Crowding in the ED

Sandra M Schneider MD FACEPImmediate Past President

American College of Emergency PhysiciansProfessor, Chair Emeritus

University of Rochester

4American College of Healthcare Executives

ER

Ill and injured

ER

Ill and injured

Uninsured/charity

SYSTEM FAILURE

Inpatients

http://www.ph.tn.tudelft.nl/~vanwijk/Athens2004/niceones/IMG_0061.JPG

Value of Emergency Medicine

Just 2%Public Education Campaign

EDs Provide the Bulk of Acute Care to the Under- and Uninsured

Active physicians (597,430)

ER DocsPrimarycare MDs Specialists

Acute visits by the uninsured(24 million)

Acute visits by underinsured –Medicaid or SCHIP (39 million)

Total acute visits(273 million)

Pitts et al. Health Affairs, Sept 2010

American College of Healthcare Executives 14

Future of Emergency Care Series

Hospital-Based Emergency Care

At the Breaking Point

Committee on the Future of Emergency Care in the United States Health System

The Perfect Storm: Health Care Braces for a Crisis

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Operational Costs Nurse Shortage Technology On-call Liability Inflation On-Call

Specialty Physician Shortage

InpatientBed Shortage

Revenue Medicaid / Medicare Managed care Uncompensated care Stock market

Balanced BudgetAct of 1997

EMTALA

ED Volume Increases

ForeignNationals

EMERGENCY DEPARTMENT

AmbulanceDiversion

ACA Effects

• Insurance Reform– Mandate– Expand Medicaid eligibility– Insurance Exchanges– Dependents up to 26– Guaranteed issue and renewability– No pre-existing condition– Essential Health benefits

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We said OK

Behavior Medicine in ED

• Deinstitutionalization since 1960’s with emphasis on community care

• Funding transferred from state to local • Community services uncoordinated,

underfunded

“The ED is expected to solve society’s problems”

• 2006 survey of state mental health authorities– 80% had shortage of MH beds– 34 states had shortage of acute care beds – 16 states had shortage of long term care beds

APA: The psychiatric delivery system is “fragile and beset by problems”

• 1 in 4 adults has a diagnosable mental illness• 5-7% of the population suffer severe mental

illness• Visits to ED likely to increase

– Mass experience – Increased use by newly insured (32% higher)– Increased use by newly uninsured (40% higher)– Catch up (New Zealand)“A constant frustration”

ME – LOS over timeSingle hospital

mean LOS (h) Number >24h0

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Bad for patients

• Number one patient safety issue• Increased adverse events• Delays in care• Decreased patient satisfaction• Increased length of stay, increased cost• Increased mortality

Evidence Crowding leads to patient safety issues

• JCAHO• 50% sentinel events occur in the ED• 1/3 are related directly to crowding

• MMWR True emergencies wait >1 hour in ED

Delays in Care

Time to pain meds

• Crowding of over 120% capacity correlated with less documentation of pain scores and longer time to pain medication in elderly individuals with hip fracture

– Hwang U J Am Geriatrics 2006

Pines J et al Acad Emerg Med 2007 14: 52

• Occupancy by quartiles• Pain Treatment delay >1hr (odds ratio)

– 2nd 1.9– 3rd 2.8– 4th 3.4

Delays in cardiac care

• When ED is on ambulance diversion, transport time for cardiac patients is 2 minutes longer – Schull MJ, et al Acad Emerg Med 2003;10: 709-16

• Door to needle time prolonged (OR 1.4 for delay >60 minutes)– Schull MJ, et al Ann Emerg Med 2004;45:84

Hospital length of stay/cost

Dolcourt B, Bilkovski RAcad Emerg Med 2007; 14:84

• CHF– ED LOS <8h

• Hosp LOS 5.3 D charges $23,572

– ED LOS >8h• Hosp LOS 8.5 d charges $39,345

• AMS– ED LOS <8h

• Hosp LOS 4.8 D charges $20,215

– ED LOS >8h• Hosp LOS 6.8 D Charges $40,725

Increase nursing homes

• Non nursing home patients• If boarded in ED >4 hours

4 times the chance of being discharge to a long term care facility

SSchneider

Phenomenology?

• Innes G, et al Acad Emerg Med 2007: 14:85• Full capacity protocol 2006• Pre/post analysis• ED volume increase• ED LOS fell by 9 hours for admitted medical

patients, 5 hours for all

Phenomenology?

