How Does Emergency Department Crowding Impact Care? (Part 2 Of 3)

This article is the second in a three-part series which seeks to dissect the challenge of emergency department (ED) crowding; why it occurs, why it’s a problem and what we need to do to overcome it. The creation of this series is driven by the ever-pressing need to secure the sustainability of our EDs, which move closer and closer to breaking point with each day. This series has been curated with the support of senior Emergency Medicine Consultants from NHS England.

In this article, we will break down the impact of ED crowding on patient care to explain why this problem urgently requires our attention.

At a high-level, ED crowding matters because of its association with avoidable and preventable morbidity and mortality [1]. A consistent correlation between patients arriving into crowded emergency departments and excess mortality and length of stay (LOS) has been found internationally [2,3]. Even more concerning is the fact that it’s often found to be the critically ill, the mentally ill, the elderly, and the vulnerable who are most affected [4]. With ED crowding also being the most common cause of delayed emergency care, it’s no wonder that is thought to be ‘one of the greatest threats to patient safety in the provision of emergency care around the world’ [5].

Diving deeper, ED crowding has direct effects on patient outcomes and the quality of care delivery. We list exactly how below.

PATIENT OUTCOMES

In terms of its impact on patient outcomes, ED crowding has been associated with:

• High patient readmission rates, with a study showing ED crowding is associated with readmission rates for conditions such as pneumonia or acute myocardial infarction [6].

• Increased walkouts due to perceived ED LOS, with a study stating that long waiting times was cited as the main reason (61%) for leaving the ED without treatment [7].

• Morbidity, with studies even showing an association between ED crowding and higher incidence of hospital-acquired pneumonia [8].

• Prolonged hospitalisation, with one study of 770 patients finding ED crowding decreased the likelihood of timely implementation of the resuscitation bundle [8-10].

• Medication errors and adverse effects, with a study showing that the presence of preventable medical errors (PMEs) was twofold higher in crowded EDs than those at optimum capacity [11-14].

• Mortality, with studies finding increased inpatient mortality amongst the critically ill [6, 8-10, 15-21].

QUALITY OF CARE DELIVERY

ED crowding also reduces the capacity for healthcare professionals to deliver high quality care. Associations include:

• Delayed assessment or treatment, with a study showing that implementation rates for protocolised sepsis care in crowded EDs decreased from 71.3% to 50.5% [22-28].

• High cost of treatment, with ED crowding causing 300 inpatient deaths, 6,200 hospital days and $17 million in costs in one study [4].

• Low satisfaction, with a study of 1,469 patients finding that ED crowding was predictive of lower ED satisfaction and lower satisfaction with the entire hospitalisation [6,24,29,30].

• High workload, with a pneumonia study showing that only 61% of patients received antibiotics within 4 hours, despite having a state-mandated ratio of doctors and nurses [31].

• Discharging patients with high-risk clinical features, with studies showing that crowding may affect clinical decision-making in conditions such as TIAs or minor strokes [32].

• High patient readmission rates to general wards and ICU, with studies of pneumonia patients finding that antibiotic administration times can be delayed due to ED crowding [31].

• Longer time to investigate patients’ medical conditions, with wait times in crowded EDs being shown in studies to be at least 10 minutes longer than in mean capacity EDs [31].

• Poor infection prevention and control measures, with hand hygiene compliance shown to be at only 29% in one study of a crowded ED [33].

• Low compliance with standards of care, with a study of 770 sepsis patients showing that high crowding groups had a significant associate with lower compliance [9].

It quickly becomes clear that this is a near universal problem, rather than just failings at an individual case level. ED departments are extremely heterogeneous; their unique pinch points and the impacts of crowding on their patients and staff will change daily, from minute to minute, hour to hour. Emergency care leaders can act on experience and gut feeling to try and combat crowding and its effects, but there is only so much they can do without a reliable measure to predict upcoming problems and judge what the impact of their proposed solutions or interventions will be.

The final article in this series will explore and evaluate various solutions to ED crowding currently in place before outlining our proposed new approach to tackling this pressing problem.

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