http://ttuem.com/page2/page5/files/ED%20Crowding%20Review.

pdf From Medscape Education Clinical Briefs Mortality Risk for Patients Admitted Via a Crowded ED CME/CE News Author: Jenni Laidman CME Author: Hien T. Nghiem, MD Faculty and Disclosures CME/CE Released: 12/21/2012; Valid for credit through 12/21/2013 CME/CE Information Earn CME/CE Credit CLINICAL CONTEXT Emergency department (ED) crowding is a prevalent healthcare delivery problem both in the United States and internationally. Increasing frequency of ambulance diversion and left-without-being-seen visits have led US EDs to nearing the "breaking point." Overall, the current situation may adversely affect the outcomes of patients requiring hospital admission. The aim of this study by Sun and colleagues was to assess the association of ED crowding with subsequent outcomes in a general population of hospitalized patients. STUDY SYNOPSIS AND PERSPECTIVE Patients admitted to hospitals via crowded EDs may be more likely to die in the hospital than similar patients admitted during slow periods, according to a study published online December 5 in the Annals of Emergency Medicine. Findings also suggest that ED crowding is associated with a slight increase in length of stay and a 1% cost increase. Benjamin C. Sun, MD, MPP, associate professor of emergency medicine, Oregon Health and Science University, Portland, and colleagues studied the admission records from 995,379 ED visits by adults to 187 California acutecare hospitals in 2007, focusing on periods of ED crowding, distinguished by the need to divert ambulances from the hospital. The data were adjusted for case mix, patient demographics, comorbidities, and primary discharge diagnosis. The researchers determined that crowding resulted in 300 inpatient deaths (95% confidence interval [CI], 200 - 500 inpatient deaths), 6200 hospital days (95% CI, 2800 - 8900 hospital days), and $17 million (95% CI, $11 million - $23 million) in costs.

The researchers' primary analysis found a 5% greater odds of inpatient death (95% CI, 2% - 8%) associated with admission via a crowded ED; a fully adjusted sensitivity analysis, however, found that patients admitted via a crowded ED had a 9% (95% CI, 4% - 13%) greater risk of dying within 3 days of admission. The primary analysis also found 0.8% increased length of stay (95% CI, 0.5% 1%) and a 1% increased cost per admission (95% CI, 0.7% - 2%). Hospitals prohibited from diverting ambulances were excluded from this study, as were children's hospitals. Diversions for reasons other than ED saturation, such as the temporary lack of a subspecialty, were excluded from the analysis. In this study, crowding was defined as days within the top quartile of daily ambulance diversion for a specific facility. Potential study limitations include that ambulance diversion "may be an imperfect measure of ED crowding," the authors write. In addition, causality cannot be presumed from this study design; it is possible that "patients with worse outcomes cause ED crowding." Nonetheless, the authors conclude that the "study provides additional evidence that ED crowding is a marker for worse care for all ED patients who might require hospital admission." "Despite mounting evidence that ED crowding is a health delivery problem that reduces access to emergency care, results in worse quality of care, and leads to lower patient satisfaction, there have... been few systematic actions to address the crisis of ED crowding," the authors continue. "Policymakers should heed the recommendations of the Institute of Medicine and address ED crowding as an important public health priority." The Institute of Medicine described an "overburdened US emergency care system" and outlined potential policy remedies in a report entitled Future of Emergency Care: Hospital-Based Emergency Care at the Breaking Point, published in 2006. "ER crowding is dangerous," Dr. Sun said in a journal news release, emphasizing that the problem is "likely to become worse in the future because of the volume, complexity, and acuity of emergency patients." This study was supported by an Emergency Medicine Foundation Health Policy grant and a US federal grant. Dr. Sun was supported by the National Institutes of Health and the University of California, Los Angeles, Older

