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Crowding in the Emergency Department

      Crowding is a serious issue that emergency departments face globally and it poses major safety risks with the potential for several adverse clinical outcomes.
      • Filippatos G
      • Karasi E
      The effect of emergency department crowding on patient outcomes.
      • Carter E
      • Pouch S
      • Larson E
      The relationship between emergency department crowding and patient outcomes: A systematic review.
      A major reason for crowding is boarding admitted patients. In fact, the National Center for Health Statistics found that wait times for treatment in Emergency Departments that were boarding patients had a longer ED stay than those that were not boarding patients.
      • Hing E
      • Bhuiya F
      Wait time for treatment in hospital emergency departments.
      At the 2015 General Assembly, delegates, alternates, and past presidents rated improving throughput, and specifically, improving the time from patient admission from the ED to an inpatient bed, as one of the top three priority clinical practice issues for ENA to address.
      Groups of eight delegates discussed the topic and came to consensus that “Quality of care is decreased exponentially by the number of hours patients are held in the Emergency Department.” The themes of patient safety, decreased patient satisfaction, nurse retention, increasing wait times, the inability to meet metrics, and increasing LWOT (left without being seen) resonated among the groups. Several groups cited studies showing that patient mortality increases with extended stays in the ED. The demand for Emergency Department services has significantly increased over the last decade. We are the primary site of acute unscheduled care. During periods of high patient concentration and increased bottlenecks of admitted patients waiting for inpatient beds, waiting room times are increasing. Hing
      • Hing E
      • Bhuiya F
      Wait time for treatment in hospital emergency departments.
      found that mean wait times from entering the ED until being seen by a provider increased 25% from 2003-2009. One group commented that “perhaps the most dangerous place in the ED is the waiting room.”
      As crowding increases, the quality of care is reduced due to lack of adequate resources.
      • American College of Emergency Physicians Crowding Resources Task Force
      Responding to emergency department crowding: A guidebook for chapters.
      Several groups felt that using ED resources to provide inpatient care in the ED taxes the staff, prevents treating critical incidents efficiently, and decreases patient satisfaction scores all while wait times increase. The focus of ED care is to stabilize patients and move them to the appropriate destination. Our practice is to care for the sickest patient first, so other patients’ care may be missed, including increased incidences of falls, infections and pressure ulcers, and missed daily medications, skin care, and DVT prophylaxis.
      Participants were asked to consider potential solutions to be implemented on both local and national levels.
      They determined that the top three local solutions were:
      • Collaboration and coordination with other hospital departments
      • Support from administration
      • Better housekeeping systems and more housekeeping staff
      The groups felt that ED nurses need to be supported by administration with strong policies in support of expedited inpatient bed availability and placement. One group felt that the culture must change to include “buy in” from management and physicians, and that it is important for everyone to “think outside the box” about admissions.
      The top three national solutions selected by participants were:
      • Collaborate with other associations
      • Develop best practices and guidelines
      • Provide education for administration
      When participants were asked to provide additional comments or thoughts about improving patient admission times the following comments were submitted:
      • Use resources wisely to increase reimbursement;
      • Create a position statement on boarding patients in the hall;
      • Create a financial penalty for boarding patients in the ED;
      • Promote the use of a standardized tools to measure staff to patient ratios and advocate for safe staffing;
      • Enhance accountability, collaboration, and responses to medical surges with the entire hospital system; and
      • Create a shared solution.
      We are all aware that evidence supports the concepts that patients held in the ED experience poorer outcomes and that safety and quality improve as patients move to an inpatient bed. Safe practice, safe care is our ultimate goal. What admission initiatives have worked in your hospitals? Let me hear from you!

      References

        • Filippatos G
        • Karasi E
        The effect of emergency department crowding on patient outcomes.
        Health Sci J. 2015; 9: 1-6
        • Carter E
        • Pouch S
        • Larson E
        The relationship between emergency department crowding and patient outcomes: A systematic review.
        J Nurs Scholarsh. 2014; 46: 106-115
        • Hing E
        • Bhuiya F
        Wait time for treatment in hospital emergency departments.
        (Updated August 28, 2012. Accessed December 8, 2015)
        • American College of Emergency Physicians Crowding Resources Task Force
        Responding to emergency department crowding: A guidebook for chapters.
        2002 (Dallas, TX)

      Biography

      Kathleen Carlson is President of the Emergency Nurses Association.