• Innes G, et al Acad Emerg Med 2007: 14:85• Hospital LOS fell by 1.0 day for all admissions

(p<0.001)• No adverse events in ED WR or inpatient care

spaces during 6 months

Increased mortality

Non STEMI

• Secondary analysis of CRUSADE data• >42,000 patients with proven non-STEMI• Prolonged ED satys:• More likely women, non white, less likely to have

HMO/private insurance• Less often received recommended treatment• OR 1.23 more likely to have recurrent MI

– Diercks B et al Ann Emerg Med 2007;50:49-96

Increase LOS (7.0 vs 6.0d) Increased mortality (10.7% vs 8.4%)

Patient safety initiatives

• Negative impact on patients needing to be seen

• 10% of TRUE emergencies wait >one hour to be seen (MMWR)

• Increased adverse events in overcrowded ED

Patient safety initiatives (cont)

• Increased LOS for hospitalized after ED hold.• Patients who LWBS or AMA as a result of

crowding and boarding may suffer adverse outcomes

• Demonstrated increase in Mortality and Morbidity

Patient safety initiatives (cont)

• JCAHO, 50% of sentinel events involve ED with 1/3 of these related to overcrowding.

• More patients suffer adverse outcomes from overcrowding and boarding than from failure to meet 4-hour rule for pneumonia or 3-hour rule for sepsis!!

49American College of Healthcare Executives

Slate.com• Waiting DoomHOW HOSPITALS ARE KILLING E.R. PATIENTS.• By Zachary F. Meisel and Jesse M. Pines

Posted Thursday, July 24, 2008, at 6:54 AM ET • Video of Esmin Green, who died in an E.R. waiting room

• Last month, Esmin Green, a 49-year-old mother of six, tumbled off her chair and onto the floor of the Kings County psychiatric E.R. waiting room in New York City. Members of the hospital staff saw her lying there but did nothing for about an hour. When Green was finally brought into the E.R., she was dead. An autopsy revealed that she died from a pulmonary embolism, which occurs when a blood clot forms in the leg, breaks off, and travels to one or both lungs. This can also kill long-haul airplane passengers who sit in one spot for hours:

50American College of Healthcare Executives

It can’t be done!

• England • Ireland

52American College of Healthcare Executives

Ireland: simulation of new ED

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•Move the patient upstairs.

Hospitalcrowding.com

Successes

• TX: Bexar Co created sobering unit and crisis services to divert from jail and ED

• MN: increased # freestanding MH hospitals/beds – “lucky”

• MI: Community wide strategic plan-Gateway to Better Health – increased primary care visits, dental services, literacy. Diverted $ to ED care, integration of services, access to MH services

Successes

• NY: Some CPEP programs take responsibility for patients from start (no clearance); coordinated with OP services and mobile teams staffed by psychiatrists

Successes

• Central Oregon Health Council– www.cohealthcouncil.org

• Care coordination of frequent visitors– 274 patients in first cohort, 600 in second– >12 visits per year– MH or chronic pain or addiction– Primarily MA, didn’t know PCP or kicked out of

medical home

Central Oregon

• Decreased ED visits, decreased LOS in ED, decreased charge per visit

• Behavior is cyclic, Individualized plans

Successes

• ME GA SC• Telepsychiatry model

Success

• South Carolina Hospital Association• shortage of psychiatrists• Solution telepsychiatry• 10K consults between 3/08 and 5/12• LOS decreased 50% (75 h in 09 to 37h)• Net cost savings of $1K per episode of care

What doesn’t work

• Building bigger ED (exception obs)• Fast track• Eliminating unnecessary visits

Value of Emergency Medicine

• Reduce potentially avoidable admissions• Reduce re-admissions• Rapid diagnostic center• Improving patient cycle-time (reduce time off from

work, reduced pain and anxiety, etc..)• Reduce unnecessary testing• Regionalization of emergency care

services/conditions• Potential interface of EM with current VBP

mainstream strategies such as ACO’s and EOC’s

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Solution

• Observation unit– Run by EM, available 24/7, separate staffing– Revenue generator– Reduced nursing staffing

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ACO’s

• Increased efficiency primary care– Acute care in ED

• Currently see 28% of all acute care• Kaiser model – phone calls, same day appointment• Increased efficiency of PCP’s• Does require communication

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ACO’s

• Decreased cost for chronic care– Case management in the ED

• High risk patients• High cost patients• Chronic illness monitoring ED or home

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ACO’s

• Decreased cost for chronic care– Telemedicine clinic

• Day cares• Prisons• Nursing homes

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ACO’s

• Decreased cost for chronic care– Expanded scope of practice for paramedics

• CHF• Frequent ER patients• Discharged patients

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