Effects of Emergency Department Expansion on Emergency Department Patient Flow

Abstract

Objectives Emergency department (ED) crowding is an increasing problem associated with adverse patient outcomes. ED expansion is one method advocated to reduce ED crowding. The objective of this analysis was to determine the effect of ED expansion on measures of ED crowding. Methods This was a retrospective study using administrative data from two 11-month periods before and after the expansion of an ED from 33 to 53 adult beds in an academic medical center. ED volume, staffing, and hospital admission and occupancy data were obtained from either the electronic health record or administrative records. The primary outcome was the rate of patients who left without being treated (LWBT), and the secondary outcome was total ED boarding time for admitted patients. A multivariable robust linear regression model was used to determine whether ED expansion was associated with the outcome measures. Results The mean daily adult volume was 128 (SD ±14) patients before expansion, and 145 (SD ±17) patients after. The percentage of patients who LWBT was unchanged: 9.0% before expansion, vs 8.3% after expansion (difference 0.6%, 95% CI = −0.16% to 1.4%). Total ED boarding time increased from 160 to 180 hours/day (difference 20 hours, 95% CI = 8 to 32 hours). After adjusting for daily ED volume, low-acuity area volume, daily wait time, daily boarding hours, and nurse staffing, the decrease in patients who LWBT was not independently associated with ED expansion (p = 0.053). After adjusting for ED admissions, ED intensive care unit admissions, elective surgical admissions, hospital occupancy rate, ICU occupancy rate, and number of operational ICU beds, the increase in ED boarding hours was independently associated with the ED expansion (p = 0.005). Conclusions An increase in ED bed capacity was associated with no significant change in the percentage of patients who LWBT, but had an unintended consequence of an increase in ED boarding hours. ED expansion alone does not appear to be an adequate solution to ED crowding.

Providing Care in Emergency Department Hallways: Demands, Dangers, and Deaths

“…The prospect of reducing ED crowding in the near future may be elusive, as many EDs have made major attempts for the past two decades with minimal or no improvement [58,59]. Simply building a larger ED to increase capacitance may not solve the problem, as the chief reason for overcrowding is "exit block, " or the impaired ability to move patients out of the ED [60,61]. However, a focused approach to solve hallway crowding has been adapted by leading hospitals [62,63].…”

Costly Emergency Department Expansions Are Ineffective to Improve Flow Without Addressing Culture and Process Efficiency

“…After an ED expansion, ED staff may have more treatment spaces available, but may also dynamically change the speed of their work in other ways to shift back to what they may see as a suitable level of performance. This may be why length of stay and left without being seen rates were not affected in the study by Mumma et al 1 On the hospital side, hospital staff similarly may have changed their workflows to the newly expanded ED space. Moving patients to inpatient beds rapidly from the ED may have become less of a priority to inpatient teams with the knowledge of the new ED space.…”

“…I n this issue of Academic Emergency Medicine, Mumma et al 1 describe the effect of an emergency department (ED) expansion on metrics of ED flow, at the University of California-Davis, a large academic medical center. After expanding adult bed capacity from 33 to 53 beds, a 60% increase, two notable things happened: ED volume increased by 13%, and there was an increase in ED boarding hours.…”

Simulation and Modeling Applications in Global Health Security

“…Modeling and simulation can be used to assess and enhance hospital surge capacity [139]. It is recommended that emergency planners collaborate with human factors and industrial engineers who are experts in risk analysis, modeling, and systems analysis.…”