Déjà vu

doi:10.1016/S0196-0644(00)70110-7

Annals of Emergency Medicine

Volume 35, Issue 1, January 2000, Pages 83-85

https://doi.org/10.1016/S0196-0644(00)70110-7 Get rights and content

Abstract

[Kellermann AL. Déjà vu. Ann Emerg Med. January 2000;35:83-85.]

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Cited by (44)

Emergency Department Crowding, Part 2-Barriers to Reform and Strategies to Overcome Them
2009, Annals of Emergency Medicine
Part 1 of this 2-article series reviews serious moral problems created by emergency department (ED) crowding. In this second part of the series, we identify and describe operational and financial barriers to resolving the crisis of ED crowding, along with a variety of institutional and public policy strategies proposed or implemented to overcome those barriers. Finally, the article evaluates 2 additional actions designed to address the problem of ED crowding, namely, distribution of a warning statement to ED patients and implementation of a “reverse triage” system for safe early discharge of hospital inpatients.
Pediatric Emergency Department Overcrowding: Electronic Medical Record for Identification of Frequent, Lower Acuity Visitors. Can We Effectively Identify Patients for Enhanced Resource Utilization?
2009, Journal of Emergency Medicine
Citation Excerpt :
At the same time, minimum standards and the safety net of care must be maintained (1). In the backdrop of these concerns, Emergency Departments (EDs) are experiencing significant levels of overcrowding, with some 100 million adults and 30 million children receiving ED care annually (1–5). These utilization patterns place a tremendous strain on EDs, stretching resources (manpower, space, and funding) to the maximum (6–8).
The objective of this study was to utilize the electronic medical record system to identify frequent lower acuity patients presenting to the Pediatric Emergency Department and to evaluate their impact on Pediatric Emergency Department overcrowding and resource utilization. The electronic medical records (EMR) of two pediatric emergency centers were reviewed from August 2002 to November 2004. Pediatric Emergency Department encounters that met any of the following criteria were classified as Visits Necessitating Pediatric Emergency Department care (VNEC):
- •
  Disposition of admission, transfer or deceased
- •
  Intravenous fluids (IVF) or medications (excluding single antipyretic or antihistamine)
- •
  Radiology or laboratory tests (excluding Rapid Strep)
- •
  Fractures, dislocations, and febrile seizures
All other visits were classified as non-VNEC. ICD-9 (International Classification of Diseases, Ninth Revision) codes from the Pediatric Emergency Department encounters were defined as representing chronic or non-chronic conditions. Patients were then evaluated for utilization patterns, frequency of Emergency Department (ED) visits, chronic illness, and VNEC status. There were 153,390 patients identified, representing 255,496 visits (1.7 visits/patient, range 1–49). Overall, 189,998 visits (74%) required defined ED services and were categorized as VNEC, with the remaining 65,498 visits (26%) categorized as non-VNEC. With increasing visits, a steady decline in those requiring ED services was observed, with a plateau by visit six (VNEC 77% @ one visit, 64% @ six visits, p < 0.001). There were 141,765 patients seen fewer than four times, representing 92% of the patients and 74% of all visits (1.3 visits/patient, 225 visits/day). In contrast, 2664 patients disproportionately utilized the ED more than six times (maximum 49), representing 1.7% of patients and 9.8% of visits (9.4 visit/patient, 30 visits/day, p < 0.001). Excluding patients with chronic illness, 1074 patients also disproportionately utilized the ED more than six times (maximum 28), representing 0.7% of patients and 3.6% of visits (8.6 visit/patient, 11 visits/day, p < 0.001). While representing < 2% of patients, frequent lower acuity utilizers of ED services accounted for nearly 10% of all visits (30/day). Low acuity patients may require only limited additional marginal resources for their individual care. However, in aggregate, inefficiencies occur, especially when systems reach capacity constraints, at which point these patients utilize limited resources (manpower and space) that could more effectively be directed toward the more acutely ill and injured patients. Therefore, identification of these patients utilizing the electronic medical record will allow for targeted interventions of this subgroup to improve future resource allocation.
