October 14, 2015 Ruth W. Leslie, Director e mail: ruth.leslie@health.ny.gov Division of Hospitals and Diagnostic & Treatment Centers New York State Department of Health Empire State Plaza, Corning Tower Albany, NY 12237 Dear Ms. Leslie: On behalf of the membership of the New York American College of Emergency Physicians (New York ACEP) I want to thank you for your letter of August 25, 2015 and for your willingness to consider reissuing the "Dear CEO" letter. As you are likely aware, the epidemic of continued boarding of hospital inpatients within emergency departments has continued to increase over the years. Over that time, we have also observed a growing body of literature that demonstrates that this practice causes deleterious effects on patient care. We have taken the liberty to include some references should you want to review the literature. We appreciate the opportunity you afforded New York ACEP to provide comments on the Guidance Document for Hospitals: Overcrowding / Emergency Preparedness Hospital Obligations and Responsibilities initially issued by the Department of Health in April 2002 and updated in October 2003. New York ACEP's recommended revisions to the Guidance Document for Hospitals are attached. Thank you for all your work and assistance in promoting quality care and safety of patients throughout New York State. If you have any questions, please do not hesitate to contact us. Sincerely, Louise A. Prince, MD FACEP President
References Regarding Boarding of Hospital Inpatients Within the Emergency Department 1. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project User Support Web site. Available at: http://www.hcup- us.ahrq.gov/. Accessed Apr 13, 2011. 2. American College of Emergency Physicians. Crowding. Ann Emerg Med. 2006; 47:585. 3. Asplin BR, Magid DJ, Rhodes KV, et al. A conceptual model of emergency department crowding. Ann Emerg Med. 2003; 42:173 80. 4. Bernstein SL, Aronsky D, Duseja R, et al.; Society for Academic Emergency Medicine, Emergency Department Crowding Task Force. The effect of emergency department crowding on clinically ori- ented outcomes. Acad Emerg Med. 2009; 1:1 10. 5. Burt CW, McCaig LF. Staffing, Capacity, and Ambulance Diversion in Emergency Departments: United States, 2003 04. Advance data from vital and health statistics; no. 376. Hyattsville, MD: National Center for Health Statistics. 2006. Olshaker JS, Rathlev NK. Emergency department overcrowding and ambulance diversion: the impact and potential solutions of extended boarding of admitted patients in the emergency department. J Emerg Med. 2006;30(3):351-356. 6. Burt CW, McCaig LF, Valverde RH. Analysis of ambulance transports and diversions among US emergency departments. Ann Emerg Med. 2006;47(4):317-326. 7. Carr BG, Kaye AJ, Wiebe DJ, Gracias VH, Schwab CW, Reilly PM. Emergency department length of stay: a major risk factor for pneumonia in intubated blunt trauma patients. J Trauma. 2007; 63:9 12. 8. Center for Medicare and Medicaid Services. Hospital Outpatient Regulations and Notices. Details for CMS-1504-FC. Available at: http://www.cms.gov/hospitaloutpatientpps/hord/itemdetail.asp?itemid=cms1240960&. Accessed Jul 14, 2011. 9. Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35(6):1477-1483. 10. Cowan RM, Trzeciak S. Clinical review: emergency department overcrowding and the potential impact on the critically ill. Crit Care. 2005;9(3):291-295. 11. Derlet RW, Richards JR. Overcrowding in the nation s emergency departments: complex causes and disturbing effects. Ann Emerg Med. 2000; 35:63 8. 12. Dunn R. Reduced access block causes shorter emergency department waiting times: An historical control observational study. Emerg Med (Fremantle). 2003;15(3),232 238. 13. Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998; 36:8 27. 14. Hollander JE, Pines JM. The emergency department crowding paradox: the longer you stay, the less care you get. Ann Emerg Med. 2007; 50:497 9. 15. Hoot RN, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008; 52:126 36. 16. Institute of Medicine. Committee on the Future of Emergency Care in the United States Health System. Hospital-based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press, 2006. 17. Joint Commission. Sentinel Event Alert, June 17, 2002; http://www.jointcommission.org/sentinelevents/ statistics. Accessed 4 June 2007. 18. Krochmal P, Riley TA. Increased health care costs associated with ED overcrowding. Am J Emerg Med. 1994;12(3):265-266. 19. Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. ED overcrowding is associated with an increased frequency of medication errors. Am J Emerg Med. 2010; 28:304 9. 20. Lie SW, et al. Frequency of adverse events and errors among patients boarding in the emergency department. Acad Emerg Med. 2005;12(5)_suppl_1:49-50. 21. Liew D, Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust. 2003;179(10):524-526. 22. Liu SW, Thomas SH, Gordon JA, Hamedani AG, Weissman JS. A pilot study examining undesirable events among emergency department-boarded patients awaiting inpatient beds. Ann Emerg Med. 2009; 54:381 5 23. Mills AM, Baumann BM, Chen EH, et al. The impact of crowding on time until abdominal CT interpretation in emergency department patients with acute abdominal pain. Postgrad Med. 2010; 122:75 81. 24. Mills AM, Shofer FS, Chen EH, Hollander JE, Pines JM. The association between emergency department crowding and analgesia administration in acute abdominal pain patients. Acad Emerg Med. 2009; 16:603 8.
