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Emergency Room Overcrowding A multi-dimensional issue, fundamental to Canadian healthcare
Demand >>> Supply ER overcrowding = the demand for emergency services exceeds the ability to provide care within a reasonable time (CADTH 2006)
Demand for ER services Not simply number of patients Volume High patient volume does not directly lead to overcrowded ERs (Schull et al. 2007) Demand is affected by the complexity and urgency of patient care, as well as the average length of stay (Drummond 2002)
Added complexities to demand The impact of non-urgent patients Large proportion of ER visits, yet are rarely admitted and utilize minimal resources (Schull et al. 2007) Frequent ER users Small proportion of ER users, but account for almost 15% of visits (Doupe et al. 2008) Tend to be frequent users of non-er services, have complex mental and physical health statuses Optimal strategy?
Supply of ER services Not an unlimited resource Community factors Alternative care and home care service availability Hospital factors Availability of admitting beds Flexibility and co-ordination within hospitals ER factors ER characteristics and policies Physician and nurse staffing Availability of acute-care beds (Schull et al. 2002)
A multidimensional problem will not be solved with a onedimensional solution
References: Canadian Agency for Drugs and Technologies in Health. 2006. Emergency Department Overcrowding in Canada: What are the issues? And what can be done? Ottawa: CADTH [http://www.cadth.ca/index.php/en/hta/reportspublications/search/publication/621] Drummond AJ. 2002. No room at the inn: overcrowding in Ontario EDs. Canadian Journal of Emergency Medicine 4(2): 91-97. Doupe MD et al. 2008. An Initial Analysis of Emergency Departments and Urgent Care in Winnipeg. Winnipeg: Manitoba Centre for Health Policy. [http://mchpappserv.cpe.umanitoba.ca/deliverableslist.html] Schull M, Slaughter PM & Redelmeier DA. 2002. Urban emergency department overcrowding: Defining the problem and eliminating misconceptions. Canadian Journal of Emergency Medicine. 4(2): 76-82 Schull MJ, Kiss A & Szalai JP. 2007. The effect of low-complexity patients on emergency department waiting times. Annals of Emergency Medicine 49 (3): 257-264.
A Discussion About the Determinants of Emergency Room (Over) Crowding Malcolm Doupe, PhD Ricardo Lobato de la Faria, MD October 14, 2009
Key Messages ER use & crowding 1 volumes of lower acuity patients do not lead to longer ER visits. 2 Frequent users have a disproportionate number of ER visits with unique characteristics. Their impact on ER patient flow is unknown. 3 ER users and especially frequent users also visit primary care physicians. Little is known about the nature of this contact and much more evidence is needed in this area. 4. There are growing numbers of ER Success Stories leading to improved patient flow. 5. Optimizing patient flow requires a multi-dimensional system-wide approach. 6. Research in key areas is needed.
Presentation Outline Conceptual Framework Background Information (ER Utilization) Input - Lower acuity patients, frequent users, contacts with family physicians Throughput - Strategies used within ERs to optimize patient flow Output - Delayed Transfers out of ERs - hospitals, nursing homes, etc. Discussion
Conceptual Framework Asplin et al. A Conceptual Model of Emergency Room Crowding. Annals of Emergency Medicine 2003;42(2). 173-180 Three interdependent components: INPUT THROUGHPUT OUTPUT Patient characteristics; Reasons for ER visit - Seriously ill & injured patients; - Referrals, desire for immediate care; - Vulnerable populations - Barriers to care. ER strategies used to care for patients - Triage and waiting process; - Stretcher use; - Diagnostics; - Boarding of inpatients. Patient disposition - Leave without seen; diversion to other ERs; - Admitted to hospital, transfers to nursing homes, home care, etc.