Americans Independence Center. Another author was supported by the National Institutes of Health and the Robert Wood Johnson Foundation Physician Faculty Scholars. Ann Emerg Med. Published online December 5, 2012. Full text STUDY HIGHLIGHTS Investigators conducted a retrospective cohort analysis of patients admitted in 2007 through the EDs of nonfederal, acute-care hospitals in California. The primary outcome was inpatient mortality. Secondary measures included hospital length of stay and costs. ED crowding was established by the proxy measure of ambulance diversion hours on the day of hospital admission. To control for hospital-level confounders of ambulance diversion, periods of high ED crowding were defined as those days within the top quartile of diversion hours for a specific facility. Hierarchic regression models controlled for demographics, time variables, patient comorbidities, primary diagnosis, and hospital fixed effects. Additionally, bootstrap sampling was used to estimate excess outcomes attributable to ED crowding. There were 995,379 ED visits resulting in admission to 187 hospitals. Results of this study revealed that patients who were admitted on days with high ED crowding experienced 5% greater odds of inpatient death (95% CI, 2% - 8%), 0.8% longer hospital length of stay (95% CI, 0.5% - 1%), and 1% increased costs per admission (95% CI, 0.7% - 2%). Excess outcomes attributable to periods of high ED crowding included 300 inpatient deaths (95% CI, 200 - 500 inpatient deaths), 6200 hospital days (95% CI, 2800 - 8900 hospital days), and $17 million (95% CI, $11 - $23 million) in costs. Additional analyses revealed that high ED crowding was associated with 9% (95% CI, 4% - 13%) greater odds of inhospital death within 3 days. Lastly, admission on days with greater than 5 ambulance diversion hours vs admission on days with 0 diversion hours was associated with 6% increased odds of inpatient death (95% CI, 2% - 10%). This study included the following limitations: Ambulance diversion hours may not be an accurate measure of ED crowding. Findings may be subject to unmeasured confounding factors. The observational design cannot exclude the possibility of endogeneity or reverse causation. Findings may be mediated through inpatient vs ED crowding. Findings may not be generalized to other settings and countries.

CLINICAL IMPLICATIONS Manifestations of ED crowding include increasing frequency of ambulance diversion and left-without-being-seen visits. Periods of high ED crowding were associated with increased inpatient mortality rates and modest increases in hospital length of stay and costs for admitted patients. CME TEST All questions must be answered in order to proceed. To receive AMA PRA Category 1 Credit, you must receive a minimum score of 70% on the post-test. A 60-year-old woman presents to the ED for a headache. On presentation, she is informed that the wait is approximately 5 hours. Of note, the patient learned that the hospital have started diverting ambulance calls. Another sign of ED crowding is if this patient is: Admitted directly to the hospital Seen within 2 hours Left without being seen All of the above According to this study by Sun and colleagues, if this patient is admitted to the hospital, which of the following outcomes is most likely to occur? Lower mortality rate Higher hospital cost Lower rate in hospital length of stay Better medical care

A crowded emergency department waiting room is more than unpleasant: New research suggests its a serious hazard to your health. Researchers recently looked at the difference in outcomes of patients who entered California hospitals through the emergency department in 2007. They looked at patients who visited the emergency department when it was saturated, working at capacity and diverting ambulances elsewhere, and those who visited at less crowded times. They found, in a new Annals of Emergency Medicine study, that patients who came in through a crowded emergency department had 5 percent greater odds of dying in the hospital. Those patients also had longer hospital stays and higher costs, the same paper finds.

There arent many differences in the types of patients who visit the emergency department when its crowded or when its empty. Of those who came in to a saturated emergency room, 10.3 percent had congestive heart failure, compared to 10.4 percent of those arriving during less crowded hours. About half of the patients in each condition were white and just under a third were African-American. The one big difference, this paper finds, is in the morality rate: Patients who came into a saturated emergency department had a 5 percent higher chance of dying in the hospital after their admission. The researchers, lead by Oregon Health and Sciences Universitys Benjamin Sun, write that this likely has to do with a crowded emergency department challenging doctors resources. ED crowding may reduce access through prolonged waiting times or through increased time to care as a result of longer ambulance transport after diversion, they write. A large literature has demonstrated the negative effect of ED crowding including delays in the treatment of myocardial infarction, pneumonia, and painful conditions. Theres reason to think this is becoming an increasingly pressing problem: The average emergency room wait time increased 25 percent between 2003 and 2009, from 46.5 minutes to 58.1 minutes, according to the CDC.

