L’overcrowding inPronto Soccorso :di chi è il problema?

Mario CavazzaUO di Medicina d’Urgenzae Pronto Soccorso

Azienda Ospedaliero-Universitariadi Bologna

Admitted patients awaiting a ward bed are boarded in the ED majors area or resuscitation suite. Frequently there are insufficient trolleys or bays for all those sick enough to require hospital admission, and as a result patients not infrequently wait on plastic chairs in hallways or open floor areas pending the availability of a ward bed.

ED overcrowding summary:• Its bad for patients, staff, and administrators.

• Most often affects:–Urban and large-volume EDs; trauma and referral centres; teaching centres.

• Efforts to mitigate ED overcrowding are worthwhile.

U.S.A.

“Crowding occurs when theidentified need foremergency services exceedsavailable resources forpatient care in theEmergency Department,Hospital, or both.”

Ann Emerg Med. 2006;47:585.

What is crowding?• Supply-demand mismatch–Long waits to be seen

–Long waits for tests

–Long waits for beds

ED crowding

A che livello parliamo di overcrowding?

• A point prevalence study ofcrowding found that the averagenurse was caring for 4 patientssimultaneously, and the averagephysician was caring for 10 patients simultaneously

Schneider SM, et al. Ann Emerg Med. 2003;42: 167-172

Measuring crowding

• How you measure crowding?

Measuring crowding• The pink elephant problem:– What is crowding?– Does crowding mean we’re just busy?

– How crowded is too crowded?

– Are we crowded or “overcrowded”?

Measuring crowding

• Two perspectives–Patient

• Waiting room time, total ED LOS, boarding time

– Can obtain retrospectively

–ED (real-time measures)• Waiting room number, occupancy, number of admitted patients, diversion status

Crowding Models• NEDOCS (National ED Overcrowding Scale)• EDWIN (ED Work Index)• READI (Real-time Emergency Analysis of

Demand Indicators)• Work Score• ED Occupancy Rate • EDCS (ED Crowding Scale)• Discrete Event Simulation• Queuing Theory

= ∑ niti/Na(BT-BA)

= sum of ESI (ti) of all active patients (ni) in ED / number of attending physicians each hr (Na) x # currently available tx bays (BT) – (BA)

= (Total # pts in ED)/ Total #ED treatment bays/hr

= a(pts in waiting rm/#ED tx ∑ nt areas) + b(∑ reverse ESI/#nurses) + c(boarders/#ED tx areas)

Using: Total #pts in ED, #tx spaces, patient arrivals, pt acuity, #staff

Calculate: bed ratio, acuity ratio, provider ratio, demand value

Uses: # attendings, # staffed beds, # critical care pts, #total staffed hospital beds, hospital occupancy

Uses: total #ED beds, #inpt beds, total #ED pts in ED, total # pts on ventilator, longest current pt stay (hrs), total # pts in ED boarding, (hrs) last pt placed in ED tx rm

Myths

–It Is an ED Problem–Uninsured Are the Problem–Non-Urgent & “Frequent Flier” Pts are Problem

–Build More Beds–Pts Who LWBS Are Not Sick–Arrival Pattern of Patients is Unpredictable

CONTRACTILITY (troughtput)

PRELOAD (input)

AFTERLOAD (output)

ECJ 2010

Rastelli G, et al, ECJ 2010

crowding causes

Non-Urgent Visits• Definition: Low-acuity ED patients seeking care in the ED.–Present even in hospitals with dedicated fast-track systems.

–Reasoning: Typically insufficient access or/and untimely access to primary care.

• Account for a small portion of total ED volume.

Cause del ricorso eccessivo al PS

• Ottenere in tempi brevi una rispostaa bisogni percepiti come urgenti

• Pazienti fragili e “lungo-sopravviventi” che necessitano di interventi in tempi rapidi

• Consapevolezza di trovare unarisposta qualificata mediata anchedall’impiego di tecnologie.

A differenza degli USA il sistemasanitario italiano offre ai cittadinimolte alternative gratuite o a bassocosto per la diagnosi e la cura, dalmedico di famiglia agli ambulatorispecialistici ospedalieri edextraospedalieri, ma questo nonsembra essere sufficiente visto ilnumero consistente di persone chearriva direttamente in pronto soccorsosenza avere interpellato prima almenoil proprio medico

Casagranda I, ECJ, 2006

L’”effetto Roemer”

L’incremento del numero dei posti letto ospedalieri per abitante determina l’aumento dei tassi di ricovero

L’”effetto Amartya Sen”

L’incremento della spesa sanitaria per abitante determina l’aumento della proporzione di popolazione che si considera malata

Frequent Flyers• Definition: 4 or more annual visits to the

ED – Responsible for 8-14 percent of the total ED

visits – Often non-urgent complaints – This includes: Chronic illness, drug seeking

patients, malingers

• However, among these patients a good portion frequently have serious pathology.

Visite ED: +26%Posti letto: - 198.000

N Engl J Med , 2006

Hospital beds

Posti letto

La DM in Italia:negli anni e nelle fasce di età

Speranza di vita a 65 anni nella popolazione italiana

15

16

17

18

19

20

21

22

23

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

anni

Femmine Maschi

Rastelli G, et al, ECJ 2010

crowding effects

consequences• Sub-standard medical care:

– Delays in time-sensitive treatments (e.g., antibiotics for infections, thrombolytics for AMI, etc);

– Outcomes: • Prolonged LOS; • Increased death (e.g., sepsis, AMI).

• Increased risks:– Medical errors;– Patient safety.

consequences• Infection Control:

– risk of contagious illnesses.• Human resources:

– Decreased job satisfaction among nurses and physicians;

– Increased sick time and absenteeism.• Loss of privacy/dignity.• Costs:

– costs associated with ED overcrowding.

Rastelli G, et al, ECJ 2010

crowding solutions

Possible Solutions•HQCA overview released January 2012.

Pre-ED (input)• Decreasing demand:

– ED wait times reporting – Media campaigns;– Improved access to primary care;– Prevention (e.g., helmet laws) initiatives;– Chronic disease (e.g., COPD) management.

• Diversions of care:– Alternative sources (WIC) of care;– EMS:

• Alternative destinations;• Ability to treat and discharge.

In-ED (Throughput)• Advanced triage.• Triage nurse ordering.• Triage liaison physician.• Enhanced diagnostics and access to results.

• Intermediate care: Obs Units.• Primary care (e.g., NPs) in the ED.• Fast track and “see & treat”.• Pt advocacy case management model

Post-ED (Output)

• Local resource• Family pract. compliance• Stakeholder compliance• WIC• Hospital bed availability• Bed management ( full capacity protocol)

CONTRACTILITY (troughtput)

PRELOAD (input)

AFTERLOAD (output)

DOVE SIAMO

DOVE VORREMMOESSERE

ConclusionEmergency department crowding is not aproblem of the EDs alone; it results from multiple system-wide factors acting to create bottlenecks that impede access to timely and high quality emergency care for all. Solutions to ED crowding will require coordinated efforts on the part of emergency physicians, federal and state policymakers, local hospitals, community leaders, EMS organizations and public and private health plan payers, as well as significant budgetary appropriations.

Our MissionGet every patient

to thebest resources

in theright place

and in the shortest time.