Emergency Department Capacity Research Articles

A Continuous Petri Net Model for the Management and Design of Emergency Cardiology Departments

Abstract The efficient management of the Emergency Department (ED) has become an important issue in the past decade. Indeed, the increased demand for emergency services has saturated the capacity of EDs that require suitable tools for the efficient flow of work and people. The paper proposes a model to describe in a concise and effective way the structure and dynamics of a critical ED of the general hospital of Bari (Italy): the Emergency Cardiology Department (ECD). The model describes in a continuous Petri net framework the complete workflow and management of patients starting from their arrival to the ED until either their discharge from the hospital or their admission in a suitable hospital department. The fluid approximation allows defining suitable optimization problems to optimize the system performances and determine the optimal resource dimension guaranteeing the efficient management of the ECD. A simulation study shows that the optimized parameters lead to an effective workflow organization while maximizing the patient flow.

The Safety of Emergency Care Systems: Results of a Survey of Clinicians in 65 US Emergency Departments

Well-functioning systems are critical to safe patient care, but little is known about the status of such systems in US health care facilities, including high-risk settings such as the emergency department (ED). The purpose of this study is to assess the degree to which EDs are designed, managed, and supported in ways that ensure patient safety. This was a validated, psychometrically tested survey of clinicians working in 65 US EDs that assessed clinician perceptions about the EDs' physical environment, staffing, equipment and supplies, nursing, teamwork, safety culture, triage and monitoring, information coordination and consultation, and inpatient coordination. Overall 3,562 eligible respondents completed the survey (response rate=66%). Survey respondents commonly reported problems in 4 systems critical to ED safety: physical environment, staffing, inpatient coordination, and information coordination and consultation. ED clinicians reported that there was insufficient space for the delivery of care most (25%) or some (37%) of the time. Respondents indicated that the number of patients exceeded ED capacity to provide safe care most (32%) or some of the time (50%). Only 41% of clinicians indicated that most of the time specialty consultation for critically ill patients arrived within 30 minutes of being contacted. Finally, half of respondents reported that ED patients requiring admission to the ICU were rarely transferred from the ED to the ICU within 1 hour. Reports by ED clinicians suggest that substantial improvements in institutional design, management, and support for emergency care are necessary to maximize patient safety in US EDs.

Public Health Initiatives in the Emergency Department: Not So Good for the Public Health?

Public Health Initiatives in the Emergency Department: Not So Good for the Public Health?

The New Emergency Department at Baylor University Medical Center

Founded as a Christian ministry of healing, Baylor Health Care System exists to serve all people through exemplary health care, education, research, and community service. Nowhere in our system is this mission better served than in the emergency department (ED) of Baylor University Medical Center (BUMC). Thirty years ago we served the community from a small area in the basement of Jonsson Hospital. Soon, the ED will occupy 75,000 square feet of Roberts Hospital (Figure ​(Figure11). Figure 1 Artist's rendition of the expanded emergency department at Baylor University Medical Center. Over the same 30 years, the practice of emergency medicine has changed significantly. One must now thoroughly work up and evaluate all who come through our doors. There must be objective evidence to admit a patient; judgment is no longer enough. Short-stay hospital admissions have become prolonged ED stays. Twenty-five percent of all Texans have no health care insurance. A much larger percentage has no medical home. There is little opportunity for insured workers to visit their physician without taking time off work, and for many, no work means no pay. Added to this great number of people are those who have emergent medical conditions or trauma, leading to an ever-increasing number of ED patients. The ED at BUMC has been at capacity for nearly 10 years. To perform efficiently, an ED can be at capacity for no more than 10% of any day. Our ED is at capacity consistently (Figure ​(Figure22). This mismatch of need and capacity has led to declining service and loss of referrals from our medical staff. Quality metrics are more difficult to maintain, and staff morale suffers. Yet, the ED continues to be one of the most efficient areas of our hospital and certainly the place to be when one is seriously sick or injured. Figure 2 Bed capacity analysis: patients in progress by hour of the day in the emergency department at Baylor University Medical Center. Data were averaged for the year 2006. The current capacity of the department is 33 beds (as represented by the horizontal line); ... A number of years ago, BUMC's board of trustees acknowledged this situation and declared that it must be resolved. Planning began well over 2 years ago, and construction will be finished by January 2008. The total capacity of BUMC's ED will increase from 34 beds to approximately 80 patient rooms, almost all of them private. In addition, a large trauma area will be available to hold up to eight severely injured persons. Technology will keep pace, with a completely computerized patient record, digital radiology, and two computed tomography scanners, one a 64-slice scanner and one a 32-slice scanner. Our patients were foremost in the planning of the new ED. The first thing one notices in our new department is “the quiet.” Sound itself leads to stress, and a quiet environment helps patients and staff alike. Computers in every room allow the staff to spend more time with each patient and be more efficient. The medical professionals will be geographically placed, maintaining our small team atmosphere and working relationships. A separate ambulatory entrance will be available for patients referred by the Baylor medical staff. Communication will be enhanced with a call center that already receives over 450 calls a day. All staff will carry cell phones so that they are quickly available. A classroom large enough to hold one third of our staff at one time will also soon be available, along with an enlarged locker room and break areas. These areas were made possible by generous private donations. Each patient room has enough chairs for family members. Each is also equipped with a television and a phone. The lighting is dimmable for comfort. Privacy curtains have been eliminated in favor of electrostatic glass, which turns opaque with a flip of a switch. The floors do not need waxing; therefore, stripping, buffing, noisy machinery, and foul odors are avoided. Trauma has its own area, a large bay with private rooms nearby. There are smaller waiting areas throughout the ED for family comfort and proximity. Our monitors will now be watched by technical assistants, and any problem will be immediately called to the treating nurse, decreasing alarm fatigue. Disaster medicine has also been considered in the new ED. A large new decontamination room has been added, and multiple negative pressure rooms are in place for respiratory isolation. Aesthetics have been considered, with artwork inside and out. The exterior will soon receive special attention, with the knowledge that this area of the campus will become more populated and utilized as the years progress. The completion of our new ED ensures that our mission to our patients and our community will be well served for many years to come.

