and to help improve survey quality in the future.Methods: This was a cross-sectional, multistage, stratified annual analysis of EDs and ED visits from the National Hospital Ambulatory Medical Care Survey public use files from 2007 to 2010, a total of 139,502 visit records. These data represent the only national measure of ED boarding. The main outcome of interest was boarding duration for individual patient visits. Data analyses accounted for complex sampling design.Results: The national median boarding time was 79 minutes, with an interquartile range of 36 to 145 minutes. The prevalence of boarding for more than 2 hours among admitted patients was 32% (95% confidence interval [CI] = 30% to 35%). Average ED volume, occupancy, acuity, and hospital admission rates increased abruptly from the second to the third quartile of median boarding duration. The half of hospitals with the longest median boarding times accounted for 73% of ED visits and 79% of ED hospitalizations nationally. Thirty-nine percent of EDs (95% CI = 32% to 46%) reported never holding patients for more than 2 hours, but visit-level analysis at these EDs found that 21% of admissions did in fact stay in the ED over 2 hours. Only 19% of EDs (95% CI = 16% to 22%) used a strategy of moving admitted patients to alternative sites in the hospital during crowded times. Conclusions:In this national survey, ED boarding of admitted patients disproportionately affects hospitals with higher ED volumes, which also see sicker patients who wait longer to be seen, but not hospitals with higher proportions of Medicaid or uninsured visits. This finding implies that, unlike other quality measures, there is a negative volume-outcome relationship for timely hospitalization from the ED.ACADEMIC EMERGENCY MEDICINE 2014;21:497-503 © 2014 by the Society for Academic Emergency Medicine I ncreasing emergency department (ED) visits have caused rising apprehension in the medical community for over half a century, 1 and the trend in ED crowding continues unabated.2 A 2009 U.S. Government Accountability Office (GAO) report concluded that the most important cause of ED crowding is the lack of access to inpatient beds, leading to prolonged ED stays for admitted patients, often in ED hallways.3 These patients are considered to be "boarding" in the ED. Since the GAO report, there have been several

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Emergency Department Overcrowding and Inpatient Boarding: A Statewide Glimpse in Time

Cited by 17 publications

References 25 publications

Initial validation of the International Crowding Measure in Emergency Departments (ICMED) to measure emergency department crowding

Initial validation of the International Crowding Measure in Emergency Departments (ICMED) to measure emergency department crowding

‘Registrar in charge shifts’: Learning how to run a busy emergency department

A Cross-sectional Study of Emergency Department Boarding Practices in the United States

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