ABSTRACT

Introduction:

The state of emergency department (ED) crowding in Pennsylvania has not previously been reported.

Methods:

We assessed perceptions of ED crowding by surveying medical directors/chairs from Pennsylvania EDs in the spring of 2008.

Results:

A total of 106 completed the questionnaire (68% response rate). A total of 83% (86/104) agreed that ED crowding was a problem; 26% (27/105) reported that at least half of admitted patients boarded for more than 4 hours. Ninety-eight percent (102/104) agreed that patient satisfaction suffers during crowding and 79% (84/106) stated that quality suffers. Sixty-five percent (68/105) reported that crowding had worsened during the past 2 years. Several hospital interventions were used to alleviate crowding: expediting discharges, 81% (86/106); prioritizing ED patients for inpatient beds, 79% (84/106); and ambulance diversion, 55% (57/105). Almost all respondents who had improved ED operations reported that it had reduced crowding.

Conclusion:

ED crowding is a common problem in Pennsylvania and is worsening in the majority of hospitals, despite the implementation of a variety of interventions.

INTRODUCTION

Emergency department (ED) crowding is a major public health problem in the United States.¹National surveys report a very high prevalence of ED crowding—as high as 91% in 2001.² Several causes for ED crowding have been proposed; however, the underlying problem is a fundamental mismatch between demand by patients for care and ED and hospital capacity.^3–5 This supply-demand mismatch has also been shown to have several adverse effects on patients during times of ED crowding. These include long waiting times, poorer satisfaction and pain control, treatment in hallways, a reduced ability to deliver time-sensitive interventions, such as antibiotics in cases of pneumonia and percutaneous intervention in acute myocardial infarction, and poorer survival and complication rates.^6–12

Several recent reports have proposed solutions to the crowding problem.^13–15 In addition, many interventions to alleviate crowding have been deployed in individual hospitals and in state-level policy. For example, the Department of Health in New York has allowed hospitals to move admitted patients to inpatient hallways when the ED is at full capacity.¹⁶ However, there are few studies that have detailed the results of interventions. There is also little published information on which interventions have been implemented, which have been difficult to implement, and which have the highest impact on improving overall patient flow.

The measurement of ED crowding has been a challenge. Several measures, such as ED occupancy and other measures, have been proposed. Prolonged ED length of stay has been associated with ED crowding and is one of the measures used to measure ED crowding retrospectively.¹⁷ In 2013, the Centers for Medicare and Medicaid Services will provide incentive payments for specific measures of ED length of stay.¹⁸ However, there are no states that explicitly require hospitals to report patient flow indicators, nor have there been any statewide assessments of the feasibility of reporting systems. In the absence of any national and state-specific reporting requirement and before hospitals start reporting in 2013, there is little information outside of investigator-initiated research to assess the prevalence of crowding. There is currently noway for patients to assess expected or actual wait times when seeking emergency services, outside of EDs who report these times publicly to the local community.

We sought to assess perceptions of ED crowding at the level of ED administration across Pennsylvania by surveying ED medical directors with the goal of (1) determining perceptions on the prevalence of and trends in ED crowding and boarding across the state and (2) assessing the reported use of various interventions aimed at alleviating ED crowding.

METHODS

RESULTS

DISCUSSION

Consistent with national reports, we found perceptions of a very high prevalence of ED crowding in Pennsylvania.^1,2 This is also consistent with previous state-level reports demonstrating a high level of ED crowding in California, Florida, Texas, and New York.^19,20 In Pennsylvania, while crowding is the largest issue facing EDs, it does not appear to occur all the time in most hospitals. This reflects the cyclical nature of ED demand, where crowding may be present at certain times of the day, week, month, or year.²¹ The supply-demand mismatch is present in most EDs some of the time, but the proportion of time for which there are insufficient resources to handle ED patients is highly variable, depending upon the hospital. Few EDs report a supply-demand mismatch all the time, but most report it part of the time. We found a similar pattern in the rates of ED boarding, where only a small proportion of EDs report that more than 50% of EDs admitted patients board for more than 4 hours and most report that somewhere between 1% to 10% board for more than 4 hours.

During episodes of crowding, there was clear consensus that crowding lowers patient and staff satisfaction. The effect of ED crowding on patient satisfaction has been reported recently, with ED crowding, hallway bed placement, and long boarding times resulting in lower patient satisfaction.⁶Quality of care was also reported to be a major issue, which is confirmed by reports that have shown an association between ED crowding and process measures, such as time to antibiotics in cases of pneumonia and the timing and provision of pain control.^7,8,22,23 In addition, a recent report found that crowding lengthens the overall time in the ED, even for high-acuity patients.¹⁷ There was also general agreement that patients leave without being seen, which is a known consequence of long waits.^24,25 However, only a minority of hospitals reported using ambulance diversion during times of crowding, which may reflect local or regional policies.

Most medical directors reported that crowding had worsened across the state during the pat 2 years. While the Emergency Medicine Transfer and Active Labor Act requires that all patients presenting to the ED have a screening examination, there have been few state or national policies that require hospitals to provide timely emergency care. In addition, because more than half of ED directors report that primary care access is worse, ED volume may be increasing to make up for the shortfall of urgent primary care services in Pennsylvania.²⁶

Most hospitals report a change in operations during crowded times. These changes most frequently include expediting inpatient discharges, prioritizing ED patients for inpatient beds, and rapidly transferring ED patients to inpatient beds. Because boarding is a central cause for crowding, it would make sense that hospitals would attempt to rapidly move admitted patients out of the ED in response to crowding.²⁷ Several strategies were used by a minority of hospitals, including cancelling elective surgeries, stopping intrahospital transfers, and moving ED patients to inpatient hallways. Because non-ED admissions generate higher revenues, it would make sense that from a purely economic perspective, hospitals would be hesitant to cancel transfers for profitable patients compared to the less profitable ED patients waiting for inpatient beds.²⁸

