Elsevier

International Emergency Nursing

Volume 29, November 2016, Pages 9-14
International Emergency Nursing

‘Care in a chair’ – The impact of an overcrowded Emergency Department on the time to treatment and length of stay of self-presenting patients with abdominal pain

https://doi.org/10.1016/j.ienj.2016.08.003Get rights and content

Highlights

  • Delayed allocation of self-presenters has a negative impact on time to treatment.

  • Significant number of patients self-present to ED and are subsequently admitted.

  • Self-presenting in time of overcrowding extend waiting time and delays treatment.

Abstract

Objectives

The aim in this study was to investigate the impact of overcrowding on the Australasian Triage Score’s (ATS) time to treatment target and the National Emergency Access Target (NEAT) for patients who self-present to the Emergency Department (ED) with abdominal pain.

Background

The causes and effects of ED overcrowding have been well described in the literature. It is a widespread phenomenon throughout the world and it can cause serious harm to patients and have a negative impact on access to emergency care. There is however, little research investigating the effect of overcrowding when patients self-present to the ED and experience a delay in being allocated a cubicle.

Methods

A retrospective analysis of 12-months of computerised records was carried out in order to determine if self-presenting patients with abdominal pain allocated a category 3 triage score who were required to ‘queue’ for a cubicle would meet ATS target and NEAT requirements. A multiple regression analysis was used to determine whether or not queuing for an ED cubicle, age and gender were predictors of meeting the ATS guidelines and NEAT requirements.

Results

Three hundred and five patients met the inclusion criteria and were included in the study. Of these 149 patients waited more than 15 min to be allocated a cubicle while 156 did not experience any delay. A multiple regression analysis revealed that gender and age were not predictive of meeting the ATS target and NEAT requirements, while delay in allocation to a cubicle was a significant predictor of not being assessed within 30 min and discharged within 4 h. Furthermore, 61.2% of patients allocated to the waiting room queue for any amount of time were admitted to the ward.

Conclusion

Queuing in the waiting room for an ED bed was a significant predictor of whether or not category three patients with abdominal pain had treatment commenced within 30 min of presentation and was associated with a longer total ED length of stay.

Introduction

Emergency Department (ED) overcrowding has been documented in the literature for over 20 years, and has been identified as a worldwide problem [11], [13], [31]. Overcrowding can be described as a situation where the number of patients waiting to be seen, undergoing assessment or waiting for discharge from the ED exceeds the physical or staffing capacity of the ED [5], [10]. The Australasian College for Emergency Medicine (ACEM) reported that presentations to ED increased by an average of 4.3% per year, while the number of hospital beds decreased by one third between 1983 and 2010 [3].

Overcrowding can be the result of several factors. One such factor is access block. In Australia, access block is defined as the situation when ED patients are unable to access appropriate hospital beds within a time no greater than eight hours [1]. Access block has been associated with an excess mortality of 20–30% [23]. In large EDs it is estimated that more than 40% of staff’s time is spent providing care to patients experiencing access block rather than attending to new emergency presentations [1]. With increasing demand on health services, hospital overcrowding is regarded as one of the most avoidable cause of harm to patients in the hospital system [27]. Overcrowding can result in patients waiting in temporary locations before being allocated a cubicle for emergency care.

Patients present to EDs by two means: via ambulance or they self-present. Ambulance “ramping” is a consequence of overcrowding and is an example of the disruption to patient flow that occurs when patients arrive to an overcrowded ED. Ambulance ramping refers to the situation where paramedics are made to queue in corridors, waiting for EDs staff to allocate the patient to a cubicle, a situation that is frequently seen in Australian EDs [14], [25]. Hitchcock et al. [14] found that ambulance ramping resulted in an increased length of stay for ambulance patients and as such warranted “close attention by health service providers” (p. 22). While ambulance ramping results in patients been cared for by paramedics in corridors waiting for a cubicle to be allocated, self-presenting patients who require a cubicle do not have access to this level of care.

The situation in which self-presenting patients cannot access ED cubicles in an appropriate timeframe is mentioned in the literature, but not well described. Boyle et al. [4] referred to patients requiring ED trolleys as ‘trolley patients’ and reported that if the number of patients requiring trolleys exceeds the number of ED cubicles then an ED is overcrowded.

Another consequence of long waiting time is patient dissatisfaction. Patient dissatisfaction can result in an increased rate of patients leaving without being seen [9]. Kulstad et al. [20] found an association between rates of leaving without being seen and the rate of ED cubicle occupancy. The ACEM [2] suggested that delays in ambulance patient transfer greater than 30 min are symptomatic of ED system failures and delays greater than 1 h should initiate an incident review.

Emergency Departments are under increasing pressure to assess, treat and discharge patients more efficiently. Wiler et al. [30] highlighted the importance of “identifying and mitigating impediments to efficient patient flow” (p. 142) and report that streamlining ED operations has a valuable effect on patient outcomes. Similar streaming approaches have been implemented in Australian EDs [6], [19]. An Australian response to ED overcrowding was the introduction of the National Emergency Access Targets (NEAT) in 2008, after the United Kingdom found that time based targets reduced overcrowding and access block [24]. NEAT have been adopted Australia wide and by 2015, all public hospitals were required to discharge 90% of their patients to a ward, another hospital or home within four hours of initial triage [12].

The aim in this study was to investigate the impact on the Australasian Triage Score’s (ATS) time to treatment target and the National Emergency Access Target (NEAT) for patients with abdominal pain self-presenting to the ED arriving at times of overcrowding.

Section snippets

Design

A retrospective review of electronic medical records over a 12-month period (from May 2012 to April 2013) was conducted in order to evaluate the impact of the delayed allocation of a cubicle when arriving in an ED in an overcrowding situation. Electronic ED records were extracted, de-identified, from the patient management system (Symphony™). Full ethical clearance was obtained from the study site and the University prior to the start of data collection.

Setting

The study took place in the ED of a major

Results

Over the 12 month period, there were 60,091 ED presentations, where patients were allocated a triage category between two and five. The data were then sorted per month to determine any seasonal variation in the data. Patients who had delayed access to ED cubicles after initial triage were separated according their mode of arrival. December had the highest number of presentations to the ED for the 12-month period (n = 5271; 8.8%) while February had the lowest number of patients (n = 4707; 7.8%). The

Discussion

ED overcrowding is not a new concept and is known to have a detrimental impact on timely patient care, patient outcomes and on the efficiency of ED processes. The aim in this study was to investigate the impact of ED overcrowding on adherence to ATS time to treatment guidelines and adherence to NEAT guidelines. The findings indicate that ED overcrowding resulted in delays in access to emergency care for self-presenting patients with abdominal pain and urgent clinical needs. These delays

Limitations

There are limitations to conducting retrospective studies. Recording accuracies cannot be excluded for the current study as electronic records were used.

While it would have been interesting to investigate the impact of queuing in the waiting room on morbidity and mortality this was not possible with the dataset used. It is therefore not possible to demonstrate that patients who spent extended periods in the waiting room had worse outcomes than patients treated without the need to queue. An

Conclusions

This study reveals that some patients self-presenting to the ED with high acuity are spending extended periods of time waiting for an ED cubicle in the same way ambulance patients are required to ramp. This study has demonstrated an association between delayed allocation to a cubicle when self-presenting and increased time to commencement of treatment and reduced adherence to NEAT and ATS time to treatment guidelines. A significant number of self-presenting patients in this study required

Funding

No funding was granted for this study.

Author contributions

BS, SB and EW all participated to the study design, data analysis and manuscript preparation.

Acknowledgements

Not applicable.

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