Patients Would Prefer Ward to Emergency Department Boarding While Awaiting an Inpatient Bed
2008, Journal of Emergency Medicine
Citation Excerpt :
There is already evidence that inpatient boarding in the ED may lead to medical errors and avoidable morbidity and mortality (1,7). It is also clear that the primary cause of this is lack of inpatient beds (1,8,9). This study suggests that the rather obvious solution of boarding admitted patients in inpatient hallways rather than the ED may be the preferred solution of most patients and their visitors quite apart from potential safety and efficiency implications.
Boarding of admitted patients in the Emergency Department (ED), rather than in inpatient care areas, is widespread. We surveyed boarded patients, patients without a disposition, and visitors at a county hospital ED serving a mixed urban and rural population. Subjects were asked “If you needed to be admitted to the hospital but no inpatient bed is available, would you prefer to be kept in an ER hallway or a hallway on an inpatient ward?” Boarded patients said they would prefer ward to ED boarding, 117/213 (54.9%; 95% confidence interval [CI] 48.0%–61.7%). Patients without a disposition 314/477 (65.8%; 95% CI 61.4%–70.0%) and visitors 370/532 (69.5%; 95% CI 65.4%–73.4%) stated a preference for ward boarding in 314/477 (65.8%; 95% CI 61.4%–70.0%) and in 370/532 (69.5%; 95% CI 65.4%–73.4%), respectively. Common reasons for preferring inpatient ward boarding were privacy concerns and reduced noise levels. Those preferring ED boarding valued easy access to a doctor.
The Effect of Low-Complexity Patients on Emergency Department Waiting Times
2007, Annals of Emergency Medicine
Citation Excerpt :
In 2002, more than 110 million emergency department (ED) visits occurred in the United States, a 23% increase since 1992.1 This increase in utilization has coincided with a period of worsened ED crowding, with surveys reporting the problem in almost every state2-5 on almost every day.3,5 Several studies have documented substantial utilization of EDs by low-acuity patients,6-8 but no study has found a convincing association between low-acuity utilization and ED crowding.
The extent to which patients presenting to emergency departments (EDs) with minor conditions contribute to delays and crowding is controversial. To test this question, we study the effect of low-complexity ED patients on the waiting times of other patients.
We obtained administrative records on all ED visits to Ontario hospitals from April 2002 to March 2003. For each ED, we determined the association between the number of new low-complexity patients (defined as ambulatory arrival, low-acuity triage level, and discharged) presenting in each 8-hour interval and the mean ED length of stay and time to first physician contact for medium- and high-complexity patients. Covariates were the number of new high- and medium-complexity patients, mean patient age, sex distribution, hospital teaching status, work shift, weekday/weekend, and total patient-hours. Autoregression modeling was used given correlation in the data.
One thousand ninety-five consecutive 8-hour intervals at 110 EDs were analyzed; 4.1 million patient visits occurred, 50.8% of patients were women, and mean age was 38.4 years. Low-, medium-, and high-complexity patients represented 50.9%, 37.1%, and 12% of all patients, respectively. Mean (median) ED length of stay was 6.3 (4.7), 3.9 (2.8), and 2.2 (1.6) hours for high-, medium-, and low-complexity patients, respectively, and mean (median) time to first physician contact was 1.1 (0.7), 1.3 (0.9), and 1.1 (0.8) hours. In adjusted analyses, every 10 low-complexity patients arriving per 8 hours was associated with a 5.4-minute (95% confidence interval [CI] 4.2 to 6.0 minutes) increase in mean length of stay and a 2.1-minute (95% CI 1.8 to 2.4 minutes) increase in mean time to first physician contact for medium- and high-complexity patients. Results were similar regardless of ED volume and teaching status.