Long Waits in the ER May Raise PTSD Risk for Heart Patients
Those who spent over 11 hours in emergency department more likely to be traumatized months later: study Monday, February 11, 2013

Related MedlinePlus Pages Emergency Medical Services Heart Attack Post-Traumatic Stress Disorder MONDAY, Feb. 11 (HealthDay News) -- People waiting for countless hours in crowded emergency rooms to be treated for a heart attack or severe chest pain may be at risk for developing post-traumatic stress disorder (PTSD), a new study suggests.

Typically, PTSD is associated with major traumatic experiences such as war or disasters, but it can also occur in highly stressful situations such as sitting in an emergency room for more than 11 hours, the Columbia University researchers said.

"The modern emergency department is excellent at acute care, but a number of health system and hospital-level pressures have overcrowded them to a point where being treated there can, at times, worsen long-term prognosis," said study author Donald Edmondson, an assistant professor of behavioral medicine.

Although it was small, this is the first study to document the psychological effects of overcrowding in the emergency room environment, he added.

"Most experts forecast that emergency department crowding will increase as health reform is implemented, because a lot of U.S. emergency departments have closed recently, and many newly insured patients will enter the system without access to good primary care, ending up in the emergency department," Edmondson explained.

For the more than 1 million Americans who have a heart attack or chest pain this year, "those overcrowded emergency departments will increase the stress of an already traumatic event, and may lead to increased PTSD symptoms and poor prognosis," he added.

The report was published in the Feb. 11 online edition of JAMA Internal Medicine.

To see what effects waiting in crowded emergency rooms might have, Edmondson's team noted the time when 135 heart patients arrived at a New York City emergency room between 2009 and 2011. The patients were part of a larger study.

Those who stayed in the emergency room for more than 11 hours were more likely to suffer symptoms of heart disease-related PTSD in the month following their stay, the researchers found.

PTSD symptoms are a risk factor for the recurrence of heart problems and death, the researchers noted. PTSD also contributes to poor quality of life, lower patient satisfaction and more use of the health care system, they added.

Symptoms of PTSD can include intrusive memories, avoidance, emotional detachment, increased anxiety, irritability and depression, according to the U.S. National Center for PTSD.

Simple organizational changes, such as better planning of surgeon schedules and protocols to handle overcrowding, have been shown to dramatically reduce emergency room crowding and improve patient outcomes, Edmondson said.

"Further, acute care and cardiac units dedicated to patients with possible heart problems not only reduce emergency room crowding, but also improve cardiac outcomes, are cost-effective and can shield patients from many frightening emergency room experiences," he said.

Dr. Donald Yealy, chair of emergency medicine at the University of Pittsburgh, agreed that the emergency room experience can be stressful to the point where one might develop PTSD symptoms.

"The limitation is [the] small size of the study and I don't know how big the impact is," he said. "But we need to look at this as one of the complications of emergency room crowding."

The solution to overcrowding needs to involve the entire hospital, he said. The emergency room is only the entry point for patients, meaning the hospital has to create systems for moving patients from the emergency room into specialized care as quickly as possible, he explained.

"Crowding is a function of the entire hospital system. It's not only an emergency department issue," Yealy said. "When the entire institution doesn't respond to the demands of the emergency department, it affects the health of each patient, particularly the sicker ones."

