Emergency Department (ED) overcrowding is a major challenge facing the health sector in both in the United States and globally. The most overcrowded hospital unit is the inpatient delivery service system. ED overcrowding forms a major hurdle in ensuring efficient provision of safe, quality, and crucial emergency care. Impediments in the ED may have deleterious implications for patients (Di Somma et al, 2015). Most policymakers, individuals purchasing care, and administrators of community and acute services acknowledge the problem as presenting an intolerable risk to patients and the wellbeing of staff.
ED crowding can be defined as the situation where the number of presenting patients exceed the available treatment rooms, or a diminutive number of staff and a huge amount of patients overwhelming the staff to provide ideal care. Overcrowding is delineated as dangerously crowded, with a zealous number of patients in ED treatment zones which pushes the ED to function beyond its aptitude. It was initially thought to be a phenomenon that affects large ED centers. However, it has been proving that overcrowding affects ED centers of various sizes and locations (Sinclair, 2017). The problem has spread rapidly, and in 2006 the Institute of Medicine conveyed a statement concerning the prospect of the US emergency, terming the Emergency service to be that in crisis.
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Background
Apart from providing care to acutely injured or the sick, the U.S healthcare structure of hospital ED is distinctive in their legal mandate to provide care for all patients, regardless of their capacity to pay for the healthcare service provided. ED guarantees healthcare for vulnerable populations who have limited choices for healthcare due to several socioeconomic impediments. Indigent, homeless, and underinsured or uninsured patients have the ED as a last resort (Momeni et al., 2018). Due to this, most of the population affected by ED overcrowding are the impoverished who cannot afford quality healthcare especially in community hospital with poor facilities. Therefore, ED has been a kind of “safety net” for these groups of patients. EDs comprise a crucial point of entry to the medical care system and provide integral service to the general public. Overcrowding is, therefore, an outcome of a system of huge problems concerning access to the required medical care at the correct time and under the right setting.
Momeni et al (2018) states that the leading cause of overcrowding is the large demand for ED care. In the US ED has become the guaranteed healthcare access for forty-four million uninsured citizens. The study by Memoni et al. suggests that of the approximated a hundred million patients, more than fifteen million lack insurance. Therefore, cumulatively ED offers extra safety net care in the US compared to other safety net providers. Since these safety net providers are purely interdependent, the burden felt by ED's is higher when other safety-net providers are incapable of meeting the demands of the population.
According to research done by Chan et al., (2015) the cause of overcrowding in ED is under-staffing. The recommended ratio of patient to nurse is 4:1. However, in most ED’s the number supersedes this. Shortage of hospital bed is also another factor that potentially contributes to crowding in EDs, especially during mass casualty occurrences. Non-availability of ED beds because the patients occupy them admitted waiting to be moved to inpatient units thereby limiting the capacity of ED’s to accept new patients while consuming the resources available. The other factor that contributes to persistent ED crowding is Exit block. These findings correlate with a study by Somma et al. (2015) which describe the scenario in which the patients that have been attended to in the ED are incapable of exiting the facility due to the absence of capacity in the systems downstream. Exit block signifies the shortcomings of hospitals, the entire social and healthcare system, to avail the resources and processes proficient of meeting the demands it’s mandated for.
Lin, Kao, & Huang, (2015) assert that overcrowding in ED's is a central concern the public health sector due to its many implications concerning the quality of medical care to patients. Crowding in ED has led to an increase in poor performance on length of stay (LOS) and waiting time. The six aspects of quality including effectiveness, safety, efficiency, timeliness, effectiveness, equity, and patient-centeredness are affected when a patient is placed in boarding. Keeping patients for long waiting periods is more infliction to patients. Boarding in ED leads to diminished patient gratification, loss of revenue from patient walkouts, dwindling safety of patients, and low staff morale. Also, LOS decreases the patient’s trust in the entire hospital institution and not just the ED area. Patient satisfaction is directly related to the LOS in the ED.
The second implication is that patients and people often presume that since the ED is crowded the nurses, physicians and the available staff must also function faster. However, this only increases the prevalence of medical errors that form part of the byproduct of multifaceted hospital challenges. Wang et al (2018) found that overcrowding in ED establishes a surrounding, in which provision of quality care may be compromised, especially when the staff experience pressure by the concurrent demands of the boarding patients and the progressive arrival of new patients. Irrespective of the capacity of the staff, ED overcrowding is the foremost example of a system hurdle developing a risky milieu for medical errors and endangering patient safety (Wang et al., 2018). Also, LOS and increased medical errors lead to increased mortality rates in overcrowded ED areas. This is further explicated in a study by Morley et al. (2015) which points out that there is an increase chance of 1.5% mortality for every hour a critically ill patient boarder in ICU.
According to Lin et al., (2015) ED overcrowding leads to increased diversion of the ambulance to other institutions. The emergency medical services (EMS) are often directed to “bypass” an ED that is overcrowded regardless of if it’s the closest. Timely emergency attendance if dependent on fast transport process and any diversion to other medical institutions only put the patient at risk due to delayed treatment (Lee et al., 2015). The difficulty of EMS locating a free ED results in a delay to embark on duty and to attend to other emergency demands, thereby, endangering anyone dependent on the EMS. Besides, overcrowded ED's also poses a threat to disaster alertness. In the incidence of disaster occurrence, overcrowded ED's will be underequipped to manage victims of mass casualties.
