L overcrowding in Pronto Soccorso : di chi è il problema?

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1 L overcrowding in Pronto Soccorso : di chi è il problema? Mario Cavazza UO di Medicina d Urgenza e Pronto Soccorso Azienda Ospedaliero-Universitaria di Bologna

2 Admitted patients awaiting a ward bed are boarded in the ED majors area or resuscitation suite. Frequently there are insufficient trolleys or bays for all those sick enough to require hospital admission, and as a result patients not infrequently wait on plastic chairs in hallways or open floor areas pending the availability of a ward bed.

Frequently there are insufficient trolleys or bays for all those sick enough to

5 ED overcrowding summary: Its bad for patients, staff, and administrators. Most often affects: Urban and large-volume EDs; trauma and referral centres; teaching centres. Efforts to mitigate ED overcrowding are worthwhile.

8 U.S.A.

9 Crowding occurs when the identified need for emergency services exceeds available resources for patient care in the Emergency Department, Hospital, or both. Ann Emerg Med. 2006;47:585.

10 What is crowding? Supply-demand mismatch Long waits to be seen Long waits for tests Long waits for beds

11 ED crowding

12 A che livello parliamo di overcrowding? A point prevalence study of crowding found that the average nurse was caring for 4 patients simultaneously, and the average physician was caring for 10 patients simultaneously Schneider SM, et al. Ann Emerg Med. 2003;42:

was caring for 4 patients simultaneously, and the average

13 Measuring crowding How you measure crowding?

14 Measuring crowding The pink elephant problem: What is crowding? Does crowding mean we re just busy? How crowded is too crowded? Are we crowded or overcrowded?

15 Measuring crowding Two perspectives Patient Waiting room time, total ED LOS, boarding time Can obtain retrospectively ED (real-time measures) Waiting room number, occupancy, number of admitted patients, diversion status

retrospectively ED (real-time measures) Waiting room

16 Crowding Models NEDOCS (National ED Overcrowding Scale) EDWIN (ED Work Index) = Uses: n i t i /N total a (B T #ED -B A ) beds, READI (Real-time Emergency #inpt Analysis beds, total of = a(pts = #ED sum in of waiting pts ESI in ED, (t i ) total of all Demand Indicators) rm/#ed # pts tx on ventilator, areas) number of attending Work Score + b( Using: longest reverse Total current #pts pt ESI/#nurses) ED, stay #tx (hrs), spaces, + total # pts = (Total ED Occupancy Rate # currently # pts available in ED)/ c(boarders/#ed patient in boarding, arrivals, tx pt (hrs) tx EDCS (ED Crowding Scale) Discrete Event Simulation Queuing Theory active patients (n i ) in ED / physicians each hr (N a ) x Total bays #ED (B T ) treatment areas) acuity, last pt #staff placed (B A ) in ED tx bays/hr rm Calculate: Uses: # attendings, bed ratio, # acuity staffed ratio, beds, provider # ratio, critical demand care pts, value #total staffed hospital beds, hospital occupancy

ESI/#nurses) ED, stay #tx (hrs), spaces, + total # pts = (Total ED Occupancy Rate # currently # pts available in ED)/ c(boarders/#ed patient in boarding, arrivals, tx pt (hrs) tx EDCS (ED Crowding

17 Myths It Is an ED Problem Uninsured Are the Problem Non-Urgent & Frequent Flier Pts are Problem Build More Beds Pts Who LWBS Are Not Sick Arrival Pattern of Patients is Unpredictable

18 PRELOAD (input) CONTRACTILITY (troughtput) AFTERLOAD (output)

20 ECJ 2010

21 crowding causes Rastelli G, et al, ECJ 2010

22 Non-Urgent Visits Definition: Low-acuity ED patients seeking care in the ED. Present even in hospitals with dedicated fast-track systems. Reasoning: Typically insufficient access or/and untimely access to primary care. Account for a small portion of total ED volume.

23 Cause del ricorso eccessivo al PS Ottenere in tempi brevi una risposta a bisogni percepiti come urgenti Pazienti fragili e lungo-sopravviventi che necessitano di interventi in tempi rapidi Consapevolezza di trovare una risposta qualificata mediata anche dall impiego di tecnologie.

24 A differenza degli USA il sistema sanitario italiano offre ai cittadini molte alternative gratuite o a basso costo per la diagnosi e la cura, dal medico di famiglia agli ambulatori specialistici ospedalieri ed extraospedalieri, ma questo non sembra essere sufficiente visto il numero consistente di persone che arriva direttamente in pronto soccorso senza avere interpellato prima almeno il proprio medico Casagranda I, ECJ, 2006

25 L effetto Roemer L incremento del numero dei posti let to ospedalieri per abitante determina l aumento dei tassi di ricovero L effetto Amartya Sen L incremento della spesa sanitaria per abitante determina l aumento della proporzione di popolazione che si consi dera malata

26 Frequent Flyers Definition: 4 or more annual visits to the ED Responsible for 8-14 percent of the total ED visits Often non-urgent complaints This includes: Chronic illness, drug seeking patients, malingers However, among these patients a good portion frequently have serious pathology.

27 Posti letto Visite ED: +26% Posti letto: Hospital beds N Engl J Med, 2006

30 La DM in Italia: negli anni e nelle fasce di età

31 Speranza di vita a 65 anni nella popolazione italiana 23 anni Femmine Maschi

33 crowding effects Rastelli G, et al, ECJ 2010

34 consequences Sub-standard medical care: Delays in time-sensitive treatments (e.g., antibiotics for infections, thrombolytics for AMI, etc); Outcomes: Prolonged LOS; Increased death (e.g., sepsis, AMI). Increased risks: Medical errors; Patient safety.

35 consequences Infection Control: risk of contagious illnesses. Human resources: Decreased job satisfaction among nurses and physicians; Increased sick time and absenteeism. Loss of privacy/dignity. Costs: costs associated with ED overcrowding.

36 crowding solutions Rastelli G, et al, ECJ 2010

37 Possible Solutions HQCA overview released January 2012.

39 Pre-ED (input) Decreasing demand: ED wait times reporting Media campaigns; Improved access to primary care; Prevention (e.g., helmet laws) initiatives; Chronic disease (e.g., COPD) management. Diversions of care: Alternative sources (WIC) of care; EMS: Alternative destinations; Ability to treat and discharge.

40 In-ED (Throughput) Advanced triage. Triage nurse ordering. Triage liaison physician. Enhanced diagnostics and access to results. Intermediate care: Obs Units. Primary care (e.g., NPs) in the ED. Fast track and see & treat. Pt advocacy case management model

41 Post-ED (Output) Local resource Family pract. compliance Stakeholder compliance WIC Hospital bed availability Bed management ( full capacity protocol)

43 PRELOAD (input) CONTRACTILITY (troughtput) AFTERLOAD (output)

44 DOVE SIAMO

45 DOVE VORREMMO ESSERE

46 Conclusion Emergency department crowding is not a problem of the EDs alone; it results from multiple system-wide factors acting to create bottlenecks that impede access to timely and high quality emergency care for all. Solutions to ED crowding will require coordinated efforts on the part of emergency physicians, federal and state policymakers, local hospitals, community leaders, EMS organizations and public and private health plan payers, as well as significant budgetary appropriations.

48 Our Mission Get every patient to the best resources in the right place and in the shortest time.

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