Ep 129 ED Overcrowding and Access Block – Causes and Solutions

There are few things as demoralizing to the ED doc than strolling past the waiting room on their way into a night shift and seeing it bursting at the seams. Well, maybe discharging half a tracking board full of patients only to find that a quick click of the ‘refresh’ button shows you’re actually losing ground. ED overcrowding is associated with increased rates of medical error, reduced patient satisfaction scores, increased physician burnout rates, increased adverse events in older patients and increased mortality rates. In this podcast – Episode 129 ED Overcrowding and Access Block: Causes and Solutions - we taking a little detour outside the ED to understand it better. We discuss the root causes, challenges and some of the solutions of one of the defining characteristics of emergency medicine in the 21st century - overcrowding. It is absolutely in the interest of every single ED provider to understand how this problem came to be, and what we can do about it. As citizens of the medical community, becoming aware of the issues that drive ED overcrowding will be a powerful asset in the drive for change. We hope to equip you with the knowledge and actionable moves to effect change on your next shift at the individual level, at the ED level, and even at the hospital and government levels… Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Anton Helman, Grant Innes, Howard Ovens, Sam Campbell and Andrew Cameron, August, 2019 Cite this podcast as: Helman, A. Ovens, H. Campbell, S. Innes, G. Episode 129 ED Overcrowding and Access Block - Causes and Solutions. Emergency Medicine Cases. August, 2019. https://emergencymedicinecases.com/ed-overcrowding-access-block-causes-solutions. Accessed [date] CAUSES OF ED OVERCROWDING Access block is the main cause of ED overcrowding The problem isn’t so much a problem of ED crowding, but rather a matter of hospital crowding and access block. Access block is the inability to get the care that is needed in a timely fashion as a result of the inability to transfer a patient out of the ED to an inpatient bed once their ED treatment has been completed. Our system has limited resources. We have to ration care. Caring for some while leaving others in a queue is called rationing. Ethicists believe that if rationing is necessary, priority goes to patients with the greatest need and interventions with the greatest benefit. Patient need can be defined by illness severity, the patient’s health gap, the potential health benefit gained by accessing care and the treatment intensity they require. In the ED patient need and health gain is highest, and when they are admitted to the hospital their need and health generally diminish. Paradoxical misallocation of resources and reverse triage A study of 25 Canadian hospitals showed that, on average, hospitals leave high-acuity patients in hallway non-care locations for an average of 46,000 hours per site per year (i.e. 46,000 hours of emergency access block), during which poor outcomes are more likely to occur. We tend to prioritize lower efficiency care for stable patients at the back end who have lower need (illness severity) and less potential for health benefit. When undiagnosed, unstabilized patients arrive with acute pain (and occult critical illness), we often leave them in ED hallways with no access care. Ironically, after these sick patients are stabilized, diagnosed and treated, as their need for care diminishes, they graduate to progressively better care circumstances—from a waiting room to an ED stretcher and, ultimately, a private room on an inpatient unit. Too often, the sickest cannot access care, because system resources have been allocated, largely to patients at much lower risk, who have less care need, and who are accruing less health benefit from the resources provided. Assuring comfort and privacy for convalescing patients,