The Data Manitoba Centre for Health Policy, Faculty of Medicine, University of Manitoba Population Use of Administrative Health Care Records. Hospital Home Care Drug Family Education Services Cost Population- Based Health Registry Vital Statistics Immunization Provider Medical Nursing Home http://umanitoba.ca/ medicine/units/mchp/ Source: Manitoba Centre for Health Policy, 2008
ERs in Winnipeg, Manitoba Population: 670,000 6 Adult ER Sites 185,000 visits / year 1 Urgent Care Site 26,000 visits / year
ER Utilization Winnipeg Population use rates by age & gender; Adult ER Sites, 2004/05 17-24 25-44 45-65 65-74 Female Male Female average (17.9) Male average (17.3) 75-84 85+ Overall 0 5 10 15 20 25 30 35 40 45 50 Percent Source: Manitoba Centre for Health Policy, 2008
Percent of visits Distribution of ER Visits by Triage Code, 2000/01-2004/05 100 90 80 70 Resuscitation Emergent Urgent Less Urgent Non-Urgent 60 50 40 30 20 10 0 2000/01 2001/02 2002/03 2003/04 2004/05 Year Source: Manitoba Centre for Health Policy, 2008
Percent of visits Distribution of ER Visits by Disposition Status, 2000/01-2004/05 100 90 80 70 60 50 40 30 20 10 0 Discharged Home Admit to Inpatient Bed Expired Transferred Left Not Seen 2000/01 2001/02 2002/03 2003/04 2004/05 Year Source: Manitoba Centre for Health Policy, 2008
INPUT 1. volumes of lower acuity patients longer ER visits. Schull et al. The Effect of Low-Complexity Patients on Emergency Department Waiting Times. Annals of Emergency Medicine 2003;(41)2. 467-476 Ontario ERs Low (less/non urgent, not arriving by ambulance, discharged home); High (admitted to hospital), Medium (else) complexity patients. 1095 8 hours intervals (2002/03); Adjustment for age, sex, hospital type (teaching, other), day of week, time of day (day, night, evening). Per 8 hour interval and after adjustment 10 additional low-complexity visits 5.4 minute increase in visit duration for a medium / high complexity patient
Total Time (hours) Median Daily Visit Duration by Number of Lower Acuity Visits, Select ER Sites, Winnipeg, 2004/05 6 5.5 Resuscitation & Emergent Urgent Less Urgent Non-urgent 5 4.5 4 3.5 3 2.5 2 plus 10 less/non-urgent patients 13.2 minute in total visit time 25 27 29 31 33 35 37 39 41 Daily Number of Less & Non-Urgent Visits (average/site) Source: Manitoba Centre for Health Policy, 2008
2. Frequent ER users. Winnipeg, Manitoba (2004/05) 105,687 Users 200,810 Visits Single Users (1 visit in a year) 59.3% 31.2% Intermediate Users (2-6 visits) 38.5% 55.3% Frequent Users (7+ visits) 2.2% (2,400) 13.5% (27,222) Highly frequent Users(18+ visits) 0.1% (223) 3.6% (7,177) 80,000 health care contacts* in 1 year. * Includes ERs, Urgent care, physician visits, hospitalizations & medical calls to Health Links Info Santé. Source: Manitoba Centre for Health Policy, 2008
Frequent Users - What we Know 1. Account for many ER and other encounters with the health care system. 2. Patients have true multidimensional needs. Frequent User Characteristics (Source: Manitoba Centre for Health Policy, 2008) 37% - 56% live in the Winnipeg Core 25% - 70% are chronic frequent ER users 54% have co-morbid physical chronic diseases such as asthma, diabetes, heart disease. 55% - 85% have co-morbid mental illnesses such as depression, personality disorders and substance abuse. Bernstein SL, Asplin BR. Emergency department crowding: old problem, new solutions. Emerg Med Clin North Am 2006 November;24(4):821-37. Bernstein SL. Frequent emergency department visitors: the end of inappropriateness. Ann Emerg Med 2006 July;48(1):18-20. Hansagi H, Olsson M, Sjoberg S, Tomson Y, Goransson S. Frequent use of the hospital emergency department is indicative of high use of other health care services. Ann Emerg Med 2001 June;37(6):561-7. Hunt KA, Weber EJ, Showstack JA, Colby DC, Callaham ML. Characteristics of frequent users of emergency departments. Ann Emerg Med 2006 July;48(1):1-8. Zuckerman S, Shen YC. Characteristics of occasional and frequent emergency department users: do insurance coverage and access to care matter? Med Care 2004 February;42(2):176-82
Frequent Users - More information needed 1. How do frequent users impact ER flow / capacity to deliver care? Frequent / highly frequent users: More likely to arrive by ambulance More likely to be triaged as less/non urgent Have longer ER visits Are more likely to leave without seeing a physician Source: Manitoba Centre for Health Policy, 2008 Highly frequent users (20+ visits) tend to have longer ER stays, have more non-urgent conditions, are less likely to require hospitalization, and use fewer services such as lab test, drugs, operating rooms, etc. Ruger et al. Analysis of costs, length of stay, and utilization of emergency department services by frequent users: implications for health policy. Acad Emerg Med 2004 December;11(12):1311-7. 2. How do ERs successfully collaborate with the necessary agencies to care for frequent users (e.g., social agencies - not just ERs or medical care)? Bernstein SL. Frequent emergency department visitors: the end of inappropriateness. Ann Emerg Med 2006 July;48(1):18-20. Olsson M, Hansagi H. Repeated use of the emergency department: qualitative study of the patient's perspective. Emerg Med J 2001 November;18(6):430-4. Ovens HJ, Chan BT. Heavy users of emergency services: a population-based review. CMAJ 2001 October 16;165(8):1049-50. Zuckerman S, Shen YC. Characteristics of occasional and frequent emergency department users: do insurance coverage and access to care matter? Med Care 2004 February;42(2):176-82.