Management strategies
There are several strategies put forward to mitigate the problem of overcrowding in the ED. The Joint Commission on Accreditation of Healthcare Organization (JCAHO) initiated criterions to improve flow of patients, behavioral health emergencies and boarding that took effect on January 2014.The criterions state that healthcare facilities must quantify and set goals to control patients boarding via the ED, recommending that patients should not board for more than four hours. Chan et al., (2015) states other organizational procedures that combats the challenge focuses on blocking patient flow is the full capacity protocol (FCP). A protocol broadly used in many nations to standardize the fundamental processes of admitting patients to the inpatient hallway. The main objectives of the protocol are procedures for verifying the time ED is at maximum volume, the criteria of executing the transfer, the category of patients deserving a hallway bed and procedure for abandoning the practice. This has helped reduce patient LOS time, enhanced patient and staff satisfaction devoid of any negative patient consequences.
However, research conducted by Milne et al (2017) suggest that creation of a rapid assessment zone is a best strategy adopted to enhance efforts of reducing ED overcrowding. In this strategy, patients are made to rotate using stretchers rather than “owning” them till they get admitted. Individuals capable of lying down to be assessed but then go back to waiting rooms to be monitored, liberating the stretchers giving room for more assessments. Besides, several hospitals are improving staffing and pay-for-performance to meet the demands of the ED care centers. The recommended staff to the patient of 4:1 is important to enhance time triage, reduce the time required to see a physician, and thereby reduce LOS. Therefore, minimize the risks connected with overcrowding.
Wang et al. (2018) argue that creation of observation units has proved effective in the management of overcrowding in ED. Adoption of small observational units creates relief in ED overcrowding by controlling patient outflow availing an alternative are for them to go. Control of patient outflow has been regarded as effective in reducing ED overcrowding. ED observation units have greatly reduced LOS and reduce the hours of ambulance diversion by approximately 40%. Observation units have made it possible to create room for freshly admitted patients.
Adoption of strategic planning by the institution has also enabled the reduction of ED overcrowding. JCAHO has recommended prior planning for patients affected by overcrowding in ED. These recommendations comprise include ED overcrowding program into broad system performance enhancement objectives; liaising with long term health institutions and home health bodies to accelerate discharge from hospital; and scheduling for provision of care to patients who are to be allocated temporary beds. The objective is to help the hospital to anticipate ED overcrowding instead of acting after it has occurred.
Recommendations
My recommendation to deal with overcrowding would be to adopt an alternative Level of Care Plan established through initiatives directed at minimizing the number of patients in patients who are no longer in demand of care offered by the facility. Patients in an emergency in most ED's are permitted to stay overnights and offered treatment in a repetitive manner. Nevertheless, the Alternative Care plan will create more room for ED’s and medical facilities initiating the doctors, nurses and care beds available.
In conclusion, ED is a crucial element in the healthcare system of any country. However, overcrowding in ED areas presents endangering of patient safety by affecting the reliability of the emergency care practice. Overcrowding in Ed reveals the failure in our healthcare system at various levels. The main cause of Ed overcrowding is insufficient inpatient volume for the ED population with the ever-rising gravity of sickness. Dealing with this menace requires a multidisciplinary approach.
Reference
Chan, S. S., Cheung, N. K., Graham, C. A., & Rainer, T. H. (2015). Strategies and solutions to alleviate access block and overcrowding in emergency departments. Hong Kong Med J , 21 (4), 345-52.
Di Somma, S., Paladino, L., Vaughan, L., Lalle, I., Magrini, L., & Magnanti, M. (2015). Overcrowding in emergency department: an international issue. Internal and emergency medicine , 10 (2), 171-175.
Lee, Y. J., Do Shin, S., Lee, E. J., Cho, J. S., & Cha, W. C. (2015). Emergency department overcrowding and ambulance turnaround time. PloS one , 10 (6), e0130758.
Lin, C. H., Kao, C. Y., & Huang, C. Y. (2015). Managing emergency department overcrowding via ambulance diversion: A discrete event simulation model. Journal of the Formosan Medical Association , 114 (1), 64-71.
Milne, V., Settles, J., & Petch, H. (2017). Emergency room overcrowding: Causes and cures - Healthy Debate. Retrieved from https://healthydebate.ca/2017/06/topic/emergency-room-overcrowding
Momeni, M., Vahidi, E., Seyedhosseini, J., Jarchi, A., Naderpour, Z., & Saeedi, M. (2018). Emergency Overcrowding Impact on the Quality of Care of Patients Presenting with Acute Stroke. Advanced Journal of Emergency Medicine , 2 (1), e3-e3.
Morley, C., Unwin, M., Peterson, G. M., Stankovich, J., & Kinsman, L. (2015). Emergency department crowding: A systematic review of causes, consequences and solutions. Retrieved from https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0203316
Sinclair, D. (2017, July). Emergency department overcrowding - implications for paediatric emergency medicine. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2528760/
Somma, S. D., Paladino, L., Vaughan, L., Lalle, I., Magrini, L., & Magnanti, M. (2015, December 02). Overcrowding in emergency department: An international issue. Retrieved from https://link.springer.com/article/10.1007/S11739-014-1154-8
Wang, Z., Xiong, X., Wang, S., Yan, J., Springer, M., & Dellinger, R. P. (2018, May). Causes of Emergency Department Overcrowding and Blockage of Access to Critical Services in Beijing: A 2-Year Study. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29573904
