Solving the worldwide emergency department crowding problem – what can we learn from an Israeli ED?

Abstract

ED crowding is a prevalent and important issue facing hospitals in Israel and around the world, including North and South America, Europe, Australia, Asia and Africa. ED crowding is associated with poorer quality of care and poorer health outcomes, along with extended waits for care. Crowding is caused by a periodic mismatch between the supply of ED and hospital resources and the demand for patient care. In a recent article in the Israel Journal of Health Policy Research, Bashkin et al. present an Ishikawa diagram describing several factors related to longer length of stay (LOS), and higher levels of ED crowding, including management, process, environmental, human factors, and resource issues. Several solutions exist to reduce ED crowding, which involve addressing several of the issues identified by Bashkin et al. This includes reducing the demand for and variation in care, and better matching the supply of resources to demands in care in real time. However, what is needed to reduce crowding is an institutional imperative from senior leadership, implemented by engaged ED and hospital leadership with multi-disciplinary cross-unit collaboration, sufficient resources to implement effective interventions, access to data, and a sustained commitment over time. This may move the culture of a hospital to facilitate improved flow within and across units and ultimately improve quality and safety over the long-term.

The experience of nurses whose role requires allocating patients to outlier and over census beds during access-block: a review of the literature

“…Alameda and Suárez [8] report outliers admission times were 22% longer and in a systematic review undertaken by Metcalfe, et al., [20] found the percentage of Medical Emergency Calls were increased among outlying patients [8,20]. Todate research has iluminated the magnitude of access block and crowding, the intricacies of solutions employed to resolve access block and the resulting impact on patients [3,7,21]. Up until now, evidence remains unreported on the experience of nurse managers responsible for managing resources at times of access block.…”

“…Solutions are designed to ensure optimal use of available resources whilst not compromising patient safety [7]. An example being, that when there are no beds available in the patient's specialty ward patients are admitted to another ward bed which may not ordinarily provide the expert care required, as an outlier or border [8,9], or implementing an over-census protocol, a decision typically made by experienced senior nurses to open surge beds [10].…”

Emergency department performances during overcrowding: the experience of the health protection agency of Brianza

“…A not negligible consequence of these prolonged increments of activity is the lowering of ED services quality and patient safety. In this sense, it has been demonstrated that ED crowding can be associated with poorer quality of care and poorer health outcomes, along with extended waits for care [17] . Similar findings are consistent with those found in our study.…”

The last decade of symptom-oriented research in emergency medicine: triage, work-up, and disposition

“…Avoiding hospitalisation, on the other hand, has many advantages: most importantly, patients will most likely prefer this. With an ever increasing number of presentations, crowding is a long known problem for urban EDs in Switzerland [95] and worldwide [96,97]. Crowding is the result of a mismatch between ED capacity and the number of patients presenting in a given period of time [98].…”