Emergency department overcrowding - implications for paediatric emergency medicine.

Emergency department (ED) overcrowding has been an international phenomenon for more than 10 years. It is important to understand that ED overcrowding is a measure of health system efficiency and is not strictly related to ED volumes or capacity. ED overcrowding is defined as a situation in which the demand for emergency services exceeds the ability of physicians and nurses to provide quality care within a reasonable time. The major factor resulting in ED overcrowding is the presence of admitted patients in the ED for prolonged periods of time, not a high volume of low-acuity patients. While limited data are available for paediatric EDs, winter respiratory illnesses set the stage for ED overcrowding, which are epidemic in adult or general EDs. Prehospital-, ED- and hospital-related factors are described in the present article, and these may help prevent or manage this important patient safety problem.

The Effects of Minimizing Ambulance Diversion Hours on Emergency Departments

This study explores the effects of minimizing Emergency Department (ED) bypass on individual hospital’s ED census, ambulance transports, and admissions. Five hospitals in a geographic area collected data over 3 weeks. The first and third week represented controls, whereas the second week hospitals minimized their usage of bypass. Data collected included hours on bypass, ED census, ambulance runs, hospital admissions, and inter-facility transfers. The total number of hours on bypass for all hospitals for pre-trial, trial, and post-trial weeks were 112.2, 0.3, and 47, respectively. There were several statistical shifts in the proportion of ambulance runs and admissions seen by individual hospitals. Clinically, these shifts in patients were minor and within ED capacity. Hospitals in a given geographic area may successfully reduce the number of hours on bypass with possible minor shifting in the number of ambulance runs and admissions that are within ED capacity.

Portable Advanced Medical Simulation for New Emergency Department Testing and Orientation

Efforts to mitigate unexpected problems during transition of an active emergency department (ED) to a new physical plant are imperative to ensure effective health care delivery and patient safety. The authors used advanced medical simulation (SIM) to evaluate the capacity of a new ED for emergent resuscitative processes and assist facility orientation before opening day. Operational readiness testing and orientation to the new ED of a large academic center were arranged through a Transportable Enhanced Simulation Technologies for Pre-Implementation Limited Operations Testing (TESTPILOT) project. Using a portable life-sized computerized manikin, the project required participants to perform assorted patient care interventions on-site. Cardiac arrest, multitrauma, uroseptic shock, and pediatric toxicology scenarios elicited the dynamics of real-life ED activities. Debriefings and surveys assessed participants' perceptions of the new facility's clinical readiness and identified areas needing administrative attention. Subjective utility of SIM orientation was compared with that of standard facility orientation. Fourteen ED clinicians and five SIM facilitators participated over two sessions. The new facility received mean (+/- SD) and median five-point Likert scale scores of 4.4 (+/- 0.8) and 5 for ability of clinical staff to perform resuscitations. The respective scores for ability of simulated scenarios to prepare staff for new ED function were 4.6 (+/- 0.5) and 5, compared with 4.2 (+/- 1.0) and 4 for non-SIM orientation (p = 0.22; not significant). Problems with equipment location, inadequate procedural surfaces, and insufficient orientation were discovered and rapidly corrected. Transportable SIM was used to evaluate the clinical functions of a new ED. Significant operational issues identified by participants were corrected before opening of the facility. Limited comparison did not reveal SIM enhancement of orientation.

