Emergency Department Crowding
This article discusses the causes of ED crowding and the effects on patient care and staff. Attached below is a quick overview of our discussion with our administrative team.
a. Boarding: time from admission decision until the patient leaves ED
Essential Overcrowding Elements
2. ED crowding has been documented in the literature to impact patient safety and mortality.
a. In an ideal state maintaining a hospital census at 85% limits ED crowding.
b. ED gridlock is assured when inpatient occupancy exceeds 90%
3. Buy-In from institutional leadership is crucial to addressing the issue of ED crowding.
4. Current reimbursement practices and financial incentives further exacerbate boarding constraints.
5. Excessive boarding results from access block, the inability to access appropriate hospital beds within a reasonable time
6. Access block is from high inpatient occupancy rates, service demand, inefficient patient flow processes
7. Crowding is predictive, and we need enforceable preemptive surge plans.
a. Consider in the same light as disaster response.
8. Solutions include: Expansion of functional hospital capacity, making inpatient ancillary services available 24/7, surgical smoothing, centralizing bed control with authority (bed czar), establishing electronic dashboards, efficient ED to inpatient nursing handoffs, synchronizing inpatient discharge with admission demand, initiatives to decrease inpatient length of stay, transitioning ED admitted patients in inpatient hallways, and implementing TJC 4-hour boarding standards.
9. Augmenting ancillary support – lab turnaround, room cleaning turn around, availability of social work, PT, OT on weekends.
References
Emergency Department Crowding: The Canary in the Health Care System | Catalyst non-issue content
Catalyst.nejm.org
https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0217