Emergency department directors named delays in inpatient bed placement as having the strongest effect on crowding. Boarding as a central cause for crowding has been confirmed in several reports.^22,29,30, Increased volume, increased acuity, and insufficient ED space were also named as strong contributors to crowding across Pennsylvania. These factors are also known causes for crowding and capacity issues. Efficiency issues were reported to have a moderate effect on crowding, such as delays in radiology and delays in consultation. A similar finding was noted in a report that detailed systematic delays in time to antibiotic administration for patients with pneumonia where one component, a delay in radiology, was a significant factor in delayed antibiotic administration.³¹

When asked which interventions had been performed to alleviate crowding during the previous 2 years, only 40% of EDs reported there had been an active intervention. The most common intervention was improving ED efficiency, which was also reported by nearly all medical directors to help alleviate crowding. About one third to one fourth of EDs reported that they had hired more staff (physicians, physician extenders, and nurses), increased ED space, or hired a bed manager. Of those interventions, hiring physician extenders seemed to have the greatest effect on reducing crowding, with more than 70% reporting an improvement. Hiring physician extenders may improve crowding by expediting care for low severity cases. Implementation of 2 interventions that involve support outside the ED was reported to be largely unsuccessful. More than 40% of EDs reported the inability to use inpatient hallways for admitted patients. In addition, 20% reported attempting to implement surgical schedule smoothing but had met with failure. Surgical schedule smoothing is the process of balancing surgery loads throughout the week (ie, an equal number of surgeries every day), as opposed to what is commonly done in hospitals, which is to schedule elective surgeries during weekdays.^32,33 Respondents did not detail why surgical smoothing and the use of inpatient floors, successful solutions to ED crowding in other states, had not been implemented in their EDs in Pennsylvania. However, of the few hospitals that had been able to implement smoothing, 4 of 6 reported that it had reduced crowding. Given these preliminary results, surgical schedule smoothing appears to be a promising intervention to reduce ED crowding. By contrast, only 1 of 5 hospitals that use inpatient floors for admitted patients reported that it has successfully reduced crowding. This may indicate that the use of inpatient floors for admitted patients as a strategy to reduce crowding may have less impact than expected.³⁴

However, these data do suggest that certain strategies to reduce crowding may have greater impact than others. Given the fact that, by itself, improving ED operations seems to universally improve ED crowding, it is unclear whether hospitals should look to their ED to improve throughput, or look more to non-ED interventions, such as surgical smoothing, which seem similarly useful, but much more difficult to implement. Comparative studies aimed at determining which interventions are most effective at reducing crowding and the logistics of implementing them (ie, the buy-in needed to achieve an intervention) will be helpful in guiding hospitals to improve ED flow.

Several barriers to improving ED crowding were listed. Approximately one half of ED directors reported that hospital administration was a major barrier. The difficulty associated with effecting change in hospitals, as well as the varied priorities of stakeholders, may contribute to this negative perception of hospital administrators. Similarly, approximately half of ED directors reported that they did not have sufficient human or financial resources to improve crowding. A reluctance of hospital administration to provide support or resources to ED crowding may be due to the way in which crowding is prioritized by hospitals and perceptions that crowding is more of an ED problem than a hospital-wide problem.

LIMITATIONS

There are several limitations to this study. The greatest limitation of this study was that we did not verify any of the answers, so it is possible that some of the survey responses may not be accurate. For example, it is unknown whether the medical directors used real data for many of the quantitative questions or whether they used estimates. In addition, these data may represent a biased sampled because we did not sample 100% of Pennsylvania EDs and because those EDs responding were more likely to have ED residency programs. Because residency programs tend to be in more populated areas, the data may overestimate the level of crowding across Pennsylvania EDs. It may be more difficult to generalize these data to community hospitals that did not answer the survey. It is also possible that respondent hospitals differed on factors that we did not report, such as ED volume. We attempted to reduce nonresponse bias by trying to maximize our response rate through using several survey requests and multiple modalities (e-mail, paper mail, and phone calls). Another limitation is that these data were obtained from medical directors, who may have their own crowding bias, affecting how they responded to survey questions. Even though we explicitly communicated that we would not publicly release the individual results from their hospitals, the fact that they identified their hospital may have influenced how they estimated the level of crowding and reported data. However, medical directors likely are in the best position to provide accurate data on this issue. We were also limited by our survey instrument, which was developed and piloted locally, but was not rigorously validated. Finally, for this study, we defined boarding as occurring 4 hours or more after a bed request. Since a recent report has defined boarding as a shorter time interval from the bed request (2 hours), our definition may have underestimated the level of boarding across the state.³⁵

CONCLUSION

According to ED medical directors across Pennsylvania, crowding is currently the number one issue facing their EDs in the state. Most directors report that crowding and boarding occur some of the time, while few report it occurs all the time. There appears to be consensus that crowding has a negative impact on patient and staff satisfaction, and in most EDs, quality of care. However, a minority report that greater resources are devoted to the ED during episodes of crowding. Several factors affecting ED crowding were identified in this report, but boarding of ED-admitted patients appears to be the most common. Many interventions have been implemented and the most successful ones include improving ED operations, hiring physician extenders, and smoothing of surgical schedule. Improving ED operations may include ED-specific interventions such as bedside registration or improvements in the way the ED itself functions. Interventions that involve collaboration outside the ED, such as moving patients to inpatient hallways and surgical schedule smoothing, have been difficult to implement in many hospitals. Hospital administration is reported to be a barrier in approximately half of hospitals, as is having suitable financial and human resources to improve crowding.