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The International Federation for Emergency Medicine report on emergency department crowding and access block: A brief summary
  1. Arshia P Javidan1,2,
  2. Kim Hansen3,4,
  3. Ian Higginson5,
  4. Peter Jones6,7,
  5. Eddy Lang8,9
  6. International Federation Emergency Department Crowding and Access Block Task Force
    1. 1Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
    2. 2Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
    3. 3Emergency Department, Prince Charles Hospital, Chermside, Queensland, Australia
    4. 4Emergency Department, St. Andrew's War Memorial Hospital, Brisbane, Queensland, Australia
    5. 5Emergency Department, Derriford Hospital, Plymouth, Plymouth, UK
    6. 6Emergency Department, Auckland City Hospital, Auckland District Health Board, Auckland, New Zealand
    7. 7Department of Surgery, University of Auckland, Auckland, New Zealand
    8. 8Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
    9. 9Department of Emergency Medicine, Alberta Health Services, Calgary, Alberta, Canada
    1. Correspondence to Arshia P Javidan, University of Toronto Faculty of Medicine, Toronto, ON M5S 1A8, Canada; arshia.javidan{at}mail.utoronto.ca

    Abstract

    Objective To develop comprehensive guidance that captures international impacts, causes and solutions related to emergency department (ED) crowding and access block.

    Methods Emergency physicians representing 15 countries from all International Federation of Emergency Medicine (IFEM) regions composed the Task Force. Monthly meetings were held via video-conferencing software to achieve consensus for report content. The report was submitted and approved by the IFEM Board on June 1, 2020.

    Results A total of 14 topic dossiers, each relating to an aspect of ED crowding, were researched and completed collaboratively by members of the Task Force.

    Conclusions The IFEM report is a comprehensive document intended to be used in whole or by section to inform and address aspects of ED crowding and access block. Overall, ED crowding is a multifactorial issue requiring systems-wide solutions applied at local, regional, and national levels. Access block is the predominant contributor of ED crowding in most parts of the world.

    • care systems
    • crowding
    • emergency care systems
    • emergency department management
    • emergency department operations
    https://creativecommons.org/licenses/by/4.0/

    This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

    https://doi.org/10.1136/emermed-2020-210716

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      Emergency department (ED) crowding and access block represent potentially the greatest threats to the core mission of emergency care across the world. The problem is pervasive, massive in scale, and amounts to a public health emergency with potentially lethal consequences.1 At its core, crowding and access block overwhelm ED resources and prevent the delivery of timely and effective care for patients. These are patients in need of necessary and immediate attention for the whole range of medical, trauma and behavioural emergencies that can impact a person or community. The causes of ED crowding and access block are complex and multifactorial and can vary considerably not only between hospitals, jurisdictions, and countries, but also within the same setting during different periods of time.1 2

      The International Federation of Emergency Medicine (IFEM) recognised that there was both an extreme need and a unique opportunity to provide EDs around the world with expert and evidence-based guidance. Recognising crowding and access block were wicked problems (problems that are challenging to solve due to complexity, breadth, and/or contradictory elements) requiring adaptive solutions, the plan was to develop a resource that could be adapted to local circumstances. The ED Crowding and Access Block Task Force was constructed with this goal and endorsed by the IFEM Board and launched at the International Conference on Emergency Medicine conference in South Korea in 2019. Since that time, the ED Crowding and Access Block Task Force Terms of Reference were approved, and the task force has seen involvement from all IFEM regions. Over 30 emergency medicine (EM) physician experts and thought leaders, with a broad range of expertise, have been joining monthly video conferences and contributing to fourteen distinct dossiers and well-referenced synopses which constitute the basis for this report (box 1).

      Box 1

      Overview of breadth of dossier topics found in the International Federation of Emergency Medicine Emergency Department Crowding and Access Block Task Force Report

      Dossier topic

      Background

      • Evidence base for effects of crowding.

      • Financial and human costs of crowding.

      • Metrics.

      • International experience.

      • Case studies and patient voices.

      Patient flow

      • Emergency medical services (prehospital services) offload.

      • Input and demand management.

      • Throughput.

      • Output and boarding.

      Management

      • Leadership.

      • Legal risks and regulatory violations.

      • Policy.

      • Advocacy.

      • Early lessons from COVID-19 and disaster medicine.

