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Analyzing Why Patients Seek ED Care

Analyzing Why Patients Seek ED Care

According to CDC data, the number of annual visits to EDs across the United States has steadily risen each year. And ED crowding continues to be a significant issue throughout the country due to progressive increases in patient volume. In addition to long wait times and frustration from ED patients, ED crowding has been associated with the risk of poor health outcomes. Several theories have been proposed as to why these trends have persisted over the years. The growing number of medically uninsured people has been identified as a major culprit, but national initiatives like the Affordable Care Act have attempted to curb this issue. Other research suggests that access to care and constraints on provider capacity may serve as important drivers of ED use. Further complicating matters is the nation’s current shortage of primary care providers (PCPs). Measuring Patient Perspectives “Few studies have attempted to measure the perspectives of patients on why they choose the ED to receive their medical care,” says John T. Nagurney, MD, MPH. In a study published in the Journal of Emergency Medicine, Dr. Nagurney, Lana Lobachova, MD, MBA, and other colleagues from Harvard University and Massachusetts General Hospital in Boston sought to measure the distribution and frequency of the reasons why patients chose the ED for their care. In this study, patients presenting to an ED with 92,000 annual visits were surveyed. According to the results, the most common reason patients gave for coming to the ED was their belief that their problem was serious (Table 1). In addition, more than one-third was referred by a healthcare provider. “Only about one-third of patients...
Patient Preferences on Boarding

Patient Preferences on Boarding

Crowding in the ED has been well-established as a problem that poses a threat to public health. Studies show that ED and hospital crowding leads to ambulance diversions, medical errors, delayed care, and increased mortality rates. “Many strategies have been tried to alleviate ED and hospital crowding, some of which involve the entire institution,” explains Peter Viccellio, MD. Using a Full-Capacity Protocol One strategy that aims to reduce ED crowding is the use of a full-capacity protocol (FCP), in which admitted ED patients are redistributed to inpatient unit hallways while they wait for regular hospital beds to open up. Some studies have shown that an FCP can decrease ED wait times, ambulance diversions, and overall hospital length of stay. A potential concern with this approach, however, is that it could reduce patient satisfaction. Recently, Dr. Viccellio and colleagues had a study published in the Journal of Emergency Medicine that examined patient preference and satisfaction with boarding in the ED versus inpatient hallways during times when there were no inpatient beds available for admitted patients. All patients were initially boarded in the ED in a hallway before their transfer to an inpatient hallway bed. “No more than two patients in our study were placed on any inpatient unit and all patients received direct care from inpatient physicians and nurse specialists,” adds Dr. Viccellio. “We didn’t compare a room versus a hallway. Rather, we looked at making decisions about where patients can receive the best care and greatest attention in difficult circumstances when a normal room is not available.” Overwhelming Results According to the results, the overall preferred location after admission...

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...

ED Crowding Worsens Outcomes

Periods of high ED crowding appear to increase inpatient mortality, lengths of stay (LOS), and costs, according to results of a review of nearly a million ED visits resulting in admission. Patients admitted during periods of high ED crowding had a 5% greater likelihood of inpatient death, 1% higher costs per admission, and about 1% longer LOS. Periods of high ED crowding were associated with an excess of 300 inpatient deaths, 6,200 hospital days, and $17 million. Abstract: Annals of Emergency Medicine, December 5,...

Examining Length of Stay in 8-Hour Shifts

In previous research, studies have documented significant links between length of stay (LOS) over 24-hour periods and hospital occupancy, the number of ED admissions, and other factors. In the May 2012 Western Journal of Emergency Medicine, my colleagues and I published a study that looked at LOS in more discreet time periods than what earlier analyses have reported. We did this because ED crowding and volume can vary greatly during a given 24-hour period. We wanted to find out which factors were associated with LOS and whether this relationship was present during all or only specific 8-hour shifts. In our analysis, independent variables were measured during three 8-hour shifts. Shift 1 was from 7:00 am to 3:00 pm, shift 2 was from 3:00 pm to 11:00 pm, and shift 3 was from 11:00 pm to 7:00 am. For each shift, the numbers of ED nurses on duty, discharges, discharges on the previous shift, resuscitation cases, admissions and ICU admissions, and LOS on the previous shift, were measured. For each 24- hour period, the numbers of elective surgical admissions and hospital occupancy were measured, since these could not be measured in 8-hour time intervals. ED Length of Stay: Roles of Occupancy & Admissions On all three shifts, LOS increased by about 1 minute for each additional 1% increase in hospital occupancy. The mean hospital occupancy in our study was 94.9%; considering this high level of demand for inpatient beds, even a 1% increase in occupancy can lead to significant delays. The demand for inpatient beds often exceeds 100% capacity during the late morning and early afternoon hours on weekdays. To...
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