Saturday, April 12, 2008

The Effect of ED Expansion

This article states that the entire hospital has to change to prevent ED overcrowding and ambulance diversion.

OSF built an observation area for ER patients, but will that be enough? Again, quality of patient care needs to be more important than the financial bottom line. And that concept has to start with OSF's Administration.

The Effect of Emergency Department Expansion on Emergency Department Overcrowding

Han JH, Zhou C, France DJ, et al (Vanderbilt Univ, Nashville, TM) Acad Emerg Med. 2007;14:338-343.

Objectives: To examine the effects of emergency department (ED) expansion on ambulance diversion at an urban, academic Level 1 trauma center.

Methods: This was a pre-post study performed using administrative data from the ED and hospital electronic information systems. On April 19, 2005, the adult ED expanded from 28 to 53 licensed beds. Data from a 5-month pre-expansion period (November 1, 2004, to March 1, 2005) and a 5-month postexpansion period (June 1, 2005, to October 31, 2005) were included for this analysis. ED and waiting room statistics as well as diversion status were obtained. Total ED length of stay (LOS) was defined as the time from patient registration to the time leaving the ED. Admission hold LOS was defined as the time from the inpatient bed request to the time leaving the ED for admitted patients. Mean differences (95% confidence interval [CI]) in total time spent on ambulance diversion per month, diversion episodes per month, and duration per diversion episode were calculated. An accelerated failure time model was performed to test if ED expansion was associated with a reduction in ambulance diversion while adjusting for potential confounders.

Results: From pre-expansion to postexpansion, daily patient volume increased but ED occupancy decreased. There was no significant change in the time spent on ambulance diversion per month (mean difference, 10.9 hours; 95% CI = −74.0 to 95.8), ambulance diversion episodes per month (two episodes per month; 95% CI = −4.2 to 8.2), and duration of ambulance diversion per episode (0.3 hours; 95% CI = −4.0 to 3.5). Mean (+/−SD) total LOS increased from 4.6 (+/−1.9) to 5.6(+/−2.3) hours, and mean (+/−SD) admission hold LOS also increased from 3.0 (+/−0.2) to 4.1 (+/−0.2) hours. The proportion of patients who left without being seen was 3.5% and 2.7% (p = 0.06) in the pre-expansion and postexpansion periods, respectively. In the accelerated failure time model, ED expansion did not affect the time to the next ambulance diversion episode.

Conclusions: An increase in ED bed capacity did not affect ambulance diversion. Instead, total and admission hold LOS increased. As a result, ED expansion appears to be an insufficient solution to improve diversion without addressing other bottlenecks in the hospital.

Comment:If you build it, they will come. But, once they come, will you have anywhere to put them? This study is additional proof to the concept that ED overcrowding is a multi-factorial problem with no simple solution. And, it is likely that the weight of the contributing factors varies between EDs and hospitals. As the population ages, ED overcrowding will likely become a greater problem. Solutions will need to include increases in the ready availability of inpatient beds and staffing, alternatives to admission (for example, cardiac CTs rather than admission for a rule out and stress test in low risk chest pain), and mechanisms to divert patients with non-urgent care needs from the ED when it is busy. In addition, there is a great need for development of models to identify when an ED/Hospital is nearing the point of requiring diversion so that measures like calling in additional ED/inpatient staffing, prompting early discharges, etc, can be implemented before the ED is in crisis mode.

S. L. Werner, MD

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