Combatting the Crowd

Authors: Peter Fielding / Editor: Nikki Abela /  Codes:  / Published: 09/11/2021

Editor’s Note: The author, Pete, is a paediatric trainee and so this is mainly written from a PED perspective.

Crowding kills. Research has shown that overcrowded EDs are less safe for the patients they care for.

It happens for a number of reasons, and RCEM has long tried to push for solutions, some of which are here. We have also covered crowding in our induction introduction here.

Overcrowding occurs when the hospital at large, is unable to meet the demands for care placed upon it by the patients. As a result, the ED, which is generally regarded as the “front door” of the hospital, is unable to cope with the number of patients the hospital is caring for.

It happens for many reasons: staff, space, internal hold ups and exit block. In short, if all roads lead to the same place, the place gets more busy and things can slow up. Add to this the problem of being unable to move patients out and EDs become heavily crowded: much like many in the country are as I type this now.

Community factors often cited by patients include (rightly or wrongly!) inability to access primary care appointments, poor social networks and having nobody to support a parental or guardian decision that their child is OK and does not need medical support, and pressure on community healthcare services (such as OPAT services for home intravenous antibiotics) which may otherwise facilitate discharge from ED and enable care in the community. Other issues, mainly in adult hospitals, include exit block from the hospital at large, e.g. for patients waiting for community placements.

Within ED, problems can occur with staffing, the skill mix of the staff on shift, a lack of adequate physical space in which to see patients, and over-zealous use of patient investigations.

In the wider hospital, problems with IT systems, waits for imaging and other investigations, availability of inpatient beds or opinions from specialist teams also contribute.

Exit block, which happens when patients in the emergency department who require admission to the hospital are unable to be moved to a bed on a ward because of a lack of availability is also a large contributor.

These lists are not exhaustive, but serve to highlight the point that ED overcrowding cannot be solved within ED alone. It is a much bigger problem than that. Overcrowding occurs when patient flow through ED and the hospital slows or stops.

This blog will serve to explore what we can do, within ED, to help ensure good patient flow and reduce overcrowding. As we head into winter months, with Covid-19 and an anticipated surge in winter-viruses requiring detailed planning of services to meet an upsurge in demand, it is vitally important that we in ED consider how best to maintain flow through our departments. 

What does the evidence say?

The evidence is clear. ED overcrowding is associated with poorer outcomes across a wide range of ED performance parameters. Overcrowding is associated with poorer patient care, with a rise in mortality and morbidity with increasing 6-hour and 12-hour patient waits. This is underpinned by clinical guidelines and protocols not being followed properly, and delays in initiating treatment.

The key to ensuring good patient flow from an ED perspective is to reduce the amount of time each patient spends in ED . This is correlated with increased patient satisfaction, reduces morbidity and mortality in adult practice, and helps prevent overcrowding. 

What tools or strategies are available to us in ED?

1. Triage

The first interaction a patient has with the clinical team in the ED is triage. Triage is a process designed to quickly assess a patient in terms of the nature of their presenting complaint, and the acuity of their presentation. This process helps to allocate finite ED resources (personnel, cubicle or room, monitoring) to those who need it most. It is a system which helps alert the clinical team to those most unwell, and who need timely clinical intervention. 

Ideally, all patients are seen and triaged within 15 minutes of booking in as the highest risk to the ED is the “untriaged” and not-known-about patient in the waiting room. This 15 minute target, aimed at reducing that risk, needs to be balanced with the concept of getting it right from the very first step of the patient journey, to make the system more efficient.

We should look to use triage to our advantage. Triage is a time to initiate basic steps to reduce the time each patient spends in ED overall. It is the time to administer antipyretics, analgesia to those with injuries, commence trials of fluid in those likely to benefit, and to collect specimens which take time to collect, such as urine samples. Play specialist staff should be made aware of anxious or distressed children, to help prepare them to be seen by the medical team. Signposting parents and carers at this stage as to what their visit to ED is likely to entail can help to manage expectations, and also ensure that patients are set up to have all of the information and specimens likely to be required to aid diagnosis and management once they are seen by a member of the medical team. 

Providing the triage practitioner is suitably trained, studies have shown that initiation of basic investigations during triage can help to speed up the time to critical decision making in each patients care (7). In practice, this works well for X-ray investigations for minor injuries. Issues surrounding privacy can prevent collection of urine samples in the ED waiting room, and this is a time-consuming task which can extend a patient’s stay in the ED and block a clinical cubicle in the department. Allocation of a more private space for this purpose, even within the main waiting room, would be of benefit. 

Triage is traditionally performed by nursing staff. In paediatric practice, with emphasis put on minimising both over-investigation and also invasive tests for children, it is difficult to order and perform blood tests from triage. This process can be assisted by having a physician as the triage practitioner, or as part of the triage team. This has been shown to lead to faster diagnosis, shorter wait times and improved patient flow through ED (3). It also allows those children who require blood tests to be identified early, so that these investigations can be performed in a timely manner, with quicker access to results to inform subsequent management.