25. Minority staff special investigations division, committee on government reform. US House of Representatives. National preparedness: ambulance diversions impede access to emergency rooms. www.house.gov/reform/ min, Oct 16, 2001. 26. Nicholl J, West J, Goodacre S, et al. The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007;24(9):665-668. 27. Pham JC, Patel R, Millin MG, et al. The effects of ambulance diversion: a comprehensive review. Acad Emerg Med. 2006;13(11):1220-1227. 28. Pines JM, Hollander JE, Localio AR, et al. The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med. 2006;13(8):873-878. 29. Pines JM, Hollander JE. Association between cardiovascular complications and ED crowding. American College of Emergency Physicians 2007 Scientific Assembly; October 8-11, 2007; Seattle, WA. 30. Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008; 51:1 5. 31. Pines JM, Localio AR, Hollander JE, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia. Ann Emerg Med. 2007; 50:510 6. 32. Pines JM, Shofer FS, Isserman JA, Abbuhl SB, Mills AM. The effect of emergency department crowding on analgesia in patients with back pain in two hospitals. Acad Emerg Med. 2010; 17:276 83. 33. Pines JM, Prabhu A, Hilton JA, Hollander JE, Datner EM. The effect of emergency department crowding on length of stay and medication treatment times in discharged patients with acute asthma. Acad Emerg Med. 2010; 17:834 9. 34. Pines JM, Pollack CV Jr, Diercks DB, Chang AM, Shofer FS, Hollander JE. The association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain. Acad Emerg Med. 2009; 16:617 25. 35. Richardson DB. The access-block effect: relationship between delay to reaching an inpatient bed and inpatient length of stay. Med J Aust. 2002;177(9):492-495. 36. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184(5):213-216. 37. Richardson DB, Bryant M. Confirmation of Association between overcrowding and adverse events in patients who do not wait to be seen. Acad Emerg Med. 2004;11(5):462. 38. Schneider SA, Winograd SM. Emergency department crowding. Emerg Med Rep. 2009; 30:13 23. 39. Schull MJ, Morrison LJ, Vermeulen M, et al. Emergency department overcrowding and ambulance transport delays for patients with chest pain. CMAJ. 2003;168(3):277-83. 40. Schull MJ, Lazier K, Vermeulen M, et al. Emergency department contributors to ambulance diversion: a quantitative analysis. Ann Emerg Med. 2003;41(4):467-476. 41. Schull MJ, Morrison LJ, Vermeulen M, Redelmeier DA. Emergency department gridlock and outof- hospital delays for cardiac patients. Acad Emerg Med. 2003; 10:709 16. 42. Schull MJ, Vermeulen M, Slaughter G, Morrison L, Daly P. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med. 2004; 44:577 85. 43. Singer, AJ, et al. The Association Between Length of Emergency Department Boarding and Mortality. Soc Ac Emer Med. 44. Sprivulis PC, Da Silva JA, Jacobs IG, et al. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184(5):208-212. 45. University HealthSystem Consortium. Homepage. Available at: http://www.uhc.edu. Accessed Apr 13, 2011. 46. Viccellio A, Santora C, Singer AJ, Thode HC Jr, Henry MC. The association between transfer of emergency department boarders to inpatient hall- ways and mortality: a 4-year experience. Ann Emerg Med. 2009; 54:487 91. 47. Weiss SJ, Ernst AA, Nick TG. Relationship between the National ED overcrowding scale and the number of patients who leave without being seen in an academic ED. Am J Emerg Med. 2005;23:288-294. 48. Weissman JS, Rothschild JM, Bendavid E, et al. Hospital workload and adverse events. Med Care. 2007;45(5):448-455.