Factors Associated with Patients Who Leave without Being Seen

Patients who leave without being seen (LWBS) can be an indicator of patient satisfaction and quality for emergency departments (ED). The objective of this study was to develop a model to determine factors associated with patients who LWBS. A modified case-crossover design to determine the transient effects on the risk of acute events was used. Over a four-month period, time intervals when patients LWBS were matched (within two weeks), according to time of day and day of week, with time periods when patients did not LWBS. Factors considered were percentage of ED bed capacity, acuity of ED patients, length of stay of discharged patients in the ED, patients awaiting an admission bed in the ED, inpatient floor capacity, intensive care unit capacity, and the characteristics of the attending physician in charge. McNemar test, Wilcoxon signed-rank test, and conditional logistic regression analyses were used to determine significant variables. Over the study period, there were 11,652 visits, of which 213 (1.8%) resulted in patients who LWBS. Measures of inpatient capacity were not associated with patients who LWBS and ED capacity was only associated when >100%. This association increased with increasing capacity. Other significant factors were older age (p < 0.01) and completion of an emergency medicine residency (p < 0.01) of the physician in charge. When factors were considered in a multivariate model, ED capacity >140% (odds ratio, 1.96; 95% confidence interval = 1.22 to 3.17) and noncompletion of an emergency medicine residency (odds ratio, 1.85; 95% confidence interval = 1.17 to 2.93) were most important. ED capacity >100% is associated with patients who LWBS and is most significant at 140% capacity. ED capacity of 100% may not be a sensitive measure for overcrowding. Physician factors, especially emergency medicine training, also appear to be important when using LWBS as a quality indicator.

The probability of emergency department diversion status as a function of inpatient occupancy

Study objectives: Emergency department (ED) diversion status is a result of a mismatch between ED capacity and various input, throughput, and output factors. It is important to measure these factors to manage ED flow and predict ambulance diversion. The most important output factor for most EDs is the inpatient medical-surgical occupancy rate, which varies considerably but predictably throughout the week. The medical-surgical occupancy rate was calculated as the sum of the number of patients occupying beds at midnight and the number of discharged patients in the previous 24-hour period divided by the total number of staffed beds. We measure the odds and probability of daily diversion status according to variability in the following daily variables: (1) medical-surgical inpatient occupancy; (2) ED volume; (3) number of ED admissions; (4) number of ED ICU admissions; (5) number of ED clinical attending physician hours and shifts; (6) ED throughput time (TPT); (7) day of week; and (8) number of elective operating room surgical cases. Methods: Data were collected retrospectively from ED and hospital electronic logs for 24-hour periods starting at midnight for 102,327 ED visits between April 15, 2002, and February 29, 2004. The association between ED diversion and each independent variable was measured in univariate analysis by Student's t tests. Variables reaching statistical significance at P value less than .05 were further analyzed in a multiple logistic regression model. Results: The baseline probability of diversion was 36%. The following 3 variables reached statistical significance in univariate analysis: (1) medical-surgical occupancy rate; (2) day of the week; and (3) TPT. In multivariate analysis, the odds ratios and increased probability of diversion status were as follows: 1.2 and 4% for each 5% increase in medical-surgical occupancy; 2.0 and 17% when TPT was greater than or equal to the median of 238 minutes; and 1.8 and 15% for weekdays compared with weekends. Conclusion: The probability of ambulance diversion on a weekday with a TPT greater than or equal to the median of 238 minutes was 68%. Increasing inpatient capacity on weekdays is likely to have a positive effect on decreasing ambulance diversion. Variability in the number of elective surgical cases was not associated with diversion status.

Overcrowding crisis in our nation's emergency departments: is our safety net unraveling?

