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When patients have to wait for long periods in overcrowded emergency departments (EDs), it’s not just an inconvenience. Evidence shows that ED crowding leads to significant patient harm, resulting from delays in treatment and increases in preventable harm. A systematic review in 2022 concluded that ED crowding was associated with higher mortality in 45 percent of the studies, worse quality of care in 75 percent, and a worse perception of care in 100 percent.
ED Crowding Has Multiple Sources
The problem of ED crowding is widely recognized. Too often, however, ED crowding is seen in isolation — as a matter of simply making ED operations more efficient. To be sure, there are ways that ED staff can improve their operations to ease crowding, but there are limits to how much those efforts can accomplish. Efficient, high-quality ED care is also dependent on factors outside the control of the ED — such as lack of sufficient and timely primary care and mental health services as well as timely availability of post-acute care services. To solve the problem of ED crowding and delays in admitting patients to the hospital, improvements in community-wide and hospital-wide patient flow are needed.
Indeed, the situation is reminiscent of the metaphor about the people who are all looking at a different part of an elephant. The one who sees a tusk thinks it’s a spear, the one who sees the tail thinks it’s a rope, and so on. Something analogous occurs when clinicians and staff only see flow problems from their perspective in the ED and within other units or departments throughout the hospital. While the ED staff see long delays in admitting patients, the clinical staff on medical and surgical units see unnecessary bed days and long delays in discharging patients to homes and community-based care settings. To improve patient flow in the ED, we need to look at the whole “elephant” — the whole system that impacts hospital-wide patient flow.
Efficiency Improvements in the ED
There is certainly some potential for improvement in the ED itself. For example:
- Separate flows in the ED (based on acuity) with dedicated clinical teams for each flow. Many EDs that have implemented these lean principles have significantly improved efficiencies and decreased the length of stay for patients discharged from the ED and for patients being admitted to the hospital.
- Create a separate protocol-driven unit for short-stay patients with relatively straightforward diagnoses. These units are intended for patients who may not be sick enough to warrant a hospital admission but are not well enough to be discharged immediately. A 2013 article found that, compared to patients under observation elsewhere in the hospital, patients in dedicated observation units with defined protocols had 23 to 38 percent shorter length-of-stay, and their likelihood of subsequent inpatient admission was 17 to 44 percent lower.
In addition, clinical teams in the ED can partner with community providers of care to shape demand for ED visits.
- Provide end-of-life care in accordance with patients’ wishes. This step often prevents admissions to intensive care units.
- Utilize case managers. These team members can facilitate discharges to home and arrange home care and timely follow-up care after discharge from the ED.
- Support patients with low-acuity needs in community-based care settings. Extend the hours of primary care offices and offer more virtual office visits for primary care, specialists, and mental health care.
Addressing Common Bottlenecks in the Hospital
Often, beds are not available in the hospital, leaving patients to wait for inexcusably long periods in the ED. A commentary in NEJM Catalyst suggests the problem is, in fact, getting worse.
Common bottlenecks and system constraints include:
- Discharge delays — Difficulty finding the right settings and needed services for patients who are otherwise ready to be discharged from the hospital causes delays. Address this bottleneck by focusing on efficient discharge planning and collaborations with family caregivers and community providers of care. In other words, focus on the “back door” in addition to the “front door” of the hospital.
- Unnecessary bed days — Unnecessary bed days occur when patients remain in the hospital for extra days or weeks after they are medically ready for discharge. Comprehensive assessments for post-acute care needs, interdisciplinary planning with a patient and their family, and decision-making can all take time and extend a patient’s stay. In addition, the lack of availability of post-acute facility beds and home care services often leads to long-term hospital occupancy. Inpatient units lose functional capacity as patients await placement in post-discharge health care settings (rehabilitation centers, skilled nursing facilities, or nursing homes).
- Uneven elective surgical scheduling — It is common for surgeons to schedule elective surgery in an uneven manner throughout the week, which can contribute significantly to hospital-wide flow problems. Efforts to “smooth” the flow of elective surgical patients throughout the week can have multiple benefits: more predictable flows of patients from the operating room to intensive care units and other inpatient units, less competition between ED and elective admissions, and more predictable and appropriate nurse staffing on units.
A NEJM Catalyst article identified essential steps to mitigate crowding in the ED, including acknowledging it as a serious problem and threat to patient safety, and urging visible, committed leadership buy-in as an essential part of the solution.
It is crucial to address hospital-wide patient flow, not just to pursue isolated improvement projects that may not have an impact on timely patient progression throughout the hospital. In addition, community-wide efforts to create timely access to care can prevent overutilization of ED services and lengthy hospital admissions. We need to see the “whole elephant” to address both system-wide hospital flow issues and the availability of community-based health care services which impact overutilization in hospitals.
Patricia Rutherford, RN, MS, is a retired Vice President for the Institute for Healthcare Improvement (IHI) and a faculty member for IHI's Hospital Flow Professional Development Program.
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