GUIDANCE DOCUMENT FOR HOSPITALS Overcrowding I Emergency Preparedness Hospital Obligations & Responsibilities Hospitals must meet the needs of the communities they serve on an ongoing basis. It is the responsibility of the hospital's Governing Body and Senior Management to review the following guidelines and to take corrective action, as appropriate. Emergency preparedness and readiness is not an episodic response, but is an ongoing commitment to maintaining a hospital's capacity and capabilities to respond to emergencies. Emergency Departments (EDs) need to remain open and fully operational to ensure that each hospital is able to maintain the capacity to respond, not only to episodic events, but to long term or seasonal periods of overcrowding. Maintaining admitted patients within the emergency department is not acceptable on multiple levels. Hospital administration must be proactive in identifying and utilizing inpatient beds for admissions from the emergency department. All hospital beds and inpatient areas should be identified and considered in determining bed assignments. During peak periods of overcrowding, as a temporary emergency measure, the use of beds in solariums and hallways near nursing stations should be utilized consistent with a facilitywide plan to alleviate hospital overcrowding and provide capacity. In the event that the number of patients needing evaluation or treatment in an ED is equal to or exceeds the EDs treatment space capacity, admitted patients should be promptly distributed to inpatient units regardless of inpatient bed availability. Ambulance diversion is an emergency response to overcrowding that is to be used sparingly and only upon the direction of the hospital s key administrative staff. Hospital administration is responsible to document and monitor all diversion practices and decisions. As hospitals proceed with emergency preparedness planning, all trauma centers, hospitals, counties, and Regional Emergency Medical Advisory Committees, are advised to meet and collectively establish and/or assess the effectiveness of and negative impact on countywide or system wide diversion policies and practices. Hospitals are expected to have in place effective ongoing monitoring protocols to track and identify length of stay patterns and deviations, both for inpatients and for patients in the emergency department. Priority attention should be given to initiating inpatient and emergency department discharge planning activities to ensure the prompt and safe discharge of patients. Efforts to coordinate and partner with community resources, nursing homes and other patient support services should be in place and functioning at all times. Hospitals should develop appropriate mechanisms to facilitate availability of inpatient beds. Hospitals should ensure that patient discharges occur early during the day to provide the required support to newly admitted surgical and emergency department patients. It is well known that the afternoon time period has a higher inpatient and emergency department patient census. The hospital must take steps to minimize this period of potentially significant lack of capacity that occurs on a daily basis.
Hospitals should work with available resources to support the care of patients presenting with psychiatric/behavioral health concerns to minimize the treatment delays that occur when these patients are waiting for transfer to an admitting facility. In the event that there is a delay to transfer due to lack of bed availability, hospitals are expected to provide appropriate care for these patients while they are awaiting admission placement. Ambulances and As an essential community resource, EMS personnel should not be detained in the emergency department due to lack of capacity and should be placed promptly back into service. To ensure that patient care needs are met by hospital staff, ambulance patients must be transferred promptly to emergency department staff. Hospitals should evaluate hospital-wide staffing levels on a hospital-wide basis. Cross training and coordination among programs and services is necessary to ensure adequate staffing levels during peak periods of need. In the event that hospital patients are boarding in the emergency department, the patients should receive the nurse (and support staff) staffing ratio that is at the level of their expected inpatient care requirements. Staffing patterns applicable to other specialized areas/units of the hospital should apply equally to the Emergency Department to ensure that patients receive a consistent standard of care, appropriate for the acuity of their condition. Hospitals must ensure appropriate physician staff availability for hospitalized patients. In the event that a hospitalized patient is boarding in the emergency department, the emergency department physician staff should not be responsible for the patient s ongoing care except in the case of emergency. The emergency department physician staff should be engaged in the care of active emergency department patients. Hospitals must assume responsibility for the quality and appropriateness of all patient care services., R regardless of a patient's location within the facility. This includes staffing, services, privacy, infection control and confidentiality protections must be consistently in place. Hospitals must make available to Emergency Departments staff the ancillary services which permit the prompt disposition of admitted patients care needs. The 24-hour availability of transport services is necessary to meet patient needs and to allow for the timely transfer of admitted patients. Hospitals are 24/7 operations and they should also ensure that ancillary services are available for hospital admitted patients over the weekend and after hours to minimize delays in patient discharge.