PERCENT 3. Most ER users & frequent users have contacts with primary care physicians Proportion of ER Users and Non Users with Primary Care Visits, Winnipeg Manitoba, 2004/05 100.0 90.0 1+ primary care visit 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Non ER Use ER User Category ER User Source: Manitoba Centre for Health Policy, 2008
PERCENT Percent of ER Patients with 9+ Primary Care Visits, by Frequent User Category, Winnipeg Manitoba, 2004/05 100.0 90.0 9+ primary care visits 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 single Frequent (7+) ER Frequent User Category Highly Frequent (18+) Source: Manitoba Centre for Health Policy, 2008
Percent Proportion of People with Visits to 2+ Primary Care Physicians, by ER Use Category, Winnipeg Manitoba, 2004/05 Sub-set of population with at least 1 primary care visit 100 90 Visits to 2+ primary care physicians 80 70 60 50 40 30 20 10 0 Non-User ER User single Frequent (7+) Highly Frequent (18+) Overall ER User Category Source: Manitoba Centre for Health Policy, 2008
Little data available THROUGHPUT Most successes in flow have resulted from process changes in throughput Electronic tracking with interval time measurements are providing early data that can be used to measure throughput components Determined by availability of stretchers or treatment spaces at any one stage
Throughput factors Stretcher ownership Most ER time is spent waiting for treatment, diagnostics, clinical decisions Successes in flow by moving patients off stretchers into alternative waiting areas: St Joseph s, Guelph sites, Seven Oaks Streaming Introduction of see and treat or minor treatment streaming (including NP run areas) diminishes LOS of both minor cases and overall LOS
Throughput factors Culture of departments and hospitals Flow orientated culture Collective responsibility for patients waiting (Seven Oaks experience) Removing separation between waiting area and treatment area (success in St Joseph)
Throughput factors Clinical practice Increased use of more advanced diagnostics to meet standard with built in access delay Some decrease need for diagnostics with rules Increased use of CT scans and MRI s Physician performance variability Very little data on this area: Productivity vs quality data is non existent Direct Care hours vs total hours not yet studied
Throughput factors Use of department as a default clinic in tertiary centers Referral Models Reliance on consults for decision making Consulting in the academic model has built in delays Resources Those with most staff do not have the best flow Not more resources but better use of them
Resources in Winnipeg Community Hospitals
ER Length of Stay 32
OUTPUT 70-90 % not admitted admissions are small number but little info on bed occupancy time Delays occur in discharge or transfer to next level of care Admission processes Availability of subsequent care spaces Links back to community Availability Time to set up
Output Some successes Linking patient back to community Building relationships and processes Strengthening primary care Delivering low intensity acute care in alternate settings Outpatient follow up tests wherever possible
Throughput and Output Output options seen as a major obstacle yet are less under the control of the emergency department Throughput changes may give us the most bang for our money Numerous scattered success have targeted throughput and to a lesser extent output ER care is only part of continuum of care Are there solutions in primary care?
Summary / Next Steps No universal solution for ER crowding best strategies will likely be tailored solutions involving multiple dimensions. A closer look at some input (primary care, frequent users) Electronic information systems understanding the successes of throughput strategies. Output solutions will be more complex and involve multiple stakeholders.
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Total Time (hours) Median Daily Visit Time* by Number of Patients Admitted to Hospital, Select ER Sites, Winnipeg, 2004/05 (adjusted for the daily # of resuscitation, emergent & urgent visits) 6 5.5 5 Resuscitation & Emergent Urgent Less Urgent Non-urgent 4.5 4 3.5 19 minutes / patient 22 minutes / patient 3 2.5 2 Per 10 additional inpatients/day 18 minutes / patient 50 52 54 56 58 60 62 64 66 68 70 Daily Number of Resuscitation, Emergent and Urgent Visits (average/site) * Of non-admitted patients. Source: Manitoba Centre for Health Policy, 2008
Proportion of ER Users with Select Person- and Visit-level Characteristics, by frequency of ER use, Winnipeg, 2004/05 Frequency of ER Use (visits/year) Single 2-6 visits 7+ visits 18+ visits PERSON-LEVEL Living in Winnipeg Core 15.6 20.4 36.5 56.5 7+ visits in previous year 0.1 1.1 22.6 70 2+ Mental illness diagnoses* 12.2 22.2 53.7 84.8 VISIT-LEVEL Less / Non urgent 41.4 36.3 38.8 51.7 Arrive by Ambulance 18 21.8 34.7 45.3 Leave without seen 5.6 5.7 9.2 14.1 Visit Duration 6+ hours 22.5 28.3 34.2 31.3 * Past diagnosis with anxiety, depression, dementia, personality disorder, Schizophrenia, substance abuse SOURCE: http://umanitoba.ca/medicine/units/mchp/deliverableslist.html