      This report examines the complexity of ED Crowding and Access Block through multiple important lenses. These range from an accounting of the impacts of the problem through to tactical and strategic solutions including policy, advocacy, operational and ‘on-the-floor’ initiatives. One overwhelmingly common theme that emerged through Task Force deliberations is that the problem may be misnamed. ED Crowding and Access Block is not an issue isolated to the ED, but fundamentally a health systems issue.1 3 Emergency Departments are well prepared to serve as the ‘safety net’ for a wide range of medical, traumatic and behavioural emergencies, however, EDs cannot fulfil this mission if they are also forced to become the ‘safety valve’ for dysfunction and limited capacity within the community and the hospital. Despite this, the Task Force would also share the view that EDs that are not contributing to solutions for healthcare system dysfunction are also part of the problem; hence the vital importance of emergency care providers who are well versed in system issues to infiltrate decision making and public awareness realms at multiple levels.

      As a ‘wicked problem’ for healthcare systems internationally, experts and thought leaders around the world have invested a remarkable amount of resources to understand the problem and formulate solutions. This report is designed to leverage that vast international experience and serve as a comprehensive global resource for EDs facing the challenge of crowding and access block. This document is meant to be used as a toolbox with each section acting as one tool of many to diagnose and treat an unsafe and overwhelmed ED. Leaders in emergency care will be able to use these instruments to address their local circumstances both on a short-term and long-term basis. This report is also meant to be shared in portion, or in its entirety, with all of the stakeholders that can be impacted by ED crowding and access block as well as the partners necessary to mitigate and distribute risk and allow emergency care to fulfil its core mission.

      The report, including the full list of authors, can be found in its entirety on the IFEM website.4

      Ethics statements

      Patient consent for publication

      References

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        . Emergency department crowding: a systematic review of causes, consequences and solutions. PLoS One 2018;13:e0203316. doi:10.1371/journal.pone.0203316pmid:http://www.ncbi.nlm.nih.gov/pubmed/30161242
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      4. ↵
        1. Javidan AP,
        2. Hansen K,
        3. Higginson I, et al
        . Report from the Emergency Department Crowding and Access Block Task Force [Internet]. Melbourne, Australia: International Federation for Emergency Medicine, 2020. https://www.ifem.cc/resources/white-paper-from-the-ifem-emergency-department-crowding-and-access-block-task-force-june-2020/. (Cited September 25, 2020).

      Footnotes

      • Handling editor Ellen J Weber

      • Twitter @APJavidan

      • Presented at This article is being simultaneously published in the International Journal of Emergency Medicine (doi: 10.1186/s12245-020-00312-x), Canadian Journal of Emergency medicine (doi: 10.1007/s43678-020-00065-9), Emergency Medicine Journal (doi: 10.1136/emermed-2020-210716), and Emergency Medicine Australasia (doi: 10.1111/1742-6723.13660).

      • Correction notice This article has been corrected since it first published. The provenance and peer review statement has been included.

      • Collaborators International Federation Emergency Department Crowding and Access Block Task Force: Arshia Javidan; Kim Hansen; Ian Higginson; Peter Jones; David Petrie; John Bonning; Simon Judkins; Eric Revue; David Lewis; Brian Holroyd; Laurie Mazurik; Colin Graham; Alix Carter; Shirley Lee; Eliecer Cohen-Olivella; Paul Ho; Ramesh Maharjan; Bianca Bertuzzi; Haldun Akoglu; Jim Ducharme; Maaret Castren; Adrian Boyle; Howard Ovens; Cheng-Chung Fang; Joseph Kalanzi; Jeremiah Schuur; Venkatesh Thiruganasambandamoorthy; Taj Hassan; Gautam Bodiwala; Pauline Convocar; Katherine Henderson; Eddy Lang.

      • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

      • Competing interests The IFEM ED Crowding and Access Block Report is referenced in the paper and is available on the IFEM website in its entirety. This article is being simultaneously published in the International Journal of Emergency Medicine (doi: 10.1186/s12245-020-00312-x), Canadian Journal of Emergency medicine (doi: 10.1007/s43678-020-00065-9), Emergency Medicine Journal (doi: 10.1136/emermed-2020-210716), and Emergency Medicine Australasia (doi: 10.1111/1742-6723.13660).

      • Provenance and peer review Not commissioned; externally peer reviewed.

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