GUIDANCE DOCUMENT FOR HOSPITALS Overcrowding I Emergency Preparedness Hospital Obligations & Responsibilities Hospitals must meet the needs of the communities they serve on an ongoing basis. It is the responsibility of the hospital's Governing Body and Senior Management to review the following guidelines and to take corrective action, as appropriate. Emergency preparedness and readiness is not an episodic response, but is an ongoing commitment to maintaining a hospital's capacity and capabilities to respond to emergencies. Emergency Departments (EDs) need to remain open and fully operational to ensure that each hospital is able to maintain the capacity to respond, not only to episodic events, but to long term or seasonal periods of overcrowding. Maintaining admitted patients within the emergency department is not acceptable on multiple levels. Hospital administration must be proactive in identifying and utilizing inpatient beds for admissions from the emergency department. All hospital beds and inpatient areas should be identified and considered in determining bed assignments. During peak periods of overcrowding, as a temporary emergency measure, beds in solariums and hallways near nursing stations should be utilized consistent with a facility-wide plan to alleviate hospital overcrowding and provide capacity. In the event that the number of patients needing evaluation or treatment in an ED is equal to or exceeds the EDs treatment space capacity, admitted patients should be promptly distributed to inpatient units regardless of inpatient bed availability. Ambulance diversion is an emergency response to overcrowding that is to be used sparingly and only upon the direction of the hospital s key administrative staff. Hospital administration is responsible to document and monitor all diversion practices and decisions. As hospitals proceed with emergency preparedness planning, all trauma centers, hospitals, counties, and Regional Emergency Medical Advisory Committees, are advised to meet and collectively establish and/or assess the effectiveness of and negative impact on countywide or system wide diversion policies and practices. Hospitals are expected to have in place ongoing monitoring protocols to track and identify length of stay patterns and deviations, both for inpatients and for patients in the emergency department. Priority attention should be given to initiating inpatient and emergency department discharge planning activities to ensure the prompt and safe discharge of patients. Efforts to coordinate and partner with community resources, nursing homes and other patient support services should be in place and functioning at all times. Hospitals should develop appropriate mechanisms to facilitate availability of inpatient beds. Hospitals should ensure that patient discharges occur early during the day to provide the required support to newly admitted surgical and emergency department patients. It is well known that the afternoon time period has a higher inpatient and emergency department patient census. The hospital must take steps to minimize this period of potentially significant lack of capacity that occurs on a daily basis.
Hospitals should work with available resources to support the care of patients presenting with psychiatric/behavioral health concerns to minimize the treatment delays that occur when these patients are waiting for transfer to an admitting facility. In the event that there is a delay to transfer due to lack of bed availability, hospitals are expected to provide appropriate care for these patients while they are awaiting admission placement. As an essential community resource, EMS personnel should not be detained in the emergency department due to lack of capacity and should be placed promptly back into service. To ensure that patient care needs are met, ambulance patients must be transferred promptly to emergency department staff. Hospitals should evaluate hospital-wide staffing levels. Cross training and coordination among programs and services is necessary to ensure adequate staffing levels during peak periods of need. In the event that hospital patients are boarding in the emergency department, the patients should receive the nurse (and support staff) staffing ratio that is at the level of their expected inpatient care requirements. Staffing patterns applicable to other specialized areas/units of the hospital should apply equally to the Emergency Department to ensure that patients receive a consistent standard of care, appropriate for the acuity of their condition. Hospitals must ensure appropriate physician staff availability for hospitalized patients. In the event that a hospitalized patient is boarding in the emergency department, the emergency department physician staff should not be responsible for the patient s ongoing care except in the case of emergency. The emergency department physician staff should be engaged in the care of active emergency department patients. Hospitals must assume responsibility for the quality and appropriateness of all patient care services, regardless of a patient's location within the facility. This includes staffing, services, privacy, infection control and confidentiality protections. Hospitals must make available to Emergency Departments ancillary services which permit the prompt disposition of admitted patients. The 24-hour availability of transport services is necessary to meet patient needs and to allow for the timely transfer of admitted patients. Hospitals are 24/7 operations and they should also ensure that ancillary services are available for hospital admitted patients over the weekend and after hours to minimize delays in patient discharge.