SOURCES: Donald Edmondson, Ph.D., assistant professor, behavioral medicine, Columbia University Medical Center, New York City; Donald Yealy, M.D., professor and chair, emergency medicine, University of Pittsburgh; Feb. 11, 2013, JAMA Internal Medicine, online

HealthDay Crowded emergency rooms can be annoying, infuriating, scary and (if you saw the brilliant documentary, The Waiting Room, about the emergency department at Highland Hospital in Oakland, Calif.) heartbreaking. Now add this to the list: Deadly A new report published online in the Annals of Emergency Medicine found that patients admitted to the hospital from the emergency department during periods of high crowding died more often than similar patients admitted to the same hospital when the emergency department was less crowded.

A crowded ER, it turns out, was also associated with longer hospital stays and slightly higher costs, the study found.

Why might this be? The authors suggest a few reasons:

ED crowding may reduce access through prolonged waiting times or through increased time to care as a result of longer ambulance transport after diversionA large literature has demonstrated the negative effect of ED crowding on throughput, including delays in the treatment of myocardial infarction, pneumonia, and painful conditions. Finally, output focuses on the transfer or discharge of patients from the ED. A common barrier to output is high inpatient occupancy, resulting in patients boarding in the ED while waiting for an available hospital bed. Prolonged boarding times may delay definitive testing and increase short-term mortality, length of stay, and associated costs. Continuity of care in the ED may be compromised by frequent nursing and physician shift changes, and ED priority on evaluating new patients may divert attention from ongoing care of boarded patients.

Heres more from the news release:

ER crowding is dangerous, said lead study author Benjamin Sun, MD, MPP, of Oregon Health & Science University in Portland. We looked at nearly a million admissions through emergency departments

across California, a large number of patients. Crowding was associated with 5 percent greater odds of inpatient death.

Researchers analyzed 995,379 emergency department visits resulting in admission to 187 hospitals. Daily ambulance diversion the practice of closing an ER to ambulances because it is too crowded to accept new patients was the measure of emergency department crowding. Admission to the hospital from the ER on days with prolonged ambulance diversion (a median of 7 hours) or high emergency department crowding was associated with 5 percent increased odds of dying in the hospital compared to admissions on days with low ambulance diversion (a median of 0 hours).

Patients who were admitted on days with high emergency department crowding had 0.8 percent longer hospital stays and 1 percent 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.

Emergency department crowding is likely to become worse in the future because of the volume, complexity and acuity of emergency patients, said Dr. Sun. Policymakers should address ER crowding as an important public health priority.

The study was supported by the Agency for Healthcare Research and Quality and the Emergency Medicine Foundation. Objective

Emergency Department (ED) crowding is a major public health problem and one that has not been well studied for its effects on education. The objective of this article was to identify best-practice, consensus recommendations to help emergency medicine (EM) residency programs and faculty maintain educational excellence in an era of ED crowding.

Methods

A geographically diverse group of 37 clinician-educator leaders in EM convened at the 2010 Council of Emergency Medicine Residency Directors Academic Assembly. The participants discussed innovative ideas and solutions to address the many educational challenges that ED crowding poses.

Results

To cope with crowding, the consensus group identified 3 educational domains, focusing on the educator, the learner, and the institutional system. Core subthemes included optimizing teaching opportunities, providing alternative teaching approaches, and redefining what faculty and learners traditionally think of as teaching. An ED rotation provides ample opportunities for teaching not only about patient care and medical knowledge but also other Accreditation Council for Graduate Medical Education competencies, such as interpersonal and communication skills, professionalism, and systembased practice.

Conclusions

Crowding in EDs poses educational challenges, but with some creativity, flexibility, and desire to make the most of a challenging situation, educational excellence is an achievable goal.