Emergency departments (EDs) are a vital component in our health care safety net, available 24 hours a day, 7 days a week, for all who require care. There has been a steady increase in the volume and acuity of patient visits to EDs, now with well over 100 million Americans (30 million children) receiving emergency care annually. This rise in ED utilization has effectively saturated the capacity of EDs and emergency medical services in many communities. The resulting phenomenon, commonly referred to as ED overcrowding, now threatens access to emergency services for those who need them the most. As managers of the pediatric medical home and advocates for children and optimal pediatric health care, there is a very important role for pediatricians and the American Academy of Pediatrics in guiding health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care.

The emergency department: rethinking the safety net for the safety net.

America's emergency departments (EDs) are in crisis. The dwindling numbers of EDs are increasingly overcrowded as they cope with rising demand. In a Health Affairs Web Exclusive, Glenn Melnick and his colleagues find that despite these trends, overall ED capacity is actually increasing in California. While this may appear to make financial sense for some hospitals, it is a costly response that does little to fix the complex problems that drive ED overcrowding. Given a convergence of factors, it may now be time to radically alter and broaden our historical expectations of the role of the ED.

Emergency department capacity and access in California, 1990-2001: an economic analysis.

Media report that hospitals are closing their emergency departments (EDs) and reducing access to ED services, raising concerns that EDs are not sustainable under competition and managed care. We analyzed financial, economic, capacity, and utilization data for California EDs for 1990-2001. We found that contrary to media reports, hospitals are not abandoning the ED market. Rather, our results show a robust market, where hospitals are adding ED capacity to meet increased demand and to maintain access. Supporting economic analyses show that EDs are sustainable since they generate a sizable and growing portion of inpatient admissions, which contribute to overall economic viability.

The Overcrowded Emergency Department: A Comparison of Staff Perceptions

Abstract Objectives: To study perceptions of physicians and nursing staff about real‐time demands and capacity of an emergency department (ED). To use ED data to calculate proposed demand ratios called Real‐time Emergency Analysis of Demand Indicators (READI) scores. To compare the READI scores with ED staff perceptions of demand and capacity. Methods: This prospective study used a computerized clinical management system to provide data about ED demand and capacity. Physicians and staff charge nurses were surveyed about perceptions of ED demand and capacity. Results were compared with mathematical READI scores, which are proposed to objectively assess ED demand. Kappa scores were used to measure intrarater reliability between the physicians' and charge nurses' assessment of demand and between the staff assessments and the READI scores. Results: Kappa scores of the perception of excess demand were as follows: between two physician groups, κ= 0.392; between one physician group and charge nurses, κ= 0.453; and between a second physician group and charge nurses, κ= 0.243. Comparing respondents who indicated that demand had or had not exceeded capacity, one of the READI ratios, the Bed Ratio, showed a significant difference in mean, 0.245 (95% confidence interval = 0.153 to 0.336), between groups. Conclusions: Real‐time data may be used to predict ED demand and resource needs. Subjective assessment of excess ED demand did not correlate between physician groups or between physicians and charge nurses. Although there was a trend toward predicting excess demand with one of the READI scores, these scores did not correlate to staff perceptions.

The Overcrowded Emergency Department: A Comparison of Staff Perceptions

To study perceptions of physicians and nursing staff about real-time demands and capacity of an emergency department (ED). To use ED data to calculate proposed demand ratios called Real-time Emergency Analysis of Demand Indicators (READI) scores. To compare the READI scores with ED staff perceptions of demand and capacity. This prospective study used a computerized clinical management system to provide data about ED demand and capacity. Physicians and staff charge nurses were surveyed about perceptions of ED demand and capacity. Results were compared with mathematical READI scores, which are proposed to objectively assess ED demand. Kappa scores were used to measure intrarater reliability between the physicians' and charge nurses' assessment of demand and between the staff assessments and the READI scores. Kappa scores of the perception of excess demand were as follows: between two physician groups, kappa = 0.392; between one physician group and charge nurses, kappa = 0.453; and between a second physician group and charge nurses, kappa = 0.243. Comparing respondents who indicated that demand had or had not exceeded capacity, one of the READI ratios, the Bed Ratio, showed a significant difference in mean, 0.245 (95% confidence interval = 0.153 to 0.336), between groups. Real-time data may be used to predict ED demand and resource needs. Subjective assessment of excess ED demand did not correlate between physician groups or between physicians and charge nurses. Although there was a trend toward predicting excess demand with one of the READI scores, these scores did not correlate to staff perceptions.