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Reducing Ambulance Diversions

Reducing Ambulance Diversions

Recent data indicate that about 45% of EDs in the United States report being “on diversion” at some point within a given year to alleviate crowding. “Although ambulance diversion has been used for quite some time, several studies link these diversions to negative consequences,” explains M. Kit Delgado, MD, MS. “These include prolonged transport times, delays in care, higher mortality, and lower hospital revenue.” Efforts have been made to reduce ambulance diversion in the past. These strategies include implementing ED patient-flow improvements. “Optimizing front end operations, such as patient triage, registration, and tracking, is also important,” says Dr. Delgado. “Other improvement efforts include adopting hospital-wide full capacity protocols to expedite the transfer of admitted patients from EDs to inpatient units.” New Insights on Diversion & Crowding Questions remain about the strategies that can best reduce diversion without increasing ED crowding and how best to coordinate these efforts. In the Western Journal of Emergency Medicine, Dr. Delgado and colleagues had a study published that systematically reviewed simulation model investigations. “Our overall goal was to gain insights on how to optimally reduce ambulance diversion,” Dr. Delgado says. The analysis identified 10 studies that used simulations modeling ambulance diversion as a result of ED crowding or inpatient capacity problems. Results showed that ambulance diversion only minimally improved ED waiting room times. Strategies that were found to reduce diversion considerably include: 1. Adding holding units for inpatient boarders. 2. Adding ED-based fast tracks. 3. Improving lab turnaround times. 4. Smoothing out elective surgery caseloads. “The desired effect of reducing ED waiting room times by diverting ambulances is likely to be very small,” says...
A Look at Patients’ Willingness to Wait for ED Care

A Look at Patients’ Willingness to Wait for ED Care

As the number of patients seeking emergency care in the United States continues to grow, so too has ED crowding and boarding. “Throughout the country, there has been an increase in volume of ED patients and boarding of patients waiting to be admitted to the hospital,” says Sanober Shaikh Syed, MD. “This can prolong wait times for many patients seeking emergency care. EDs nationwide are struggling to balance demand with capacity.” Prior studies have shown that the longer patients wait, the more likely they are to leave without being seen (LWBS). These analyses have also revealed that a significant portion of patients who LWBS are classified as needing emergent or urgent medical care. A key question that remains unanswered is how long patients are willing to wait before they choose to LWBS by a healthcare provider. Waiting Thresholds Before Leaving the ED Dr. Syed and colleagues conducted a study evaluating patients’ threshold for waiting before they choose to leave the ED waiting room without being seen by an ED provider. The study, published in the Western Journal of Emergency Medicine, also looked at whether willingness to wait was influenced by other factors, including illness severity, age, and insurance status. “Knowing the limits to which patients will wait may be useful in tailoring strategies to reduce wait times,” Dr. Syed says.   In the study, patients who were triaged were given a questionnaire to determine how long they would wait for medical care. The authors also assessed data on age, gender, race, insurance status, and triage acuity level. More than half of the 340 patients who answered the survey were...
How ED Crowding Affects Outcomes

How ED Crowding Affects Outcomes

Previous studies have sought to establish a definitive relationship between ED crowding and subsequent mortality, but these investigations often have shortcomings, such as small hospital samples and a lack of adjustment for comorbidities, primary illness diagnoses, and potential hospital-level confounders. In addition, many of these analyses restrict data to specific subgroups, such as patients with acute myocardial infarction, trauma, pneumonia, or critical illness. New Evidence on Inpatient Death In an effort to address these limitations, my colleagues and I conducted a study to assess the effect of ED crowding on patient outcomes. Our study, which was published in the Annals of Emergency Medicine, looked at nearly 1 million admissions through EDs across California. Daily ambulance diversion was the measure of ED crowding. According to our results, ED crowding was associated with 5% greater odds of inpatient death. Patients who were admitted on days with high ED crowding had 0.8% longer hospital stays and 1.0% increased costs per admission. Periods of high ED crowding were associated with 300 excess inpatient deaths, 6,200 hospital days, and $17 million in costs. These findings persisted after extensively adjusting for patient demographics, comorbidities, and primary discharge diagnosis. Although other analyses have reported similar associations, our study generalizes these findings to a larger sample of hospitals and unselected admissions from the ED. ED Crowding: A Marker of Poor Quality Care Our findings support the notion that ED crowding is a marker of poor quality of care. Unfortunately, factors underlying the issue of ED crowding are likely to become worse. As Americans are living longer than ever, this has increased the volume, complexity, and acuity of...
Improving ED Communication & Patient Throughput

Improving ED Communication & Patient Throughput

Among the many Affordable Care Act initiatives rumbling through the healthcare industry, the introduction of 30 to 40 million new patients is certain to create additional stress to an already overburdened healthcare system. As a result, hospitals must find ways to increase their patient throughput and operational efficiency. Unfortunately, inefficient inpatient discharge practices continue to create unnecessarily long hospital stays. Patient throughput in the ED impacts the rest of the hospital system. ED lengths of stay generally increase when hospital occupancy levels exceed 90%, so enhanced communication and patient throughput are vital throughout the acute care setting. Although many factors can hinder patient flow, nearly 70% of clinicians cite communication as the most challenging cause of patient throughput delays. EDs: The Communication Ground Zero Communication in the ED sets the course for patient flow throughout the hospital. Safe, efficient, quality care in the ED requires frequent and effective communication. Nearly half of EDs report operating at or above capacity, and wait times and patient visits have risen steadily for the last 20 years. Initial communication with ED patients must be a top priority. As soon as patients register at the ED, they must be clearly informed of their anticipated treatment. Early communication about details, such as estimated wait times, anticipated discharge times, and availability of immediate treatments for minor symptoms, can smooth transitions of care.  Intricacies are sometimes forgotten but have a tremendous impact on patient throughput. The physical design of individual patient rooms can greatly affect throughput. When rooms are well-designed and provide optimum flexibility, patients can receive faster, more efficient care. In order to save space for...

Improving the Problem of ED Boarding

According to previous research, boarding inpatients in EDs is one of the main drivers for crowding. In the August 2012 issue of Health Affairs, my colleagues and I explained what is known about the causes and dangerous effects of boarding, strategies that have been demonstrated to alleviate boarding but are underused, and possible regulatory steps that will be needed for hospital leaders to increase efforts to address boarding. Crowding & Boarding: A Costly Problem Inpatients who are boarded in EDs burden already busy ED staff and are kept in brightly lit, loud environments for many hours or even days. Not surprisingly, studies have shown that boarding increases morbidity and mortality, lengthens hospital stays and durations of intubation, worsens pain control, and compromises care. Patients may also have greater exposure to hospital-acquired infections. Boarding also affects measures to which hospitals are held accountable, including time to receipt of antibiotics for patients with pneumonia and the development of bedsores. Furthermore, long waits due to crowding cause some patients to leave EDs before being seen by physicians, robbing them of care and decreasing hospital revenue from their visit. [polldaddy poll=7044226] Boarding occurs when inpatient beds are not available to patients admitted through the ED. This sometimes is the result of hospitals being at full capacity, but inefficient operations may also be partly to blame. Even when hospitals are not at full capacity, hospital leaders who don’t fully understand the costs of boarding may preferentially reserve beds for patients whom they consider more profitable than ED patients (eg, elective surgery patients for whose care is assured reimbursement). Evidence is mixed on whether this...
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