Go to: Introduction Emergency department (ED) crowding is a national public health crisis.1 According to the American College of Emergency Physicians, crowding occurs when the identified need for emergency services exceeds available resources for patient care in the emergency department, hospital, or both.2 Crowding has been shown to result in slower processes of care and lower satisfaction scores by patients.,311 Very few studies, however, have assessed the impact of crowding on education in the ED.,1214

Crowding may both harm and benefit the education of medical students and residents in academic EDs. When patient volume and demands exceed ED resources, attending physicians are drawn away from traditional teaching opportunities because of pressing clinical issues, bottlenecks in patient flow, and other administrative problems. Learners may lower their standards for clinical care, patient privacy, and professionalism. In contrast, ED crowding may benefit other aspects of education. Learners can hone skills in time management, resource prioritization, and professionalism in stressful environments.15

The sparse literature on solutions to balancing education and service in academic EDs prompted the Council of Emergency Medicine Residency Directors (CORD) to convene a consensus group at the 2010 CORD Academic Assembly. To our knowledge, there have been no publications summarizing bestpractice recommendations for maintaining educational excellence in a crowded clinical environment before now.

Go to: Methodology More than 100 emergency medicine (EM) residency directors, clerkship directors, and other faculty members with an academic niche in education attend the annual CORD Academic Assembly. Conference attendees were asked to attend a 3-hour session to elicit insight about innovative practices addressing the educational challenges that ED crowding poses. A geographically diverse group of 37 EM educational leaders participated.

The group initially reviewed the literature on the impact of crowding on education. In informal, smallgroup sessions, members discussed the educational challenges and generated innovative ideas and bestpractice solutions. These small-group sessions then reconvened to share examples and discussion points. The large-group dialogue was moderated by the first author and a digital audiotape was made. The 2-hour, large-group discussion was later transcribed and coded into domains and core subthemes. Member-checking was conducted by e-mail 2 weeks after the conference to assess trustworthiness and face validity.

Crowded Emergency Rooms Linked to PTSD in Chest Patients By Shannon Pettypiece - Feb 12, 2013 7:00 AM GMT+0200 Facebook Share LinkedIn Google +1 1 COMMENT Print QUEUE Q

Chaotic, overcrowded emergency rooms may cause some heart patients to develop post-traumatic stress disorder, a condition commonly associated with combat on the battlefield that can shorten life spans. Patients suffering from chest pain who came to the emergency room of a New York City hospital during the busiest times were more likely to have symptoms of the disorder than those who showed up at quieter periods, according to a report released yesterday in JAMA Internal Medicine. 1:29 Feb. 12 (Bloomberg) -- Jane King summarizes the top stories this morning on the Bloomberg Business Report. (Source: Bloomberg) PTSD occurs in about 12 percent of heart attack patients and has been found to double their risk of dying over the next one to three years, said Donald Edmondson, a researcher on the study and assistant professor at Columbia University whose research focuses on the behavioral effects of disease. A hectic emergency room may intensify the emotional stress and fear of having chest pain causing patients to feel they are in greater danger, out of control and not being communicated to properly. A heart attack is in and of itself a life-threatening terrifying event, your body has turned against you, and you dont know if youre going to live through this thing, said Edmondson in an interview. An overcrowded ER can exacerbate that. The study tracked 135 patients who came to the emergency room at a New York City hospital with a condition called acute coronary syndrome. The researchers compared the traffic at the emergency room during the time they were there with whether the patients experienced symptoms of PTSD a month later. They found a direct correlation between the level of crowding at the ER and PTSD symptoms. On average, the patients spent nine to 11 hours at the ER, and the emergency room admitted 25 percent more patients during its busiest 24-hour periods, Edmondson said. Anxiety Disorder PTSD, which is best known for occurring in veterans of war or victims of an assault, is an anxiety disorder in which people experience flashbacks, nightmares and mood swings that disrupt their daily lives. The finding adds to growing evidence that overwhelmed emergency departments can have greater consequences for patients than lengthy weight times, researchers said. Patients were more likely to die at the emergency room when it was overcrowded compared to during less busy times, according to a study published in December in the Annals of Emergency Medicine. Emergency rooms across the U.S. may get even more crowded as the 30 million Americans expected to get health insurance under the 2010 health law drive up demand for health services, Edmondson said.

This is not just heart attack patients coming through the ER and being frightened, it is all of our patients, he said. The way we do this and decide to allow our ER to function may be impacting both the psychological quality of life and prognosis of our patients.