Emergency department overcrowding: the Emergency Department Cardiac Analogy Model (EDCAM)

Summary

Increasing patient numbers, changing demographics and altered patient expectations have all contributed to the current problem with ‘overcrowding’ in emergency departments (EDs). The problem has reached crisis level in a number of countries, with significant implications for patient safety, quality of care, staff ‘burnout’ and patient and staff satisfaction. There is no single, clear definition of the cause of overcrowding, nor a simple means of addressing the problem. For some hospitals, the option of ambulance diversion has become a necessity, as overcrowded waiting rooms and ‘bed-block’ force emergency staff to turn patients away. But what are the options when ambulance diversion is not possible? Christchurch Hospital, New Zealand is a tertiary level facility with an emergency department that sees on average 65,000 patients per year. There are no other EDs to whom patients can be diverted, and so despite admission rates from the ED of up to 48%, other options need to be examined. In order to develop a series of unified responses, which acknowledge the multifactorial nature of the problem, the Emergency Department Cardiac Analogy model of ED flow, was developed. This model highlights the need to intervene at each of three key points, in order to address the issue of overcrowding and its associated problems.

Introduction

There is clear evidence to support the growing concern with emergency department (ED) overcrowding (Asplin et al., 2003, Canadian Association of Emergency Physicians and the National Emergency Nurses Affiliation, 2003, Haugh, 2003, Weiss et al., 2002, Dunham, 2001). This is not a new problem, nor is it of sudden onset. Over the last two decades, concerns have been raised in a number of Western countries about the increasing numbers of patients attending EDs. Specific acknowledgment has been made of possible ‘inappropriate’ ED use and the tendency of some patient groups to seek ‘primary health care’ from the emergency provider (Richardson, 1999a, Richardson, 1999b, Robertson-Steele, 1998, Togi, 1997, Toulson, 1996, Halfon et al., 1996). The focus in more recent times has shifted to view the problem from a wider perspective. Issues such as ‘bed-block’ have been identified (where patients cannot be moved from the ED facility to definitive treatment areas) indicating the inability of hospitals to respond to supply and demand surges, together with the need for ambulance diversion and related health system inefficiencies acknowledged as significant contributing factors. Despite the gradual shift to a wider focus, there remains an essentially isolationist approach in much of the literature, with the interactive nature of ED, community and hospital services given little emphasis. While it is often necessary to deal with single aspects at a time, due to the sheer size of the problem, this must be done within a framework that acknowledges that other factors impact on the likely outcome.

Numerous authors have examined specific responses to ED overcrowding, including those who have focused on limiting the number of patients presenting by tightening (or at least defining) the criteria by which ‘appropriate’ patient conditions are identified (Franco et al., 1997, Lowry et al., 1994, Afilalo et al., 1994, Lowe et al., 1994, Prince and Worth, 1992). Attempts to define acceptable reasons for patients to seek care from an emergency facility have typically been derived following a retrospective audit of patient charts, assessed by medical experts and focused on those patients with triage categories indicating a lesser degree of urgency. The role of primary care has also been widely discussed. Suggestions made include the identification and subsequent re-referral of ‘primary care’ patients back to the primary care setting. Other options include the development of Advanced Nurse Practitioner roles and nurse led clinics (Bache, 2000, Barr et al., 2000, Crux, 1997). The inclusion of primary care providers either in or adjacent to emergency care facilities has also been considered (McLauchlan and Harris, 1998, Robertson-Steele, 1998, Rajpar et al., 2000). Each of these approaches identifies contributing elements of the problem, but are based on the assumption that the solution lies within the Emergency Department itself. The overall context within which emergency care occurs needs to be considered, and the inherent limitations in an isolated approach acknowledged. There have been several attempts to identify ‘inappropriate’ reasons for presenting to the ED, yet this assumes that there is a single ‘gold standard’ definition, agreed on by all concerned (Gill et al., 1996). Similarly, in identifying ‘primary care’ as an inappropriate use of emergency service resources, it is assumed that this category is easily (and prospectively) identifiable. Failure to recognise the social context, and the expectations of a changing society, further impact on the ability to set in place effective interventions.

These are only two from a range of issues contributing to overcrowding in EDs, and in order to develop a comprehensive approach, it is necessary to work within an overall model of ED care, and then to recognise the specific elements contributing to overcrowding, and how each can be addressed. Focusing on one aspect of the problem in isolation is limited in terms of its overall utility and ability to progress the problem. A specific emergency care model has been developed within the Christchurch Hospital Emergency Department, which provides an overview of the range of factors relating to ED patient flow, and within which individual areas can be evaluated, and for which targeted interventions can be developed.