Emergency Department Overcrowding Following Systematic Hospital Restructuring Trends at Twenty Hospitals over Ten Years

Abstract

Abstract. Objective: Hospital restructuring often results in fewer inpatient beds, increased ambulatory services, and closures of hospitals or emergency departments (EDs). The authors sought to determine the impact of systematic hospital restructuring on ED overcrowding. Methods: Time series analyses of average monthly overcrowding for EDs in Toronto, Ontario, Canada, from 1991 and 2000 (n = 20 hospitals, 120 months) were conducted. Autoregression models evaluated the rate of increase of overcrowding before and during systematic restructuring. A secondary analysis included total ED visits, patient age, and sex distribution as covariates. Seasonality was assessed by means of spectral analysis. Results: Severe and moderate overcrowding averaged 3% and 14% of the time each month, respectively, over the whole period. Before restructuring (n = 74 months), severe and moderate overcrowding averaged 0.5% and 9% per month, respectively; during restructuring (n = 46 months), the monthly averages were 6% and 23%, respectively. Neither severe nor moderate overcrowding was increasing before restructuring. During restructuring, however, both increased significantly (severe 0.2% per month [p < 0.0001]; moderate 0.5% per month [p < 0.0001]). Similar results were found after controlling for ED utilization. Female gender independently predicted increased overcrowding; older age predicted reduced moderate overcrowding; number of total visits was not a predictor. Spectral analysis revealed significant seasonality in overcrowding. Conclusions: Hospital restructuring was associated with increased ED overcrowding, even after controlling for utilization and patient demographics. Restructuring should proceed slowly to allow time for monitoring of its effects and modification of the process, because the impact of incremental reductions in hospital resources may be magnified as maximum operating capacity is approached.

Understanding hospital and emergency department congestion: an examination of inpatient admission trends and bed resources

“…As demand continues to increase for specialty services, such as ambulatory cancer care, 23 monitoring the ambulatory-emergent-inpatient feedback relationships will be essential when making decisions about hospital resource allocation. 24 We also observed that the proportion of GIM admissions that were repeat visits grew significantly during the study period. This may reflect overly aggressive discharge planning, lack of outpatient care coordination or deficits in the quality of care.…”

Can a universal influenza immunization program reduce emergency department volume?

“…The cost-effectiveness of vaccinating low-risk people remains controversial, [19][20][21][22][23][24][25][26][27][28][29][30] and although numerous studies have looked at the causes of ED utilization and overcrowding there are no data suggesting influenza causes overcrowding. [31][32][33][34][35][36] However, although universal vaccination may have little influence on ED volumes, vaccinating individuals at high risk for complications arising from influenza provides an average direct cost savings of $117 per person, in addition to reducing the number of hospitalizations and deaths.…”

Emergency Department Overcrowding: Analysis of the Factors of Renege Rate

“…[1][2][3] Although the reasons and mechanisms are complex, 4,5 increasing volume and lack of inpatient beds are clearly major factors. [6][7][8] Conceptual models such as the input-throughputoutput model, 9 the Fields chaos model, 10 and the ED Cardiac Analogy Model 11 have been introduced in an effort to understand the factors of overcrowding and their mechanisms. Even the definition of overcrowding is problematic, 12 giving rise to various proposals for measuring ED crowding [13][14][15] and developing consensus on indices of overcrowding.…”