Low-complexity ED patients are associated with a negligible increase in ED length of stay and time to first physician contact for other ED patients. Reducing the number of low-complexity ED patients is unlikely to reduce waiting times for other patients or lessen crowding.
Ambulance Diversion and Lost Hospital Revenues
2006, Annals of Emergency Medicine
We estimate ambulance revenues lost from each hour spent on ambulance diversion at an urban teaching hospital’s emergency department (ED) and examine the financial impact of increased ICU capacity, which reduced diversion hours by 63%.
This was a secondary analysis of administrative data to determine the time and date of ambulance arrivals, as well as the insurance status and revenues from each ED patient arriving by ambulance between January 1, 2002, and December 31, 2003. The primary outcome measure was hourly revenues (ie, payments to the hospital) for ambulance patients.
Ten thousand three hundred one adult, non–trauma-system ED patients arrived by ambulance in 2002 and 2003, with average hospital revenues of $4,492. Each hour spent on diversion was associated with $1,086 (95% confidence interval $611 to $1,461) in forgone hospital revenues from ambulance patients. In August 2002, the study hospital increased its staffed ICU beds from 47 to 67, and diversion decreased from an average of 307 to 114 hours per month. In association with the reduction in diversion, the hospital received more patients by ambulance, which translated into approximately $175,000 in additional monthly revenues from ambulance patients. However, these gains were relatively small in relation to total ambulance revenues and to their large monthly variance.
Ambulance patients generated substantial revenues for hospital services. Decreasing diversion time led to improved revenues. The potential for increased revenues may provide some incentive for hospitals to take greater efforts to reduce ambulance diversion.
The effect of crowding on access and quality in an academic ED
2006, American Journal of Emergency Medicine
Emergency department crowding has the potential to cause undesirable outcomes. We evaluated ED access and provider and patient assessments of quality.
This multimethod study, done in an urban academic ED, included descriptive analysis of administrative records, paired physician and nurse provider surveys, and pre- or postpatient surveys regarding expectations and experiences. Our outcomes were rates and characteristics of patients who left without being seen (LWBS), provider ratings of crowding/compromised care, and patient satisfaction.
During data collection periods, 11 743 patients registered, and 9% LWBS. Patients who LWBS tended to be younger than 45 years (relative risk [RR] = 1.7; 95% confidence interval [CI], 1.5-1.9), of nonurgent/stable triage acuity (RR = 3.1; 95% CI, 2.5-3.8), and without insurance (RR = 1.5; 95% CI, 1.3-1.7). Seventy-four percent of all patients had insurance, and 28% were private. Doctors and nurses had 81% agreement (κ = 0.54) in their assessment of crowded conditions, which were temporally associated with LWBS rates (P < .01). In 47% of 57 shifts, at least 1 provider felt that crowding was compromising quality of care. Of 423 sequential ED waiting room patients approached, 310 (73%) enrolled and 174 (56%) of these completed phone follow-up. On average, patients felt that they should be seen within 1 hour but expected to wait for 2.1 hours. Patient's perceived that wait times on follow-up averaged 3.5 hours, 5+ hours for LWBS patients. Visit satisfaction was inversely related to patient's perceived wait times.
We find that ED crowding increased LWBS rates and patient satisfaction. Systemwide changes in ED organization will be necessary for the ED to fulfill its role as a safety net provider and meet public health needs during disaster surge capacity.

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Déjà vu☆,☆☆,★

Abstract

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

A Report from the American College of Emergency Physicians Task Force on Hospital Overcrowding and Emergency Department Overload

Too sick to wait

JAMA

Hospital Emergency Departments: Unevenly Affected by Growth and Change in Patient Use

The care of HIV-infected adults in the US

N Engl J Med

The reemergence of tuberculosis as an emergency department concern

J Emerg Nurs

Injuries due to firearms in three cities

N Engl J Med