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ED Waits Linked to Higher Costs, LOS

 |  By John Commins  
   December 07, 2012

The common-sense assumption that longer waits in crowded emergency departments are bad for patients' health is bolstered by a new study.

The study, Impact of Emergency Department Crowding on Outcomes of Admitted Patients,  published online this week in the Annals of Emergency Medicine, found that admission to the hospital from the ED on days with prolonged ambulance diversion or high ED crowding was associated with 5% increased odds of dying in the hospital compared to admissions on days with low ambulance diversion.

The study also linked crowding to longer hospital lengths of stay and increased costs per admission.

Lead author, Benjamin Sun, MD, an emergency physician with the Oregon Health & Science University in Portland, says the findings confirm what he had expected.

"It is something that seems to resonate with common sense, but there isn't a whole lot of evidence to support it, which is why we think this is a significant paper," Sun says.

The difference is the size and sweep of Sun's study.

"There have been studies that have looked at the relationship between crowding and outcomes. They've been limited in that they look at a roughly small number of patients or hospitals," Sun says.

"The way this differs from prior work is No. 1, we looked at a large number of patients in a large geographic area in California. In contrast, other papers have focused on the patients who were trauma or heart attacks. We looked at everybody who got admitted to the hospital."

The team analyzed 995,379 ED visits resulting in admission to 187 hospitals in California during 2007. Daily ambulance diversion was the measure of emergency department crowding.

Findings
Patients who were admitted on days with high emergency department crowding had .8% longer hospital stays and 1% increased costs per admission. Periods of high emergency department crowding were associated with 300 excess inpatient deaths, 6,200 hospital days and $17 million in costs, the study found.

"Our findings are robust," Sun says. "Every way we sliced the data it showed that the system is such that if you came into the hospital on a really busy day and you were admitted you had a higher rate of death than if you were admitted on a day when it wasn't so busy."

Although a trip the emergency room is not something that individual patients can pencil in, Sun says that hospitals should be able to track ebb and flow in their EDs.

"For most hospitals the number of patients who need to be admitted from the ED is a very predictable thing," he says. "What the profession has learned over the past 10 years of research is that ED crowding is driven by the availability of inpatient beds. When you say ‘ED crowding' it is a symptom of a problem somewhere else in the hospital."

"This is something that leaders in hospitals are increasingly aware of," he says. "Folks who run hospitals are trying to figure out how to reduce the boarding of admitted patients in the ED and how to improve the through-put of the patient in the inpatient side."

Solutions to ED Crowding
Sun says the American College of Emergency Physicians has guidelines that could help hospitals alleviate ED crowding and boarding. He detailed three recommendations "that seem to be very effective although the political will to implement these might be challenging."

1.Manage Flow
For starters, he says there needs to be someone in the hospital whose job is to manage inpatient flow.

"One common name that is given is the bed czar," Sun says. "This is either a physician or a nurse manager who is always monitoring the availability of inpatient beds. This is across all services but usually medicine and surgery are the two major services you have to watch out for."

"This may require the bed czar to know how many patients are getting elective procedures  because those patients are guaranteed to require a bed after the operation. Have one person or a few people who are given the responsibility of knowing what is going on throughout the hospital so they can facilitate through-put, making sure beds are turned over as quickly as possible, making sure of their known bed needs, that the hospital is prepared for that."

2.Spread Out the Boarders
Another solution is to spread the burden of the overcrowded ED throughout the hospital.

"In a lot of the hospitals I've worked at, when the hospital is crowded you just board a bunch of patients in your hallway. You may have multiple patients in stretchers who in theory are admitted, but because there is no place to put them, they just fill up the hallway in the ED," Sun says.

"What's so special about the ED hallways? Spread these patients out throughout the hospital."

3.Control 'Artificial Variation'
A third suggestion that Sun called "the most effective, but also the most difficult," involves controlling "artificial variation."

"The numbers of patients who are admitted from the ED is like clockwork. It's very predictable. That is natural variation," Sun says.

"Artificial variation is when you have different needs for hospital beds that are based on things that physicians in the hospital can control. For example, let's say the surgeons in your hospital decide to do all their surgeries on Monday, Tuesday and Wednesday. On those days you are going to have a tremendous backup because all the inpatient beds are going to be taken up by post-surgical patients. Then for the rest of the week you then have oversupply of beds because those post-surgical patients are discharged and you have an excess of inpatient beds. Spread out the surgical schedule over an entire week."

Although the affects of healthcare reform on ED crowding were not addressed in the study, Sun was asked to speculate.

"That's a complicated question. Nobody really knows," he says. "It could make boarding worse because now that more people are going to be insured they will use the hospital more so that might contribute to ED crowding. We've seen this happen in Massachusetts where the expansion of insurance to pretty much the entire population at the least has not helped ER crowding and it probably has increased the volume of people who go to the ED."

"On the other hand, it might help in the sense that there are payment reforms going on and there is a big push to try to figure out how to keep patients out of the hospital. Right now it is really unknown. It could affect in both directions and nobody knows until we actually go to it."

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John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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