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Special Report

Eliminating Crowding in the ED is Not a Pipe Dream (Seriously)

Shaw, Gina

doi: 10.1097/
    ED crowding
    ED crowding:
    ED crowding

    Emergency medicine's crowding guru Peter Viccellio, MD, doesn't mince words. ED crowding can be fixed. Not reduced, not spread out over the week, not just in low-volume EDs, but virtually eliminated in every ED in the country.

    Let that sink in, and then consider this: Hospitals with the most crowded emergency departments have, on average, adopted more interventions intended to address the issue than the least crowded EDs, but a significant proportion of the most crowded hospitals had not — in the hospital or the ED.

    Hospitals with the most crowded EDs (quartile 4) adopted more interventions overall than less crowded hospitals (a mean of 7.99, compared with 6.89 at quartile 3 hospitals, 6.27 at quartile 2, and 5.06 at quartile 1), but major gaps persisted, according to a study by Jesse Pines, MD, MBA, the director of the Center for Healthcare Innovation and Policy Research and a professor of emergency medicine and health policy at the George Washington University School of Medicine and Health Sciences in Washington, D.C., and colleagues. (Health Aff [Millwood] 2015;34[12]:2151.)

    The study found that nearly one in five of the most crowded EDs (18.9%) had not even adopted bedside registration, one in four had not adopted computer-assisted triage, and 94 percent had not adopted surgical schedule smoothing.

    The researchers analyzed the data for 341 hospitals each year, a total of 139,502 patient encounters representing a nationwide average of 127 million ED visits annually, from the 2007-2010 National Hospital Ambulatory Medical Care Survey. They specifically looked at the emergency department visits, a probability sample conducted annually by the CDC's National Center for Health Statistics that includes approximately 36,000 ED visits per year.

    ED crowding interventions at the hospital and ED levels increased by an average of 25 percent during that period, with the mean number of interventions rising from 5.2 to 6.6. Of nine ED-level interventions and eight hospital-level interventions considered, seven overall had a significant increase. The implementation of two interventions, in particular, more than doubled between 2007 and 2010: Full-capacity protocols, which went from being adopted by 21 percent of hospitals to 45.6 percent, and radio-frequency (RFID) tracking to follow a patient's location within the ED, which increased from 9.8 percent to 20.7 percent of hospitals.

    “The more crowded a hospital's ED is, the more of these interventions they tended to have. But there still are many hospitals out there that are not adopting them despite good science demonstrating the effectiveness of these practices,” Dr. Pines said. “One obvious reason is that implementing many of these interventions requires considerable resources. What is different from other health care interventions, like trying to get providers to document something in the electronic health record, improving crowding requires a multidisciplinary process, a team with a champion, buy-in from senior administration, the ability to review good data, and commitment over time. Because it requires so much energy over a long period of time, many hospitals may not prioritize it, as compared with the other quality improvement initiatives.”

    Dr. Pines noted that the growing use of ED crowding as a quality measure may spur more actions on these interventions. “Currently, the Centers for Medicare and Medicaid Services measures length of stay in the ED, and uses it as a quality indicator for public reporting; it will also be used for reimbursement,” he said. “And the most recent version of the Medicare star ratings, released in mid-2016, included ED flow metrics as about four percent of a hospital's overall rating. But even with these incentives and education about what hospitals can do to alleviate ED crowding, many institutions struggle to figure out not just what they can do, but what they should do. It's important for hospitals to look at their own data and understand the most important interventions that they can achievably implement.”

    Smooth Smoothing

    Ironically, the intervention that evidence suggests could be quite effective at any level is the one that has been adopted the least (only 6% in the Health Affairs study). It is inexpensive and easy to implement, to boot, because it requires only a change in administrative protocol. Schedule smoothing, as its name suggests, smooths out the peaks and valleys in elective surgical admissions.

    Another study demonstrated the effectiveness of schedule smoothing, but found the percentage of hospitals adopting this intervention grew by less than one percent, from 3.9 percent in 2007 to 4.6 percent in 2010. (Emerg Med J 2010;27[8]:593.) Quartile 3 and 4 hospitals adopted surgical smoothing at a slightly higher rate (6%) than quartile 2 (5.4%) and quartile 1 (1.1%), but across the board, this intervention lagged woefully behind all of the other strategies tracked in the study. Smoothing was also the least-adopted measure in a 2013 nationwide ED survey. (West J Emerg Med 2013;14[2]:85.)