Triage also allows the process of streaming to occur. Streaming is a process by which those patients arriving through the front door in ED are cohorted into groups, often based upon the nature of their presenting complaint. It may be, for example, that minor injuries, those with coughs and colds, or babies with feeding problems are grouped together, and a dedicated number of clinicians are allocated to that particular group. This allows a focused approach on a particular clinical problem, and can enable those suitable for a quick discharge are identified, seen promptly and managed accordingly. It is useful to use streaming for patients of low acuity, who from triage are identified as being likely able to be discharged home, to ensure that they do not have prolonged waits in the department while children with increased acuity move ahead of them in the queue as a clinical priority. A senior, experienced clinician can help to alleviate overcrowding by managing such patients quickly and efficiently. There is evidence to suggest that streaming helps promote patient flow and reduce waiting times in ED compared to a comparative system not using a streamed model (8). Some departments are also trialling streaming to other places directly from triage, e.g. to health visitors, clinics, urgent care centres and pharmacists. This may make triage longer, but reduces the waiting time and improves departmental efficiency further along the patient journey, for those who do need to be seen in the ED.

In some EDs, a senior clinician or nurse in triage has aided the diverting of patients to more appropriate services, such as clinic slots, walk-in centre appointments, pharmacists or specialty teams.

2. Rapid Assessment and Treatment (RAT assessment)

RAT assessments involve a senior member of the medical team, often a consultant, providing a time-limited medical assessment of each child arriving to ED. This allows minor, self-limiting conditions to be identified early and to be discharged with appropriate advice, re-direction of suitable presentations to more appropriate services, and appropriate investigations and management to be initiated for patients as soon as they arrive to ED. Those patients who are likely to require admission or more time-consuming investigation would otherwise be triaged and wait to be seen in the more conventional manner. 

This process is a very useful way of identifying and managing “quick wins”. It is a powerful tool in preventing overcrowding, and ensures patients attending ED are approaching the correct service. It has been shown to reduce time to be seen by a doctor, and overall wait time in ED.

This needs to be balanced by the requirement for the consultant to be else-where. It takes a clinician off the shop floor possibly seeing the sicker patients, which potentially should be seen sooner than the minor ailments of the patients they are assigned to assess.

3. “Doc-in-a-box”

This process allocates a particular team to an ED cubicle. Such a team may consist of a doctor or nurse practitioner, a healthcare assistant and a nurse. A suitable patient stream is then identified by the ED team leader, and a separate queue created for this mini-MDT. The team involved should have the skillset to quickly manage a wide range of complaints, such as minor injuries and fractures. The team being based in one geographical location in ED helps to prevent time being wasted searching for a suitable cubicle to see patients, and also helps to mitigate against patient flow problems that happen when all available areas to see patients in ED become occupied. 

4. Patients seen in primary care

A lot of patients arrive to ED having been seen before-hand by their general practitioner or at a walk-in centre. Patients who have already been seen by a qualified health professional should ideally be referred to a relevant inpatient team, e.g. direct to surgical team, providing they do not need resuscitation or immediate stabilisation. If this pattern becomes apparent, this should be highlighted as a team so that discussions can be had at senior and managerial level to help prevent ED overcrowding. 

These are some of the techniques that are employed locally in our busy tertiary-level paediatric ED. Heading into winter, ensuring good patient flow and preventing overcrowding will become more important than ever, particularly in the midst of a global pandemic. We hope this article shares some of the techniques that we are mostly all using, and encourages others to come forward with their ideas or experiences of systems that you use in your workplace to help manage crowding in ED. Please tweet or comment to share your ideas on how to prevent problems going into winter.

Other RCEM & RCEMLearning Resources

Official Documents

References/Further reading

  1. Rowe BH, Guo X, Villa-Roel C, et al. The role of triage liaison physicians on mitigating overcrowding in emergency departments: a systematic review. Acad Emerg Med. 2011;18:11120.
  2. Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008 Jan;51(1):1-5.
  3. Jarvis PR. Improving emergency department patient flow. Clin Exp Emerg Med. 2016 Jun 30;3(2):63-68.
  4. Diercks DB, Roe MT, Chen AY, et al., Prolonged emergency department stays of non-ST-segment-elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/American Heart Association guidelines for management and increased adverse events. Ann Emerg Med. 2007 Nov;50(5):489-96.
  5. Fee C, Weber EJ, Maak CA, Bacchetti P. Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia. Ann Emerg Med. 2007;50:5019.509.e1.
  6. Taylor C, Benger JR. Patient satisfaction in emergency medicine. Emerg Med J. 2004 Sep;21(5):528-32.
  7. Rowe BH, Villa-Roel C, Guo X, et al. The role of triage nurse ordering on mitigating overcrowding in emergency depart ments: a systematic review. Acad Emerg Med 2011;18:1349-57.
  8. Oredsson S, Jonsson H, Rognes J, et al. A systematic review of triage-related interventions to improve patient flow in emer gency departments. Scand J Trauma Resusc Emerg Med 2011; 19:43.
  9. Bullard MJ, Villa-Roel C, Guo X, et al. The role of a rapid as sessment zone/pod on reducing overcrowding in emergency departments: a systematic review. Emerg Med J 2012;29:372-8.
  10. The Royal College of Emergency Medicine: COVID-19 Resetting ED Care.

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