    That brings us back to emergency medicine's crowding guru, who earned that informal title when he was the first to say admitted ED patients should be boarded in inpatient hallways rather than ED corridors. (EMN 2003;25[5]:25;“Everybody's trying, but they're bringing a knife to a gun fight,” said Dr. Viccellio, MD, the vice chair of emergency medicine at the State University of New York at Stony Brook and a nationally recognized expert on crowding. “They want to be successful, so they try something and it works. Maybe they convene a big group to get housekeeping to clean the rooms more quickly, reducing it from 35 to 20 minutes. Everybody celebrates this big accomplishment. But that's no help if you don't have a bed to clean. All of the things we do on boarding don't address the fact that we don't have beds to clean.”

    He noted that an ACEP paper, “Emergency Department Crowding: High-Impact Solutions,” included many of the interventions tracked in the Health Affairs study, such as inpatient hallway boarding and active bed management using a “bed czar.” (May 2016;

    “They listed 50 different things you can do to improve crowding, but 45 of them aren't going to solve the problem,” Dr. Viccellio said. “There is only a small set of strategies that are known to actually make this go away, and not just make it better, all of which have to do with smoothing schedules across the day, across the week, and through the weekend.”

    The authority on schedule smoothing is Ukrainian-born mathematician and systems engineer Eugene Litvak, PhD, who was featured in an Emergency Medicine News article last year. (“Meet the Man Who Solved the Hospital Overcrowding Problem,” EMN 2016;38[6]:16; The central tenet of his work is the idea of smoothing elective surgical admissions across the week, by number and by type. “If you have surgical patients who you know will need post-surgical ICU care, you don't bring them all in on Monday,” Dr. Viccellio said.

    That's just one element of smoothing. But two others — early discharge and weekend discharge — combined with smoothing the elective surgical admissions, have the potential to virtually eliminate ED crowding.

    Early and Weekend Discharge

    Late afternoon discharges contribute to admission bottlenecks, crowding, and increased length of stay (LOS). Dr. Viccellio pointed to a successful “discharge before noon” initiative at NYU Langone Medical Center in New York, which increased the patients discharged before noon from seven percent in January 2012 to 38 percent 13 months later. (J Hosp Med 2014;9[4]:210.) “This had a profound impact on their capacity and onboarding, and length of stay was almost a day shorter,” he said.

    Weekend discharges can also alleviate bottlenecks in the ED. “At most hospitals, there is a lot of inactivity on weekends, and then Monday is flooded with incoming surgeries and patient discharges,” said Dr. Viccellio. Perhaps nothing demonstrates the impact of weekend discharges more clearly than as-yet unpublished data compiled by the New York State Department of Health. Dr. Viccellio said patients discharged on a Saturday had an average length of stay of 3.9 days, but patients discharged on a Monday stayed an average of 7.3 days.

    Dr. Viccellio said the emergency department at Montefiore Medical Center's Moses campus in the Bronx implemented weekend discharges, with dramatic results. ED boarding had been almost totally eliminated within a year of discharging patients on Saturdays and Sundays. “They were able to close a 30-bed inpatient unit because they just didn't need it,” said Dr. Viccellio. “At our institution as well and in New York statewide, almost half of our discharges now are on weekends. When you have a steady flow in and out of your institution, you see a surprising capacity that you didn't realize that you had. Patients get into inpatient units more quickly, LOS is shorter, it's easier on the nursing and medical staff, and you realize tremendous savings.”

    If these three steps could virtually eliminate ED crowding, why is smoothing the least adopted intervention? Because it requires significant change, Dr. Viccellio said. “You don't have to ask people to work harder, but you do have to ask them to work differently, and there seems to be a profound deficit of the leadership needed to make this happen. At the institutions that have done this, it's been because senior leadership has decided that this is what they're going to do. If you need to lift five pounds, you can do it incrementally, but if you have to lift 1,000 pounds, you're going to need to find a different way to do things.”

    Objections will always be raised about the practicality of these strategies. “‘The insurance company hasn't approved the discharge and won't do it until Monday,’ is one common claim. That's right because you didn't ask them on Thursday or Friday,” Dr. Viccellio said. “‘We can't discharge on weekends because nursing homes won't take patients on weekends’ is another. But a lot of patients aren't going to nursing homes; they're going home. And the nursing home industry is also changing substantially. Around here they're asking for patients on weekends.”

    Dr. Viccellio said any hospital can do this. “Based on my knowledge of mathematics and what's happened with smoothing at institutions that have tried it, I believe this is a completely fixable problem to the extent that the institution has a huge party at the end,” he said.

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